3.3 Irish National Early Warning System (INEWS Version 2) Protocol

Irish National Early Warning System (INEWS Version 2) Protocol

The Irish National Early Warning System Version 2 (INEWS V2) is NCEC National Clinical Guideline No. 1, published in September 2020 and developed under the HSE National Deteriorating Patient Recognition and Response Improvement Programme. It replaced the 2013 National Early Warning Score (NEWS) guideline.

Scope matters and is examinable. INEWS V2 applies to adult (16 years and over), non-pregnant patients in acute settings. It does not apply to children - who are covered by the Paediatric Early Warning System (PEWS) - or to obstetric patients, who are covered by the Irish Maternity Early Warning System (IMEWS). A candidate who scores a pregnant woman on an INEWS chart has used the wrong tool.

The guideline is explicit that INEWS should be used as an aid to clinical judgement and decision making, not as a substitute for it.

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1. The Seven Scored Parameters

Each parameter is weighted from 0 to 3 according to how far it departs from the normal range. The table below reproduces the scoring bands on the INEWS V2 adult patient observation chart.

Four Scoring Points Candidates Get Wrong

1. A heart rate of 40 or below scores 2, not 3. This is a genuine difference from the UK NEWS2 chart that many overseas nurses have trained on. The low score is deliberate: INEWS V2 handles severe bradycardia through a separate single-parameter trigger (below) rather than through the aggregate.
2. Systolic BP has no mid-range penalty until 250. The 0-point band runs from 111 to 249 mmHg, and only >= 250 scores 3. The chart carries a separate instruction that a systolic BP of 200 or above should be rechecked manually and reviewed by a doctor, which is how severe hypertension is captured.
3. There is no dual SpO2 scale. UK NEWS2 uses a Scale 1 / Scale 2 system with a lower target range for patients at risk of hypercapnic respiratory failure. INEWS V2 has a single SpO2 row. A COPD patient whose stable baseline saturation is 89% will score on the standard row; the correct route to adjusting the response is a modified escalation protocol authorised by a Registrar or Consultant, not a second scoring scale. (Clinically, the oxygen target of 88-92% for patients at risk of hypercapnic respiratory failure still applies - but that is an oxygen prescription, not an INEWS scale.)
4. Any supplemental oxygen scores 2. One litre per minute via nasal cannulae and 15 litres per minute via a non-rebreather mask score identically. Room air scores 0.

The ACVPU Element

New Confusion (C) scores 3 alongside Voice, Pain and Unresponsive. New-onset confusion is treated as a vital sign in its own right - an early marker of sepsis, hypoxia, hypoglycaemia or cerebral hypoperfusion. Never assume confusion is chronic in an older adult without a documented baseline; assume it is new and score it.

Measurement Technique on the Chart

The chart itself specifies technique for two parameters:

• Respiratory rate: assess for a full 60 seconds. Counting for 15 seconds and multiplying by four, or writing 16 by habit, masks the single most sensitive marker of deterioration.
• Heart rate: check the pulse manually to ascertain rate, rhythm and quality. A monitor reading alone will not detect an irregularly irregular pulse or a thready volume.

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2. The INEWS Escalation and Response Protocol

The escalation protocol printed on the observation chart sets out who responds, how quickly, and how often observations must be repeated. Local hospitals set the named responders in their implementation policy, but the tiers and timeframes below are the national template.

Two single-score triggers sit outside the aggregate bands and are printed separately on the chart:

Two further chart rules sit outside the aggregate score:

• For INEWS scores of 0-2, an urgent response (SHO or ANP service) can still be called if there is clinical concern. The score is a floor, not a ceiling.
• Heart rate <= 40 requires immediate medical review, and systolic BP >= 200 requires a manual recheck and doctor review, irrespective of the aggregate.

The Single-Parameter Trigger Means Immediately, Not Within the Hour

This is the highest-yield point in the whole section, and the one most often taught wrongly - in both directions.

A patient whose aggregate score is only 3 because their systolic BP is 88 mmHg has a score of 3 in a single parameter. Read off the aggregate band alone and you would call an SHO to review within 1 hour with 4-hourly observations. The single-score trigger overrides that: the SHO must review immediately, with half-hourly observations or as the patient's condition indicates, escalating to the Registrar if there is no response to treatment or you remain concerned, and considering activation of the ERS.

Be equally careful not to over-state it. Recommendation 19 of National Clinical Guideline No. 1 defines the tiers by aggregate score - bedside response 0-2, urgent response 3-6, emergency response 7 or more - and then adds that "escalation should occur for any patient with a score of 3 in any single parameter." A single-parameter 3 is a mandatory immediate escalation within the urgent-response tier; it is not automatically the emergency-response tier, which is the aggregate >= 7 band that brings staff with critical-care competencies and the ERS.

flowchart TD
    A["Record all seven parameters and total the INEWS score"] --> B{"Aggregate >= 7?"}
    B -->|Yes| F["EMERGENCY RESPONSE<br/>Registrar to review immediately; inform Consultant<br/>Half hourly; continuous monitoring; consider ERS"]
    B -->|No| S{"Score of 3 in any single parameter?<br/>Or score of 2 for HR &lt;= 40?"}
    S -->|Yes| T["SINGLE-SCORE TRIGGER<br/>SHO to review IMMEDIATELY<br/>Half hourly or as condition indicates<br/>Registrar if no response; consider ERS"]
    S -->|No| C{"Aggregate score?"}
    C -->|"4 - 6"| E["URGENT RESPONSE - THINK SEPSIS<br/>SHO or ANP to review within 1 hour<br/>1 hourly observations; screen for sepsis"]
    C -->|"3"| D["URGENT RESPONSE<br/>SHO or ANP to review within 1 hour<br/>4 hourly observations"]
    C -->|"2"| G["BEDSIDE RESPONSE<br/>Nurse in Charge to review<br/>6 hourly observations"]
    C -->|"0 - 1"| H["BEDSIDE RESPONSE<br/>6 hourly for first 24 hours after admission,<br/>then 12 hourly minimum"]
    G --> I["Any clinical concern? Urgent response may still be called"]
    H --> I

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3. Governance: Modified and Deferred Escalation

Modified INEWS Escalation and Response Protocol

A nurse may never alter the scoring bands or the calculated score. Where a patient has a stable abnormal baseline - severe chronic lung disease, autonomic neuropathy, an end-of-life care plan - the response to the score can be modified, but only under strict governance:

• The escalation and response protocol must not be modified within the first 24 hours following admission. This reflects the vulnerability of the newly admitted patient; monitoring in that window was in fact increased to 6-hourly in Version 2.
• After 24 hours, only a Registrar or Consultant may document a modified INEWS Escalation and Response Protocol on the observation chart, recording the rationale, the specific altered actions and escalation, and a review timeframe.
• The modified protocol must be reviewed at least every 24 hours.
• The nurse continues to record the true observed values and the true calculated score; what changes is the documented response to them.

A distinction is drawn in the guideline between an ordinary medical plan of care and a modified INEWS Escalation and Response Protocol. The latter is a specific, documented decision by a Registrar or Consultant.

Deferred Escalation (Nursing)

Version 2 introduced a nurse-led deferral. A registered nurse may use clinical judgement to defer escalation for a maximum of 30 minutes where the nurse judges that the trigger has an immediate, identifiable and reversible cause. The rationale must be documented, the patient re-assessed within that window, and if the score does not improve, escalation must occur as per protocol. Deferral is a documented clinical decision with a hard time limit, not permission to wait and see.

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4. Common Pitfalls