Physiological Parameters & NEWS2 Scoring Matrix
Each parameter is scored from 0 to 3 based on deviation from normal physiological ranges. Scores reflect physiological stress and risk of cardiac arrest or unplanned ICU admission.
| Parameter | Score 3 | Score 2 | Score 1 | Score 0 | Score 1 | Score 2 | Score 3 |
|---|---|---|---|---|---|---|---|
| Respiration Rate (/min) | ≤8 | — | 9–11 | 12–20 | — | 21–24 | ≥25 |
| SpO2 Scale 1 (%) | ≤91 | 92–93 | 94–95 | ≥96 | — | — | — |
| SpO2 Scale 2 (%) | ≤83 | 84–85 | 86–87 | 88–92 (air) | 93–94 (O2) | 95–96 (O2) | ≥97 (O2) |
| Air or Oxygen? | — | Oxygen | — | Air | — | — | — |
| Systolic BP (mmHg) | ≤90 | 91–100 | 101–110 | 111–219 | — | — | ≥220 |
| Pulse (/min) | ≤40 | — | 41–50 | 51–90 | 91–110 | 111–130 | ≥131 |
| Consciousness | — | — | — | Alert (A) | — | — | CVPU (New) |
| Temperature (°C) | ≤35.0 | — | 35.1–36.0 | 36.1–38.0 | 38.1–39.0 | ≥39.1 | — |
Clinical Risk Tiers & Escalation Response
Ward nursing staff must execute escalation protocols according to the aggregate score:
• Low Score (0): Minimum 12-hourly monitoring.
• Low Score (1–4): Minimum 4–6 hourly monitoring; inform registered nurse to assess need to increase frequency.
• Low-Medium (RED 3 in a single parameter): Urgent review by ward nurse and attending junior doctor within 1 hour.
• Medium Score (5–6): Urgent review by doctor with core competencies in acute care; minimum 1-hourly monitoring.
• High Score (7+): Immediate emergency assessment by Critical Care Outreach Team (CCOT) or Medical Emergency Team (MET); continuous monitoring of vital signs and transfer to Level 2/3 care if indicated.
The SBAR Escalation Communication Framework
When calling a doctor or outreach team for a deteriorating patient, standardise handover using SBAR (Situation, Background, Assessment, Recommendation) to prevent critical delays.