Anaesthesia, 2005, 60, pages 547–553

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A physiologically-based early warning score for ward

patients: the association between score and outcome*
D. R. Goldhill,1 A. F. McNarry2, G. Mandersloot3 and A. McGinley4
1 Consultant, Anaesthetic Department, The Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex,
HA7 4LP, UK
2 Research Fellow, 3 Consultant, Anaesthetic Department, 4 Nurse Consultant, Patient-at-Risk Team, The Royal
London Hospital, Barts and The London NHS Trust, Whitechapel, London E1 1BB, UK

Summary
We analysed the physiological values and early warning score obtained from 1047 ward patients
assessed by an intensive care outreach service. Patients were either referred directly from the wards
(n = 245, 23.4%) or were routine critical care follow-ups. Decisions were made to admit 135
patients (12.9%) to a critical care area and limit treatment in another 78 (7.4%). An increasing
number of physiological abnormalities was associated with higher hospital mortality (p < 0.0001)
ranging from 4.0% with no abnormalities to 51.9% with five or more. An increasing early
warning score was associated with more intervention (p < 0.0001) and higher hospital mortality
(p < 0.0001). For patients with scores above one (n = 660), decisions to admit to a critical care
area or limit treatment were taken in 200 (30.3%). Scores of all physiological variables except
temperature contributed to the need for intervention and all variables except temperature and heart
rate were associated with hospital mortality.
. ......................................................................................................
Correspondence to: David R. Goldhill
E-mail: david.goldhill@rnoh.nhs.uk
*Preliminary analysis of this data was presented at the Intensive Care
Society, London, December 2002.
Accepted: 12 February 2005

Patients admitted from the wards to an intensive care unit
(ICU) have a much higher mortality than those admitted
from the emergency department or the operating theatres
[1]. Patients may be on the wards for days or even weeks
before admission to an ICU. The longer they are in
hospital before ICU admission, the worse their prognosis
[2]. Approximately 25% of deaths in patients admitted to
an ICU occur after discharge back to a ward and many of
these deaths are in relatively low-risk patients [1]. After
hospital admission, but before ICU referral, management
may be suboptimal and this is associated with an increased
mortality [3, 4]. In addition, critical incidents on the
wards that result in serious adverse outcomes are common
[5]. Early identification of the sickest patients (or those
who may become so) may allow earlier intervention,
including admission to a critical care unit, thus potentially
improving their outcome.
The majority of patients who suffer a cardiorespiratory
arrest in hospital have gross physiological abnormalities
recorded in the hours preceding the arrest [6–10].
Abnormal physiological measurements, along with a
patient’s history, examination and investigations, are
central to objectively identifying at-risk ward patients
[10]. One way of identifying potentially critically ill
patients on the wards is through physiologically based early
warning scores [11, 12]. These assign an increasing
number of points to increasingly deranged physiological
values. The early warning scores presently in use have both
physiological parameters and scores selected by clinicians
based on their experience. For an early warning score to
be applicable to a wider group of hospital patients,
information is needed as to which physiological variables
are most important and at what values. At The Royal
London Hospital the intensive care outreach service uses
an early warning score, the Patient-At-Risk (PAR) score,
to help identify and trigger a response for such patients.
This study had two main objectives. These were to
explore the raw physiological data in order to learn more
about the importance and contribution of each physio-
logical parameter, and to determine the value of the

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D. R. Goldhill et al. Æ Physiologically-based early warning score Anaesthesia, 2005, 60, pages 547–553
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subjectively derived Patient-At-Risk score as a means of hospital’s patient administration system. All this infor-
identifying ward patients who could benefit from critical mation was recorded onto a form and entered into a
care support. Microsoft ACCESS (Microsoft Corporation, One Micro-
soft Way, Richmond, WA) database. Validation of the
data consisted of a visual check of the forms and error
Methods
checking within the database. Data was extracted for all
Ethics committee approval was obtained for the data patients seen by the outreach service. If patients had more
analysis presented. Members of the intensive care out- than one outreach service episode during their hospital
reach service routinely reviewed two groups of patients: stay, only the data from the first episode were analysed.
primary referrals from the wards of any patient causing Each outreach service episode had three possible
concern or who triggered an early warning score outcomes: alive remaining on the wards (WARD),
response, and patients discharged to a ward from a critical transferred to a critical care area (CRITICAL CARE),
care area (ICU, surgical High Dependency Unit (HDU) and either treatment limitation decision that critical
and the Coronary Care Unit (CCU)). care was not appropriate or death while under review
Patients were reviewed until they were discharged by the outreach service (THERAPY LIMIT). The
from the outreach service, were admitted to a critical care patients’ status at hospital discharge was also recorded.
area, died on the ward or a decision was made that critical Data was grouped by Patient-At-Risk score with scores
care admission would be inappropriate. This was consid- of seven and eight being amalgamated, as were scores
ered an outreach service patient episode and could consist above eight.
of one or more assessments. Each time a patient was In order to understand the association between phy-
assessed, a Patient-At-Risk score was calculated from siological values and outcome, the values of all param-
seven physiological variables (Table 1). eters, except level of consciousness and urinary output,
In common with other presently available early were ordered from lowest to highest and then divided
warning scores, points are awarded for physiological into groups of 50 patients. The highest and lowest values
derangement. Raw physiological values were recorded for this range were noted, as was the hospital mortality.
for temperature, heart rate, arterial systolic blood pressure, A range of values was identified for each parameter
respiratory rate, and oxygen saturation (SpO2). Level of associated with a hospital mortality of < 15%, 15% to
consciousness was classified as alert, confused, responds to < 25%, 25% to < 35% and ‡ 35%. Hospital mortality was
voice, responds to pain and unresponsive. Urinary output also determined for groups of level of consciousness and
was classified by volume of urine in ml.kg)1.h)1 and urinary output defined in the Patient-At-Risk score.
whether patients were usually dialysis dependent. Values We explored the relationship between hospital mor-
in the predefined normal range scored zero and a tality and physiological abnormality, defined for each
maximum of up to three points was awarded for variable as a Patient-At-Risk score of greater than zero.
physiological derangement. The individual points were The relationship of the Patient-At-Risk score to decisions
summed for the total Patient-At-Risk score. made following the outreach episode and hospital out-
Other information recorded included the patient’s come was also examined.
sex, age, and any decisions following outreach service Statistical analyses were performed with STATISTICAL
involvement. Hospital outcome was retrieved from the PACKAGE FOR THE SOCIAL SCIENCES version 11.5 for

Table 1 The Patient-At-Risk early warning score.

Points scored

3 2 1 0 1 2 3

Temperature; C <35.0 35.0–35.9 36.0–37.4 37.5–38.4 ‡38.5

Heart rate; beats.min)1 <40 40–49 50–99 100–114 115–129 ‡130
Systolic blood pressure; mmHg <70 70–79 80–99 100–179 ‡180
Respiratory rate; breaths.min)1 <10 10–19 20–29 30–39 ‡40
SpO2; % <85% 85–89% 90–94% ‡95%
Level of consciousness Alert Confused Responds Responds to pain
to voice or unresponsive
)1 )1
Urine output; ml.kg .h nil <0.5 dialysis* 0.5–3 >3

*Dialysis: normally dialysis dependent.

548
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Anaesthesia, 2005, 60, pages 547–553 D. R. Goldhill et al. Æ Physiologically-based early warning score
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Windows (SPSS, Chicago, IL) and GRAPHPAD PRISM Table 3 Patient details by hospital outcome. Values are number
version 4.00 for Windows (GraphPad Software, San (proportion), mean (standard deviation (SD)) or median [inter-
quartile range].
Diego, CA) using logistic regression analysis, t-test,
Mann–Whitney U-test, Kruskal–Wallis test, Chi-Squared
Hospital outcome
tests and Chi-Squared for trend as appropriate.
Alive Dead

Results n (% of total no. of patients) 894 (85.4) 153 (14.6)

Age; years (SD) 53.4 (20.1) 70.4 (14.4) p< 0.001
The outreach service database contained 1552 outreach Male; (%) 540 (60.4) 83 (54.2) NS
service episodes with 2933 Patient-At-Risk scores Receiving oxygen; (%) 479 (53.6) 120 (78.4) p< 0.001
between 17 August 2001 and 27 January 2003. We Stay before assessment; days 6 [3–12] 9 [4–21] p= 0.001
Hospital stay; days 21 [11–38] 20 [9–41] NS
excluded 350 episodes in patients who had previous Primary referral; (%) 172 (19.2) 73 (47.7) p< 0.001
outreach service assessments during the same hospital Outreach service outcome; n (%) p< 0.001
admission. A further 36 episodes were excluded where WARD 778 (87.0) 56 (36.6)
CRITICAL CARE 97 (10.9) 38 (24.8)
the patient was in a critical care area when first seen. THERAPY LIMIT 19 (2.1) 59 (38.6)
Scores, not the physiological values, were recorded in the
earliest days of our outreach service and so, after Outcome at the time of hospital discharge; Primary referral: ward
excluding patients with missing values, there were 1047 patient referred to the outreach service because of a trigger score or
general clinical concern. The other patients were routine follow-ups
episodes with complete data for analysis. after discharge from a critical care area; Outreach service outcome –
Table 2 contains details of the 1047 patients grouped WARD: remained on ward receiving ongoing care, CRITICAL CARE:
by outcome following completion of the outreach service patient transferred to a critical care area within the hospital, THERAPY
LIMIT: treatment limitation decision that critical care was not appro-
episode. Primary referrals accounted for 245 (23.4%) priate or death while under review by the outreach service; NS: not
patients with the others being follow-up assessments of statistically significant (p > 0.05). The percentage in row one is of the
patients who had been discharged from a critical care area. total number of patients (n = 1047). All other percentages are of the
number in each column.
The primary referrals were in hospital for a median of
4 days (interquartile range 2–11 days) before assessment.
A decision was made to admit 81 (33.1%) of the primary (Table 4). Table 4 also gives the incidence for each range
referrals to a critical care unit and a treatment limitation of the physiological values.
decision was made in a further 37 (15.1%). In the critical There was a highly statistically significant relationship
care discharge group, 54 (6.7%) were re-admitted to a between the number of physiological abnormalities,
critical care area while under outreach service surveillance defined as a Patient-At-Risk score of greater than
and treatment limitation decisions were made in a further 0, and hospital mortality (Chi-Squared for trend
41 (5.1%). Table 3 shows similar data grouped by hospital p < 0.0001) (Table 5).
outcome. Table 6 gives details of the outcome of the outreach
The physiological data have been presented as a range service episode and hospital outcome by Patient-At-Risk
of values associated with a range of hospital mortality score. When looking at the ability of the scores to

Table 2 Patient details stratified by

outcome at end of outreach episode. CRITICAL THERAPY
WARD CARE LIMIT
Values are number (proportion), mean
(standard deviation (SD)) or median
[interquartile range]. n (% of total no. of patients) 834 (79.7) 135 (12.9) 78 (7.4)
Age; years (SD) 53.6 (20.0) 61.1 (19.3) 72.4 (15.4) p< 0.001
Male; (%) 509 (61.0) 73 (54.1) 41 (52.6) NS
Receiving oxygen; (%) 421 (50.5) 111 (82.2) 67 (85.9) p< 0.001
Stay before assessment; days 6 [3–12] 5 [2–18] 8 [3–18] NS
Hospital stay; days 21 [11–38] 24 [11–47] 13 [6–29] p< 0.001
Primary referral; (%) 127 (15.2) 81 (60.0) 37 (47.4) p< 0.001
Hospital mortality; (%) 56 (6.7) 38 (28.1) 59 (75.6) p< 0.001

WARD: remained on ward receiving ongoing care. CRITICAL CARE: patient transferred to a critical
care area within the hospital. THERAPY LIMIT: treatment limitation decision that critical care was
not appropriate or death while under review by outreach service; Primary referral: ward patient
referred to the outreach service because of a trigger score or general clinical concern. The other
patients were routine follow-ups after discharge from a critical care area.
NS: not statistically significant (p > 0.05). The percentage in row one is of the total number of
patients (n = 1047). All other percentage are of the number in each column.

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Table 4 Hospital mortality associated with a range of physiological values. Mortality is observed hospital mortality expressed as a
percentage of the number in that particular group. Values are n (proportion).

Hospital mortality range

‡35% 25 – <35% 15 – <25% <15% 15 – <25% 25 – <35% ‡35%

Temperature; C <35.5 35.5–36.4 36.5–37.5 37.6–38.4 ‡38.5

n (%) 26 (2.5) 262 (25.0) 641 (61.2) 84 (8.0) 34 (3.2)
Mortality (%) 38 17 12 17 26
Heart rate; beats.min)1 <60 60–99 100–119 ‡120
n (%) 35 (3.3) 687 (65.6) 234 (22.3) 91 (8.7)
Mortality; % 23 12 16 31
Systolic blood pressure; mmHg <90 90–99 100–109 110–159 ‡160
n (%) 34 (3.2) 50 (4.8) 110 (10.5) 722 (69.0) 131 (12.5)
Mortality (%) 50 30 17 11 16
Respiratory Rate; breaths.min)1 <6 6–24 25–29 30–34 ‡35
n (%) 1 (0.1) 769 (73.7) 130 (12.5) 64 (6.1) 80 (7.7)
Mortality (%) 100 9 21 28 41
SpO2; % <85 85–89 90–94 ‡95
n (%) 24 (2.3) 37 (3.5) 146 (14.0) 837 (80.2)
Mortality (%) 46 35 17 12
Level of consciousness Alert Confused or Unresponsive
responds to
voice or responds
to pain
n (%) 724 (69.6) 288 (27.7) 28 (2.7)
Mortality (%) 9 25 50
Urine output; ml.kg)1.h)1 0 – <0.5 ‡0.5 or on dialysis*
n (%) 116 (12.4) 819 (87.6)
Mortality (%) 40 11

*Dialysis: normally dialysis dependent.

Table 5 Number of physiological abnormalities and associated hospital mortality. Values are number (proportion) or odds ratio (95%
confidence interval).

No. of physiological abnormalities

0 1 2 3 4 ‡5

Patients; (%) 176 (16.8) 261 (24.9) 262 (25.0) 196 (18.7) 98 (9.4) 54 (5.2)
Mortality (%) 4.0 4.6 10.7 23.0 33.7 51.9
Odds ratio 2.12 3.61 9.00 22.35 26.0
(1.08–4.18) (1.93–6.78) (4.64–17.45) (10.17–49.13) (10.31–65.60)

Physiological abnormality for each parameter was defined as the range associated with a Patient-At-Risk early warning score of more than zero
(Table 1).
Logistic regression explanatory variable = number of physiological abnormalities. Odds ratio compared to zero abnormalities; significance for one
abnormality p = 0.03, for other number of abnormalities p < 0.0001.
An increasing number of physiological abnormalities was associated with a higher hospital mortality (Chi-squared for trend, p < 0.0001).

discriminate between patients who needed intervention except temperature contributed to the model predicting
(CRITICAL CARE or THERAPY LIMIT combined) the need for intervention and all components except
from those who did not, the area under the receiver temperature and heart rate contributed to the model
operating characteristic (ROC) curve of the Patient-At- predicting hospital outcome.
Risk score was 0.822. Increasing Patient-At-Risk scores Selecting a suitable trigger score will determine the
were associated with increased intervention and hospital outreach service workload. There were 387 patients
mortality (Chi-Squared for trend p < 0.0001). Examin- with Patient-At-Risk scores of one or less, of whom 15
ing the Patient-At-Risk score, binary logistic regression (3.9%) died in hospital and interventions were made in 13
using backward conditional data entry at a value of (3.4%). There were 660 patients scoring two or more
p < 0.05 showed that all physiological components points, of whom 138 (20.9%) died in hospital and

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Table 6 Early warning (Patient-

At-Risk) score, intensive care outreach Patient-At-Risk score Outreach outcome (%) Hospital outcome (%)
outcome and hospital outcome. Values CRITICAL THERAPY
are percentage or n (%). Score n (%) WARD CARE LIMIT Alive Dead

0 176 (16.8) 98.3 1.7 0.0 96.0 4.0

1 211 (20.2) 95.3 4.7 0.0 96.2 3.8
2 173 (16.5) 88.4 7.5 4.0 88.4 11.6
3 142 (13.6) 81.7 14.1 4.2 90.8 9.2
4 112 (10.7) 68.8 23.2 8.0 83.0 17.0
5 78 (7.4) 61.5 20.5 17.9 76.9 23.1
6 55 (5.3) 65.5 20.0 14.5 72.7 27.3
7&8 57 (5.4) 42.1 29.8 28.1 47.4 52.6
‡9 43 (4.1) 14.0 44.2 41.9 46.5 53.5

Outreach outcome: WARD: remained on ward receiving ongoing care; CRITICAL CARE: patient
transferred to a critical care area within the hospital; THERAPY LIMIT: treatment limitation
decision that critical care was not appropriate or death while under review by outreach.
Hospital outcome: Alive: alive at discharge or transfer from hospital; Dead: died in hospital.

interventions were made in 200 (30.3%). If the threshold Our study included only those patients already selected
were to be increased to four or more points, 345 patients to receive outreach care. They are therefore likely to be
would be identified, of whom 105 (30.4%) died in among the sickest patients in the hospital. We were
hospital and interventions were made in 154 (44.6%). interested in the ability of the Patient-At-Risk score to
identify, from within this group, patients with poor
outcome. However, the Patient-At-Risk score is not used
Discussion
to predict outcome. In common with other physiolog-
Intensive care outreach services were introduced through- ically based early warning scores it is a screening tool
out much of the United Kingdom in the latter half of designed to alert clinical staff to a potential problem with
2000 and early 2001. The Audit Commission’s 1999 a patient. Our data confirm the strong association
report, ‘Critical to Success’, first used the term ‘outreach’ between abnormal physiology and decisions made. It is
in this context [13]. The ‘highest priority recommenda- interesting that a single array of measurements taken on
tions’ included agreeing ‘danger signs’ to help identify the wards when the patient is seen for the first time by the
patients at risk of deteriorating. Comprehensive Critical outreach service also provides valuable information about
Care [14], a Department of Health Report published in hospital outcome. Critical care scoring systems such as
2000, further developed the concept of outreach. APACHE II [19] predict outcome on the basis of
Professor Hillman and colleagues pioneered medical physiological abnormality measured in the ICU but there
emergency teams (METs) in Australia [15] with call-out is little information about the relationship between
criteria based upon deranged physiological values. The physiological abnormality and outcome in ward patients.
introduction of medical emergency teams has been The physiological variables in the Patient-At-Risk
shown to reduce cardiorespiratory arrests on the wards score are routinely measured on a ward. Our analysis
and decrease mortality [16, 17]. In our hospital we depends upon the range of values used to assign points in
piloted our outreach service in 1997 [18]. This showed the Patient-At-Risk score. Although these values are in
that there were large numbers of critically ill patients on broad agreement with other groups, our conclusions
the wards. When our outreach service was aware of the might have been different if other thresholds had been
seriously ill ward patients, cardiorespiratory arrests were selected. A review of the physiological data (Table 4)
prevented. suggests that gross abnormalities of all the physiological
Compared to hospital survivors, patients seen by our parameters are associated with adverse outcomes. More
outreach service who died in hospital were older and data are necessary to permit formal statistical analysis to
were more likely to be primary referrals than patients derive critical thresholds.
recently discharged from a critical care area. The high A single score has the benefit of being simple and
percentage of primary referrals who were admitted to a widely applicable. It is likely, however, that different
critical care area, died or had decisions made to limit groups of patients will influence the score in different
treatment, demonstrates that this group of patients was ways. For example, different triggers may be appropriate
appropriately selected for involvement with the outreach for medical or surgical patients, or for primary ward
service. referrals as opposed to patients stepping down to the

2005 Blackwell Publishing Ltd 551

D. R. Goldhill et al. Æ Physiologically-based early warning score
. ....................................................................................................................................................................................................................
wards from critical care areas. A logical next step would
be to introduce more physiological monitoring onto
hospital wards. An early warning score could be used to
trigger a graded response where lower scores mandate a
minimum frequency of monitoring. As scores increase,
the frequency of monitoring could increase and patients
could be placed in higher intensity care areas. At certain
thresholds a prompt medical response should be initiated
and standards could be laid down with respect to the time
to attend, and the seniority and expertise of personnel to
be contacted.
Our data are from a single institution in one health care
system. More information from a wider group of hospitals
is required to validate the conclusions. Compared to
other health care systems, the United Kingdom is short of
critical care facilities, which may, in part, be responsible
for the higher mortality among high-risk patients [20].
Because the outreach service only saw selected patients
we do not know what percentage of the hospital
population could potentially benefit from assessment
and intervention. A point prevalence study in our hospital
in 2002 found that 10.9% of the patients not on the ICU
had three or more physiological abnormalities and a 30-
day mortality of 21.3% [21]. A further 20.1% had two
abnormalities and a 9.2% 30-day mortality. If only those
patients with a Patient-At-Risk score of two or greater
are assessed, a high-risk group is identified in whom
decisions on critical care admission or treatment limita-
tion are made in about 30%. However, even the patients
who the outreach service concluded were well enough
to remain on the ward received outreach care. These
patients were assessed by the outreach service and
suggestions were often made regarding the most appro-
priate treatment interventions. Follow-up continued,
sometimes for several days, until it was felt that the
outreach service had nothing more to contribute directly.
This follow-up role may save lives, decrease the number
of critical care re-admissions and provide valuable con-
tinuity between the critical care units and the wards [22].
Changes in the delivery of healthcare and the training of
doctors [23] and nurses may have resulted in less ward
based knowledge and skills to be able to recognise, assess
and manage seriously ill patients. The outreach service
is also involved in educating ward staff to look after
seriously ill patients.
These findings are relevant to all staff involved in the
delivery of critical care. Patients are not concerned where
their care is delivered and the ICU does not exist in
isolation from the rest of the hospital. Evidence suggests
that there are considerable numbers of critically ill
patients on acute wards in the UK. Many are in hospital
for days before their eventual demise or admission to a
critical care area. Physiologically based early warning
552
Anaesthesia, 2005, 60, pages 547–553
scores are one way in which patients could be identified
and tracked. There is now some evidence to suggest that
early intervention may improve outcome. The imple-
mentation of a system to ensure regular, accurate
measurement and recording of physiological values at
the bedside should be possible. We would suggest that
this is an essential part of any hospital-wide system
involving high-risk patients.
References
1 Goldhill DR, Sumner A. Outcome of intensive care patients
in a group of British intensive care units. Critical Care
Medicine 1998; 26: 1337–45.
2 Goldhill DR, McNarry AF, Hadjianastassiou VG, Tekkis
PP. The longer patients are in hospital before Intensive Care
admission the higher their mortality. Intensive Care Medicine
2004; 30: 1908–13.
3 McQuillan P, Pilkington S, Allan A, et al. Confidential
inquiry into quality of care before admission to intensive
care. British Medical Journal 1998; 316: 1853–8.
4 McGloin H, Adam SK, Singer M. Unexpected deaths and
referrals to intensive care of patients on general wards. Are
some cases potentially avoidable? Journal of the Royal College
of Physicians of London 1999; 33: 255–9.
5 Vincent C, Neale G, Woloshynowych M. Adverse events in
British hospital: preliminary retrospective record review.
British Medical Journal 2001; 322: 517–9.
6 Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL.
Clinical antecedents to in-hospital cardiopulmonary arrest.
Chest 1990; 98: 1388–92.
7 Sax FL, Charlson ME. Medical patients at high risk for
catastrophic deterioration. Critical Care Medicine 1987; 15:
510–5.
8 Franklin C, Mathew J. Developing strategies to prevent
inhospital cardiac arrest: analyzing responses of physicians
and nurses in the hours before the event. Critical Care
Medicine 1994; 22: 244–7.
9 George AL Jr, Folk BP 3rd, Crecelius PL Campbell WB.
Pre-arrest morbidity and other correlates of survival after
in-hospital cardiopulmonary arrest. American Journal of
Medicine 1989; 87: 28–34.
10 Buist MD Jarmolowski E Burton PR, et al. Recognising
clinical instability in hospital patients before cardiac arrest or
unplanned admission to intensive care. A pilot study in a
tertiary-care hospital. Medical Journal of Australia 1999; 171:
22–5.
11 Goldhill DR. The critically ill: following your MEWS.
Quarterly Journal of Medicine 2001; 94: 507–10.
12 Anonymous. The National Outreach Report 2003. London:
DH and Modernisation Agency, 2003.
13 Audit Commission. Critical to Success. London: Audit
Commission, 1999.
14 Department of Health. Comprehensive Critical Care. A Review
of Adult Critical Care Services. London: Department of Health,
2000.

2005 Blackwell Publishing Ltd
Anaesthesia, 2005, 60, pages 547–553
. ....................................................................................................................................................................................................................
15 Lee A, Bishop G, Hillman KM, Daffurn K. The Medical
Emergency Team. Anaesthesia and Intensive Care 1995; 23:
183–6.
16 Buist MD, Moore GE, Bernard SA, et al. Effects of a
medical emergency team on reduction of incidence of and
mortality from unexpected cardiac arrests in hospital: pre-
liminary study. British Medical Journal 2002; 324: 387–90.
17 Bellomo R, Goldsmith D, Uchino S, et al. A prospective
before-and-after trial of a medical emergency team. Medical
Journal of Australia 2003; 179: 283–7.
18 Goldhill DR, Worthington L, Mulcahy A, Tarling M,
Sumner A. The patient-at-risk team: identifying and
managing seriously ill ward patients. Anaesthesia 1999; 54:
853–60.
19 Knaus WA, Draper EA, Wagner DP, Zimmerman JE.
APACHE II: a severity of disease classification system.
Critical Care Medicine 1985; 13: 818–29.

2005 Blackwell Publishing Ltd
D. R. Goldhill et al. Æ Physiologically-based early warning score
20 Bennett-Guerrero E, Hyam JA, Shaefi S, et al. Comparison
of P-POSSUM risk-adjusted mortality rates after surgery
between patients in the USA and the UK. British Journal of
Surgery 2003; 90: 1593–8.
21 Goldhill DR, McNarry AF. Physiological abnormalities
in early warning scores are related to mortality in adult
inpatients. British Journal of Anaesthesia 2004; 92: 882–4.
22 Ball C, Kirkby M, Williams S. Effect of the critical
care outreach team on patient survival to discharge from
hospital and readmission to critical care: non-randomised
population based study. British Medical Journal 2003; 327:
1014–7.
23 Smith GB, Poplett N. Knowledge of aspects of acute
care in trainee doctors. Postgraduate Medical Journal 2002; 78:
335–8.
553