assessments. The unit's charge nurse may consider assigning
the patient a higher dependency bed status, which would
place the patient in a 1:2 patient assignment rather than the
typical 1:3, thereby making it more feasible for the patient's
nurse to increase assessments and monitoring of the patient
and implement the recommended modifications to the
treatment plan. If a patient scores a 5 or greater (color
code: red), the same steps are followed as described for color
code yellow (score 3–4) with the addition of notifying the
patient's attending physician of their patient's elevated CCHEWS
score. The patient's resident or nurse practitioner
must also examine the patient when they are notified of the
high C-CHEWS score. As a team the clinicians determine if
a CICU evaluation should be activated to assess for CICU
transfer. It is not uncommon for patient's C-CHEWS scores
to remain elevated while the treatment plan is initiated.
Should the score increase during the treatment phase, the
algorithm is activated again.