Adapting the NEWS early warning tool to assess patients in the community
Creating baseline measurements in the patient’s own home ‘makes perfect sense’
Creating baseline measurements in the patient’s own home ‘makes perfect sense’
With increasing numbers of acutely unwell patients being cared for at home, accurate assessment of whether someone is improving or deteriorating is critically important.
‘Safety is paramount in the management of any patient, but especially so when the person is acutely ill,’ says community matron and emergency nurse practitioner Pauline Angell, who works in rapid response, part of the urgent care division at North Somerset Community Partnership (NSCP).
A baseline measurement for handover
Back in 2011 – a year before the Royal College of Physicians (RCP) introduced its now widely used National Early Warning Score (NEWS) system – staff at the partnership had begun to devise their own early warning system, using it in their community hospital in Clevedon. ‘We were ahead of the curve,’ says Ms Angell.
She subsequently became part of a collaboration with Bristol Community Health and the West of England Academic Health Science Network to implement NEWS in the community.
‘Every patient who is ill starts their journey at home, so it makes perfect sense to begin to monitor from here,’ she says. ‘An objective marker such as NEWS gives a baseline measurement when you’re handing over to colleagues.’
What is NEWS?
NEWS – the National Early Warning Score – is a system created in 2012 to identify acutely ill patients who are at risk of clinical deterioration or death and prompt a timelier clinical response.
NEWS2 was a 2017 update designed to identify sepsis, alternative oxygen targets for people with underlying lung disease, and the onset of delirium.
Although NEWS was originally developed for use mainly in acute care, it is being used increasingly in the community. It advocates a simple aggregate scoring system to standardise the assessment and response to acute illness.
Six physiological parameters, already routinely measured in hospitals and pre-hospital care, are recorded on a standardised chart. These are:
- Respiration rate
- Oxygen saturation
- Systolic blood pressure
- Pulse rate
- Level of consciousness or new confusion
A score is allocated to each parameter as they are measured, with the magnitude of the score reflecting the extent to which the parameter varies from the norm. The score is then aggregated and uplifted by two points for people needing supplemental oxygen to maintain their recommended oxygen saturation.
In addition to recording physiological observations, the RCP also recommends the following interventions for monitoring any deterioration:
- Physiological observations should be recorded and acted on by staff who have been trained to undertake these procedures, and understand their clinical relevance
- Physiological track and trigger systems should be used
- There should be a graded response strategy
- An escalation protocol should be in place
- A communication tool should be used
Tracks improvement and deterioration
As one of three patient-facing matrons, Ms Angell acts as a case manager, visiting those patients who are very unwell and have more complex needs. Referrals to the rapid response service may come from the patient themselves (by activating their personal emergency alarm), hospital staff or other healthcare professionals, including GPs and paramedics.
At the outset, healthcare professionals carry out a holistic assessment, including any diagnostics such as taking blood, urine or sputum samples, and sepsis screening. A complete set of observations is recorded, creating the patient’s first early warning score, and this is repeated at every visit, tracking any improvement or deterioration.
‘An older person with sepsis can sometimes appear on the surface to be fine, but when you take their measurements you can see how ill they really are’
Pauline Angell, community matron, North Somerset Community Partnership
‘We can see from their score whether or not we’re getting on top of things – and if we’re not, that’s the time they may need to be transferred to hospital,’ says Ms Angell. ‘Using this system, you can maintain safety, which will have better outcomes for patients.’
She admits that before they began to use NEWS, it was more difficult to identify patients who were beginning to decline. ‘Depending on the experience of the nurse, an advanced practitioner may well have spotted it, but it’s also relying on the same person seeing the patient every day,’ she says.
The early warning system has proved particularly helpful with patients who show less obvious signs of illness. ‘For example, an older person with sepsis can sometimes appear on the surface to be fine,’ says Ms Angell. ‘But when you take their measurements you can see how ill they really are. It’s really shown its worth to assist with decision-making.’
How to spot deterioration
- Use an objective measurement, such as NEWS (National Early Warning Score), advises Ms Angell. ‘It helps tremendously,’ she says. ‘It will give you a really good idea of whether your patient is improving or deteriorating. It should go hand in hand with your clinical assessment skills’
- If scores are high, ask yourself why, says Karen Field, clinical service lead for urgent care and community nursing services for Bristol Community Care. ‘For example, if someone’s temperature is high, it may simply be that the room is too hot,’ she says
- Be vigilant about sepsis. ‘NEWS has really helped, especially when sepsis hasn’t been that obvious,’ says Briony Hawkins, advanced clinical practitioner at Bristol Community Health. The Sepsis Trust advises that a NEWS of 5 or more should always prompt screening, including immediate checks for red flags
- Listen carefully to your patient and what their family thinks, advises Ms Field. ‘Especially if someone is saying, "my mum isn’t usually like this",’ she says. ‘Use your eyes and ears and look at how the patient is presenting’
Ms Angell says challenges have included making sure that every staff member has the right equipment to be able to carry out all the necessary observations. ‘For instance, everyone had to have three sizes of cuff to ensure blood pressure measurements are accurate,’ says Ms Angell.
Initially, nurses and healthcare assistants were trained, with physio and occupational therapists following suit in the past couple of years.
‘It’s all about making every contact count,’ says Ms Angell. ‘If therapists are seeing a patient at home, they take a set of observations, escalating if needed. To start with there was some apprehension, but now it’s very well embraced and works extremely well.’
'As time goes on there will be more and more we can do in the community – and that has to be a good thing'
Enabling health professionals to communicate with each other is key to the system's success, she believes. ‘It works because it’s a common language between the community, acute trusts and the ambulance service. GPs are using it now too,’ says Ms Angell. ‘We have a measurement and everyone knows what we’re talking about.’
It also supports North Somerset Community Partnership’s ethos of ‘your own bed is the best bed’. ‘The drive is very much to keep people out of hospital, when it’s safe, sending them in for shorter periods of time, knowing we can monitor them at home,’ says Ms Angell. ‘If we can keep a patient at home safely, it’s so much better for them. We know that when they go into hospital, often they don’t move around, so they can lose muscle mass very quickly and they never regain it. As time goes on there will be more and more we can do in the community – and that has to be a good thing.’
For hospital nurses, worries about a patient are usually escalated to medical staff, but in the community, it can be a different story.
‘You don’t have that immediate doctor to hand,’ says advanced clinical practitioner Briony Hawkins, who works for Bristol Community Health. Her role is to support more junior staff who have concerns about their patient and are unsure what to do next. ‘And we have to be cautious because we don’t have the resources they have in an acute trust, where staff are on hand 24 hours a day,’ she says.
Clinical judgement plays a role
In practice, if nursing staff record a NEWS (National Early Warning Score) of 3 or more, they contact Ms Hawkins’ team for immediate guidance. ‘We may already know the patient well, so we’ll use our clinical judgement,’ she says.
Their advice is also based on checking the person’s medical history, their medications and any previous observations to assess what is normal for them. For example, if someone has a long-term condition, such as chronic obstructive pulmonary disease (COPD), their scores may be constantly elevated. It may also be that they’ve been prescribed medication, but it hasn’t had enough time to work.
‘We then try to guide the staff to keep the patient safe, escalating as appropriate,’ explains Ms Hawkins. This may include visiting the patient to carry out a clinical review, more regular monitoring, or referring to other services such as those for long-term conditions or the patient’s GP.
Ms Hawkins’ role includes teaching NEWS to all nursing bands. ‘It’s very much about coaching and upskilling staff to manage the different situations they may come across,’ she says. ‘Our nurses go out and visit a whole range of patients and they never know quite what they’re going to walk into. On paper, it might look like a routine visit, but when they get there the patient is very unwell with a chest infection, or something else we weren’t expecting.’
Support in making decisions
If a patient is very unwell, the advice can be to call an ambulance, staying with them until they’re admitted. ‘The NEWS will support your thought process in making that decision,’ says Ms Hawkins. Showing a patient their score can even persuade those who are reluctant to be admitted. ‘No one wants to go into hospital, but if they can see on a chart that they’re very poorly, it helps,’ she says. In contrast, it can reinforce a clinician’s judgement to keep someone at home. ‘I’d say it’s helped me avoid hospital admission as much as transfer people there,’ she says.
However, someone’s early warning score is only part of the equation. ‘It’s not just about the tool,’ she says. ‘It helps us to assess risk, but you need an overall concept of the patient and what’s happening with them.’
The importance of a standardised system
While Bristol Community Care was among the first community organisations to use an early warning system, it wasn’t a standardised form used by everyone, and there was no specific training. ‘When you handed over after seeing a patient, it wasn’t talked about,’ recalls Karen Field, clinical service lead for urgent care and community nursing services. ‘It wasn’t robust or used in the way it’s used now.’
Working in collaboration with North Somerset Community Partnership, the organisation introduced a new early warning system based on NEWS, but incorporating its own escalation system. At the same time, it introduced a day-long training programme for registered staff, later adding a half-day’s programme for non-registered colleagues. This training has now been extended throughout the organisation, to include community nursing staff, reaching hundreds of healthcare professionals.
Original audit of the previous system, carried out in 2011, showed that only 70% of staff had recorded patients’ respiratory rates, with 77% recording temperature. After the project began, rates increased to 100% in July 2013, with monthly audits carried out by 'champions'. ‘When someone starts to use something new, it may not always be filled in correctly,’ says Ms Field. ‘It took a lot of work to get staff using the form properly, recognise the poorly patient and escalate to someone.’
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There are also clear challenges in using a system in the community that was originally devised for acute settings, particularly for chronically ill patients who are on long-term oxygen. While this automatically generates a score of 2, patients are not necessarily unwell, explains Ms Field. ‘We did think about not scoring it, but in the end felt we needed to keep it standard,’ she says. ‘Now we talk more about baseline for these patients, looking at their previous observations.’
Initially she admits, there were ups and down. ‘It’s the same with any change,’ says Ms Field. ‘It was about getting people on board, starting with those we were training, and our champions. What really helped was when staff came back to handover and we asked what the patient’s NEWS was. If they didn’t have it, they had to go back and carry out the observations. They soon got the idea it was a standard expectation and not something you could choose to do or not.’
Lynne Pearce is a health journalist