Analysis

What is the National Early Warning Score (NEWS2) and why is it important?

NEWS2 has created a common language so nurses can act quickly to help deteriorating patients – but clinical judgement is still vital

NEWS2 has created a common language so nurses can act quickly to help deteriorating patients but clinical judgement is still vital

Rapid treatment saves lives but efficient systems help too, and the National Early Warning Score (NEWS) is now well established as a way to help detect life-threatening deterioration in patients.

NEWS was first produced by the Royal College of Physicians (RCP) in 2012, with an updated version, NEWS2 , published five years later.

This was not the first early warning scoring system to be used in the NHS, but before its adoption there was no standardised approach.

2012

NEWS was first launched by the Royal College of Physicians

...

NEWS2 has created a common language so nurses can act quickly to help deteriorating patients – but clinical judgement is still vital

Picture: iStock

Rapid treatment saves lives but efficient systems help too, and the National Early Warning Score (NEWS) is now well established as a way to help detect life-threatening deterioration in patients.

NEWS was first produced by the Royal College of Physicians (RCP) in 2012, with an updated version, NEWS2, published five years later.

This was not the first early warning scoring system to be used in the NHS, but before its adoption there was no standardised approach.

2012

NEWS was first launched by the Royal College of Physicians

‘The difficulty was that each trust used a slightly different scoring system,’ says British Association of Critical Care Nurses chair Nicki Credland.

‘The escalation of patients was different depending on where you worked, which was particularly difficult for doctors who tend to rotate between trusts.’

As the original NEWS document put it, staff in one hospital ‘were not necessarily speaking the same language’ as those in a neighbouring organisation.

The result was lack of consistency in the detection of, and response to, acute illness. The remit of the working group that drew up NEWS was to establish a single ‘track and trigger’ approach that could be used throughout the NHS.

‘The whole point of developing a national score was that it took away that element of differentiation and made it more national and across the board,’ Ms Credland says.

What are the six elements of the NEWS2 tool?

NEWS2 uses six physiological parameters to identify acutely ill patients:

  • Respiration rate.
  • Oxygen saturation.
  • Systolic blood pressure.
  • Pulse rate.
  • Level of consciousness or new-onset confusion.
  • Temperature.

A score is allocated to each parameter and recorded on a standardised chart, with the scores reflecting how far the patient is deviating from the norm. Aggregate scores determine the required urgency of the clinical response.

NEWS2 is not a replacement for clinicians’ experience and skill

The system effectively has two arms, Ms Credland says – monitoring and escalation – and nursing staff play an important role in both.

‘Nurses will often be the ones who are doing the scores. Then they will decide whether they need to escalate to someone else – the nurse in charge of the ward, a doctor or a critical care outreach team.

John Dean: ‘NEWS2 is only part of any clinical assessment’

‘And nurses will also be involved on the other side too. Critical care outreach, for example, is often made up of critical care nurses, so it will be nurses who respond to the call for help.’

The RCP has always been clear that NEWS2 is an aid to assessment and not a substitute for a clinician’s experience and skill in detecting deterioration.

‘NEWS2 should always be used as part of clinical judgement and not on its own,’ says RCP clinical director for quality improvement and patient safety John Dean.

‘It measures what it measures and is only part of any clinical assessment.’

Why clinical judgement is a crucial part of using NEWS2

NEWS is an adjunct to clinical decision-making, says the NEWS2 guidance. It is ‘not a barrier or alternative to skilled clinical judgement’.

The guidance says there will be circumstances when a healthcare professional judges that the warning score underestimates their concern for the patient’s clinical condition. In these cases, care must be escalated to a more senior clinical decision-maker.

In circumstances in which the healthcare professional feels that the score may be overestimating the severity of a patient’s clinical condition, they should also escalate decision-making to a more senior decision-maker in the clinical team to determine whether escalation of care is warranted or not.

As NEWS2 clearly states: ‘Any concern about a patient’s clinical condition should prompt an urgent clinical review, irrespective of the NEWS.’

So what might that mean in practice?

In March 2020, the RCP published additional guidance designed to address clinicians’ questions that had arisen since the introduction of NEWS2.

The guidance offered further explanation of NEWS2 parameters and included more detail on the action to be taken if a patient’s NEWS2 score rises.

My patient has a high NEWS2 score – what are my next steps?

A NEWS2 score of 7 or above that is new for the patient indicates that:

  • The patient should be monitored every 30 minutes initially.
  • The registered practitioner must urgently inform a clinician who is competent in the assessment of acutely ill patients.
  • Assessment is expected within 30 minutes.
  • If there is no improvement, a review by a senior clinician is expected within 60 minutes.
  • Moving the patient to an environment with monitoring facilities should be considered.

Source: NEWS2 additional guidance

Evidence behind the use of NEWS2

NEWS2 is endorsed by NHS England and NHS Improvement in all trusts. In Scotland, as part of its ‘deteriorating patient’ workstream, the Scottish Patient Safety Programme uses NEWS2 for the early recognition of acute physiological deterioration of adult patients. In Wales, NEWS2 has been rolled out in all acute hospitals as part of the Rapid Response to Acute Illness Learning Set programme. In Northern Ireland, the Health and Social Care safety forum of the Public Health Agency has recommended the adoption of NEWS2.

Dr Dean says it is used as a track and trigger tool in 94% of hospitals in England as well as in ambulance services. Increasingly, it is being used to help identify deterioration in patients in community settings.

‘It is also widely used internationally, in about 30 countries,’ he adds.

But is there evidence that it works?

Yes, says Ms Credland, who is well placed to judge as she is completing a doctorate on the subject.

‘We know, for example, that it prevents admissions to intensive care and readmissions for patients who have been transferred back to the ward.

‘It reduces cardiac arrest rates and complications after surgery because staff will be quicker to pick up that a patient is deteriorating clinically.

Six

Number of physiological parameters to identify acutely ill patients in NEWS2

‘They will put in place interventions to prevent that deterioration getting to the point where either the patient needs escalation to intensive care or they have a cardiac arrest.’

Dr Dean adds: ‘The main measure of success is reductions in cardiac arrest calls, which have reduced by more than 50% in many studies.’

Beyond the UK, similar outcome measures are found wherever early warning scores are used, Ms Credland says.

Limitations of NEWS2 include inconsistent monitoring

However, an article published in Nursing Standard in 2020 highlighted limitations associated with systems such as NEWS2, among them the risk of overlooking parameters that are not scored, such as urine output.

‘Neglecting to monitor and interpret urine output may delay the diagnosis of acute kidney injury,’ wrote nursing lecturer Zoe Butler.

Also, systems are dependent on the people who operate them and, to an extent, the efficiency and working practices of the wider organisation.

NEWS2, on its own, is therefore no guarantee that a patient at risk of becoming seriously ill will be identified and the correct response initiated.

Ms Credland says systematic review has identified three areas where NEWS2 scores can fail to trigger appropriate action.

The first is calculation – adding up the scores incorrectly, for example, or missing out one of the six NEWS2 parameters.

But why might a nurse or doctor fail to allocate a score to each of the vital signs? ‘Lots of reasons,’ Ms Credland says. ‘It might be a simple mistake. Or because it’s the middle of the night and they didn’t want to wake the patient to record their blood pressure, for example.’

‘It’s not just about having a sheet of paper to fill in. It’s about making sure you understand what a clinically deteriorating patient looks like and how important it is to try and do something about that quickly’

Nicki Credland, chair, British Association of Critical Care Nurses

The second potential point of failure is frequency of monitoring.

‘If the score says you should be doing observations every half hour but your staffing levels on the day are such that you don’t have the staff to do that, then this will affect your ability to comply with the score,’ Ms Credland explains.

NEWS2 requires an effective clinical response

During the COVID-19 pandemic, could the effectiveness of NEWS2 have been diminished by the sheer volume of rapidly deteriorating patients, coupled with the extreme pressure on a depleted workforce?

‘Absolutely,’ Ms Credland says. ‘There’s a definite link between safe staffing levels and the completion of early warning scores. COVID-19 will only have exacerbated something that was there already.’

The final area where NEWS2 might fail is in the clinical response.

A high NEWS2 score means the patient must be referred to someone skilled in critical care assessment.

‘But that relies on human decision-making to a degree,’ Ms Credland says. ‘It relies on the individual who has taken those observations picking up the phone and referring.’

Nicki Credland: ‘There’s a definite link between safe staffing levels and the completion of early warning scores’

For example, if a 20-year-old man is sitting up and talking and does not appear seriously ill, but has an early warning score of 7, the clinician might assume he is not as sick as his observations would suggest and therefore not refer him.

Or a newly qualified nurse may not feel especially confident about escalating the patient to a registrar or consultant, which is where multidisciplinary teamwork and good communication come into play.

Equally, if a patient is referred to a critical care specialist, the system depends on that clinician then going to see and assess the patient.

‘I used to be a critical care outreach sister and I was the only one on call for the entire hospital for a 12-hour day,’ Ms Credland says.

‘If you’ve got five or six referrals that come in at the same time, you have to triage the ones you think are most important, based on the information you’ve got.

‘It goes back to making sure we put measures in place to ensure staff can use early warning scoring systems in the best way possible.’

Some of that comes down to education. ‘Nurses and medics need to be educated in recognising and responding to clinically deteriorating patients,’ Ms Credland argues.

‘It’s not just about having a sheet of paper to fill in. It’s about making sure they understand what a clinically deteriorating patient looks like and how important it is to try and do something about that quickly.’

Improved NEWS2 training and a common language for all settings

The RCP’s Dr Dean agrees that triggering escalation and the response that follows can be variable, but adds: ‘That’s down to its implementation rather than the tool.

‘In COVID-19 it has been shown to be the most accurate assessment of severity of illness.’

The RCP is continuing to explore how best to deliver training for clinicians in identifying and responding to patients at risk of deterioration. A NEWS2 e-learning tool is available via the RCP website. Use of the resource is free for NHS employees and costs £5 for others.

As for the future of NEWS2, Dr Dean says it is under continual review in terms of its impact and implementation.

‘Current developments include wider use by community care and by patients themselves, and more standardised responses to a trigger to escalate assessment.’

2017

NEWS2, the updated version of the early warning score, was introduced

In the meantime, NEW2 continues to promote a ‘common language’ across the multitude of settings in which acutely ill patients are cared for.

In a foreword to the 2017 NEWS2 guidance, Sir Bruce Keogh, who at the time was national medical director for NHS England, said universal means of communication can reduce the chance of failure.

He drew parallels between healthcare and air traffic control systems that use shared standards and language throughout the world to prevent disasters.

‘Imagine what would happen if each airport pursued their own way of working,’ he wrote. ‘The NHS should be no different.’

NEWSflash: an early warning score for nursing homes

A nurse consultant has helped develop an early warning scoring system based on NEWS2 for use in nursing and residential homes.

Suzie Southey, based at Saxmundham Health, a GP practice in Suffolk, works closely with staff in homes to monitor long-term conditions and identify early signs of deterioration.

But identifying those signs was often based on a subjective assessment and could be problematic. Working with a software designer, the team at the surgery developed an online method of relaying residents’ observations to practice staff, allowing any concerning signs to be assessed and, if necessary, investigated.

Called NEWSflash, the system is a stripped-back version of NEWS2 and measures just three parameters: respiratory rate, oxygen saturation and temperature.

Implementing NEWS2 in care homes would have been too time-consuming for care assistants, Ms Southey says. ‘Also, the parameters in older people are skewed anyway, so they’re already scoring higher and the subtle changes may be missed.’

Further information


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