NEWS is a well validated track-and-trigger early warning score system that is used to identify and respond to patients at risk of deteriorating. It is based on a simple scoring system in which a score is allocated to physiological measurements already undertaken when patients present to, or are being monitored in health care settings. The following six simple physiological parameters are included in the scoring system:
- Respiratory rate
- Oxygen saturations
- Systolic blood pressure
- Pulse rate
- Level of consciousness
A score is allocated to each physiological parameter, the magnitude of the score reflecting how extreme the parameter varies from the norm. This score is then aggregated, and uplifted for people requiring oxygen.
An elevated NEWS score does not provide a diagnosis; it helps identify a sick patient who requires urgent clinical review in a standardised way.
The Royal College of Physicians (RCP) recommend that sepsis should be considered in any patient with a NEWS2 score of 5 or more – ‘think sepsis’. However NEWS2 should be used alongside clinical judgement as a high score for some individuals, i.e. those at the end of their life may need to be interpreted differently.
NEWS was founded on the premise that (i) early detection, (ii) timeliness and (iii) competency of the clinical response comprise a triad of determinants of clinical outcome in people with acute illness.
To ensure NHS staff moving between health care settings use a consistent set of measures to diagnose patients and communicate about deteriorating patients in a common language.
To ensure communication about deteriorating patients between professionals across healthcare settings is consistent.
NEWS can help to spot the signs of sepsis early and can save thousands of lives.
Following evaluation of NEWS, the scoring chart has been updated (to NEWS2) as follows:
- the recording of physiological parameters has been reordered to align with the Resuscitation Council (UK) A,B,C,D,E sequence
- the ranges for the boundaries of each parameter score are now shown on the chart
- the chart has a dedicated section (SpO2 Scale 2) for use in patients with hypercapnic respiratory failure (usually due to COPD) who have clinically recommended oxygen saturation of 88–92%
- the section of the chart for recording the rate of (L/min) and method/device for supplemental oxygen delivery has been improved
NEWS2 has now received formal endorsement from NHS England and NHS Improvement to become the early warning system for identifying acutely ill patients.
The recent patient safety alert effectively mandates NEWS2 in all acute and ambulance settings.
A recent patient safety alert was cascaded to all acute hospital trusts caring for adult patients, mandating them to transition to NEWS2 by March 2019. Although, to qualify for the sepsis CQUIN payment, trusts must be using NEWS2 by January 2019.
A recent patient safety alert was cascaded to all ambulance trusts caring for adult patients, mandating them to transition to NEWS2 by March 2019.
NEWS2 should be used for all pre-hospital patients who are ill or at risk of deteriorating, including those suspected of having sepsis. NEWS2 should be considered as part of the wider assessment and should support colleagues to identify deterioration early and prioritise resources in times of surge.
From September 2018 a new national clinical quality indictor will be rolled out for ambulance services in England on suspected sepsis. The inclusion criteria for the indictor will require a NEWS2 score of 7 or above.
Acute mental health settings
The use of NEWS2 is encouraged to assess physical deterioration of adults in acute mental health facilities. It could also be used for communication and handover when patients are transferred to and from acute hospitals.
Community and primary care settings
NHS England is working alongside partners to collate robust evidence on the use of NEWS2 in community and primary care.
Clinical judgement should always be used, even if the NEWS2 score is normal. Healthcare professionals should escalate deteriorating patients for review whenever they are concerned, even if the NEWS2 appears to be reassuring.
In addition, the recommended frequency of observations and review/escalation should be increased if there is clinical concern that the patient appears to be more unwell than the recorded NEWS2 score.
Although accurate recording of the NEWS2 is important, reliable response and escalation is equally important. This should be the same whether paper or electronic systems are used.
The frequency of observations and review/escalation is based upon the aggregate NEWS2 (as outlined in the RCP guidance); however, this should be increased/ escalated if there is concern (or ‘gut feel’) that the patient is sicker than they appear.
NEWS2 should not be used as the sole criterion for prioritisation of patients being admitted to hospital via ambulance services.
NEWS2 should not be used in children (under 16 years), or pregnant women.
NEWS2 should not be modified from the guidance published by the RCP, to reduce variation in identification and response to deteriorating patients in England.
A service will be deemed to be NEWS2 compliant if all healthcare professionals within the organisation are using the NEWS2 scoring system as part of recording vital signs and escalation processes.
Full details on NEWS2 and links to NEWS2 training resources and charts containing the recommended clinical thresholds and materials are available on the RCP website.
The goal of the CQUIN ‘Reducing the impact of serious infections (Antimicrobial Resistance and Sepsis)’ is to reduce the impact of serious infections. It aims to support timely identification and treatment for sepsis and a reduction of clinically inappropriate antibiotic prescription and consumption. The CQUIN will help to encourage adoption of NEWS2 in acute trusts. During 18/19, acute and emergency units should be transitioning to use the National Early Warning Score (NEWS 2) to support screening of patients. By Q4 of 2018/19, payment will only be made if over 90% of screened cases have utilised NEWS 2 (where it is appropriate to use NEWS 2).
The overall deadline for acute and ambulance trusts to transition to NEWS2 is March 2019, however the CQUIN is part of the way we are encouraging providers to make the switch – so if they are using NEWS2 sooner (i.e. by Q4 of 2018/19), they will be financially rewarded.
NEWS2 observations cannot be done for a patient that refuses. If patients with mental health or learning disabilities refuse certain more invasive observations, then those that can be calculated should be recorded and communicated.
Observations should be recorded by staff that are trained and competent. Appropriate staff need to be taught to recognise deteriorating patients; how to calculate and track a NEWS2 and about appropriate escalation.
There is currently no single Paediatric Early Warning Score (PEWS). A National PEWS board for England has been established, led by Royal College of Paediatric and Child Health and supported by NHS England and NHS Improvement to define a single PEWS.
No, although use of NEWS2 in the community is being encouraged as it can be an additional tool for professionals to use in support of clinical decision making.
NEWS2 has been validated for all-cause patient deterioration.
Although there is currently limited evidence for the predictive value of NEWS2 in the community or a primary care setting, it provides an objective assessment of a patient’s physiological state and adds to clinical judgement. For example, it may be useful to measure baseline NEWS2 in frail patients in order to detect a change against this baseline.
NHS England is working with partners across the system to gather more robust evidence on the use of NEWS2 in a community setting, including case studies of best practice.
The use of NEWS2 is encouraged (as an adjunct to clinical assessment but not a replacement) to support the assessment of physical deterioration of adults in community and primary care settings. Professionals can use NEWS2 to communicate vital signs data in a common language. The thresholds provide a guide to the severity of the illness.
The earlier a complete set of observations is done (e.g. in the patient’s home or GP surgery), the sooner a patient can be placed on a track and trigger score; and improvement or deterioration against this baseline can be detected.
A number of general practices (West of England; Liverpool and Wessex) have found the use of NEWS and NEWS2 to be helpful as an adjunct to decision making; as a prompt to do a complete set of observations and when communicating with the rest of the healthcare pathway about deteriorating patients. This enables colleagues in other settings (e.g. ambulances, emergency departments, acute medical units) to plan, prioritise and place patients safely and appropriately.
It is particularly important to document and hand over complete physiological observations when discussing or transferring potentially unwell patients across healthcare settings and between shifts. Community organisations that have adopted this have found that NEWS2 improves the reliability of this process.
NEWS2 can facilitate communication at the interfaces of care such as when requesting ambulance transfer or hospital assessment.
Without communicating full physiological observations (that ambulance call handlers and hospital colleagues can use to calculate the NEWS2 from), colleagues find it extremely difficult to ascertain who the most sick and most in need are, particularly when the system is extremely busy.
NEWS2 should be considered as part of the wider assessment and could support colleagues to identify deterioration early and prioritise resources in times of surge.
NEWS2 can empower staff to be listened to if they have concerns about a patient.
For people in care homes, knowing their baseline NEWS2 score may help a doctor who has to assess them acutely to determine whether they are worse than baseline or not (especially if this is not their usual doctor).
A NEWS2 assessment might also help healthcare professionals decide that a patient doesn’t need an emergency referral, and if the person re-presents a few hours or days later, the healthcare professional seeing the patient for the second visit can use the measurement alongside their clinical judgment to see if the score has changed since the person was last assessed.
There is a delicate balance between infection treatment (which requires administering antibiotics) and antimicrobial resistance (The process of becoming resistant to antibiotics due to over prescription / inappropriate usage of antibiotics).
NEWS2 excels at identifying those who are deteriorating due to serious infections such as sepsis, and enhances the timeliness of the identification.
NEWS2 should always be utilised in conjunction with clinical judgement. Using NEWS2 in isolation could lead to patients at risk of negative outcomes, e.g. chest pain with low NEWS2, being overlooked.
Some people may think that NEWS2 assessment could result in GPs taking more time to measure and record unnecessary observations, however if the score is used alongside clinical judgment it should increase the chances that an acutely unwell person gets seen faster and receives urgent treatment much sooner.
A full set of observations takes 2 minutes and it should not be undertaken in every single patient, but only where there is worry or concern that the patient may be unwell and when referral onwards may be required.
There is evidence from the West of England, where a whole system approach is taken to use National Early Warning Scores – NEWS and NEWS2 to standardise communication and improve recognition across all points of the healthcare system.
Urgent Care 24, who deliver a range of urgent and primary care services across Merseyside, are also supporting teams in primary care, care homes, pharmacy and acute care environments to develop skills and knowledge to work together to achieve significant reductions in death from sepsis and to improve all aspects of the patient’s journey. This includes calculating NEWS2 for each patient to promote accurate clinical assessments of all patients being considered for transfer and has led to a large increase in the reliability of recording and handing over a full set of physiological observations.