These slides are to explain why the Trust is adopting the National Early Warning Score which is being adopted across all sectors of health care in the UK and beyond. 1
The first EWS was devised in 1997 by Morgan et al. Since then over 100 different systems have been developed and used in the UK. The Royal College of Physicians, Royal College of Nursing and the National Outreach Forum collaborated to produce one National system the National Early Warning Score (NEWS). Originally designed for use in acute trusts, there is an increasing drive to promote the use of NEWS (along with SBAR) as part of the language to describe a patient s condition, so that it is used in all discussions about patients, and particularly in handover and transfer. A key driver for the development of NEWS was NICE Clinical guideline 50 produced in 2007 which made (amongst other things) recommendations about what an EWS should look like. 2
NEWS combines two different types of scoring system. It is a single parameter scoring system that means that one physiological observation may be enough to prompt for an escalation review. It is also a multi-parameter or aggregate scoring system where minor changes in several physiological parameters can trip the need for an escalation review. NEWS is a way of coding information derived from vital signs so that an assessment of the clinical risk for a patient based on observations can be made. That risk assessment allows coding into low medium and high. Because it provides a convenient description of a patient it is useful in informing communication about patients. It also steers communication towards the right questions being asked. For example a doctor who is referred a patient with a high NEWS score, is almost certainly going to seek more detailed information about which parameters are causing a score to be high. Knowing a NEW Score speeds up the transfer of necessary information when used with SBAR. NEWS includes the six physiological parameters listed and it also includes a score for a patient receiving supplemental oxygen. It is important to note that the two most important physiological parameters to indicate deterioration are respiratory function and neurology. Respiratory function has three elements that contribute to NEWS (respiratory rate, oxygen saturation and whether the patient is receiving oxygen). 3
Neurological assessment uses AVPU but it is weighted so that if a patient is anything but A (alert) they should have an escalation review. 3
NEWS was originally produced based on physiological evidence from thousands of observations. The idea of the score is that the higher the number the sicker the patient. There is a complication where patients have different oxygen target saturation ranges to comply with recommendations about safe oxygen use promoted by the British Thoracic Society (BTS). NEWS was designed to be more sensitive than a large number of different EWS systems. A more sensitive scoring system is one that trips a response sooner. For patients who require a lower (88-92%) target oxygen saturation range, the system is too sensitive and in some situations could be harmful. Therefore a decision has been made to make a rule about oxygen saturation scoring when a patient has the lower target saturation range. 4
NEWS is designed for use with adults. There are other systems for use with children, neonates and pregnant women (over 20 weeks). In addition there are circumstances where NEWS is not relevant (e.g. if a patient is in the process of dying where knowing scores for physiology will not influence treatment). The use of NEWS is not recommended for obstetric patients and although a maternity early warning system does exist in adult (non-obstetric) wards it is recommended to seek advice. It may be safer to continue to use NEWS even though it will trip false positives and therefore more frequent reviews. In fact regular increased frequency medical reviews are probably useful. NEWS still provides useful information. 5
The chart is a complex document with many elements. It has a grid to record observations. It has a sheet to log interventions or actions taken to elevated NEWS (or pain) scores. It has a clinical response chart which dictates what action should be taken where there is not a detailed management plan for an individual patient. The chart is colour coded to help in the totalling of the aggregate NEW Score, which is written in a row towards the bottom of the chart. In addition there is a section for doctors to write any modified triggers that may be required for an individual patient 6
This section is used to record the physiological observations in a form that will allow a visual appreciation of the trend of observations. You need three pieces of information to be able to see a trend, and in reality a lot more than that. Observations should be recorded in one of two ways. The most common is as a dot which is joined to the previous observation by a clear line, so that the observations appear as a line graph. For extreme values; that means any observation in the red cells (or in the case of high temperature an amber). This means that observations are presented as a damped linear trend. This means that the visual display of poor physiology is not obvious. Therefore the actual NEW Score becomes important and its accuracy is very important. It is better to look at the scores and not just rely on looking at an observation of the trend. 7
This section is for logging any NEW Scores (or Pain scores) that require intervention. For NEWS that means single parameter scores of 3 or combined scores of 5 or more for one level of review and 7 or more for a more senior review. It is also recommended that HCAs log referral of a NEW Score above 0 to a registered nurse. Similarly if a pain score requires an intervention, this should be logged. Doctors may write some comments in this section, as well as in the patient s ongoing review / continuation sheets. The information is a clear account of what was done about particular scores. (One of the failures of any EWS is that people do not document actions taken, or not taken). 8
This section is for senior doctors to write in any changes to the trigger for referral. Anyone recording observations should look here for advice on whether a referral for review is required. A revised trigger takes precedence over the NEWS clinical response on the chart. If there is doubt then the clinical response should be followed. This should be completed as a series of bullet points rather than a long paragraph, so that staff recording observations can understand what is required. In addition to a medically derived NEWS revised trigger for an individual patient, some departments may have local standards. The use of these must be documented. 9
There is a lot of information about pain scoring on the chart. The chart provides general advice about analgaesia as well as two methods for scoring pain. Any patient having pain should have their pain experience recorded. There is the verbal or visual analogue scale (VAS) or the Abbey Pain Scale. The VAS is a 1-10 pain score with 0 being no pain and 10 being the rating given to the worst pain imaginable. Not all patients are appropriate for the VAS to be used. If a patient has significant cognitive impairment then the use of Abbey is recommended. Pain scores are not part of NEWS but are recorded on the front of the chart under the NEW Score. Pain scores may be recorded at rest or on movement or both. The ranges of each pain score system are different which means that it is important to write a V or an A in the row underneath the actual pian score so that the number can be understood. The number 10 (without more information) could be a moderate to severe pain score on Abbey, or the worst pain imaginable on VAS. In addition to pain scoring, any patient receiving analgaesia should have the side effects of their analagaesia monitored. And acted on if necessary. 10
The outline clinical response is generic advice. Precise details of who to bleep are on posters displayed in wards and clinical areas. A prompt to Sepsis 6 is included on the chart. 11
NEWS is heavily weighted towards respiratory function which is a sensitive marker of impending acute illness. Patients get a score for respiratory rate, a score for being on oxygen and a score for oxygen saturations. The score for oxygen saturations that a patient gets is influenced by the oxygen saturation target range that is prescribed for that patient. 12
There are simple rules for the scoring of the oxygen saturation target range. These are printed on the observation chart and spelled out above. When calculating the NEW Score it is easiest to add up the score as scored on the chart, then look at the saturation target range and then adjust the score according to the target saturation range. More likely to be accurate that way. 13
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The Outline clinical response refers to the action that should be taken in response to an elevated NEW Score. Because the chart is in use in two hospitals and in many different departments, the clinical response section does not give details of bleep numbers. Every department has its own referral processes on posters in wards and departments. The outline clinical response also prescribes the minimum frequency of observations. It is always acceptable to do more than NEWS suggests. Less should only be done as part of a senior clinical management plan (revised trigger) or documented and agreed local standard. The clinical response should be followed unless a trigger has been re-set, or a local departmental standard exists. The clinical response is very clear. A single parameter score of 3 is enough to prompt a review. Additionally an aggregate score of 5 or more should prompt a review. NEWS also has a senior review for a patient with a NEW Score or 7 or more. If a patient is very sick (peri-arrest) a resuscitation team call should be put out. Also on the chart is a prompt for sepsis 6 which is the care bundle for how sepsis once diagnosed should be managed. It is worth noting that a patient may have sepsis and a low NEW Score. If a patient has sepsis and a high NEWS they may already heave 15
severe sepsis. The sepsis six prompts are a useful reminder of the give three / take three approach. If there are concerns about sepsis then a review should be sought. Note that NEWS is not designed to replace clinical judgement, it is there to support it. It is always acceptable to do more than NEWS; less than NEWS clinical response requires a senior medical review. 15
NEWS and SBAR go together well. Although it refers to EWS, the advice on this poster remains as good as it was and should be followed. 16
Where a NEWS clinical response is required, (or a patient requires a trigger to be reset), it should be logged on the Action Report section of the chart. In addition an SBAR sticker should be completed and inserted in the clinical record. 17
NEWS is not a complete assessment of a patient. It is a summary of the physiological observations and that is all. It does not address many things that a patient who is unwell may need. If a patient is very unwell a close monitoring of urine output will be required. Any patient who is being referred for a review is likely to need a fluid balance chart with accurate input and output monitoring. Urine output is not included in NEWS but in many instances is as important. 18
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