A national early warning score for acutely ill patients

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e5310 (Published 8 August 2012)
Cite this as: BMJ 2012;345:e5310

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No NEWS is good news. I would like to sound a word of warning as to the use of NEWS in the real world.

Other risk scores, like MEWS and PEWS, have been in widespread use for some years. The introduction of NEWS brought about a significant lowering of the threshold for contacting senior medical input and involvement of critical care teams.

The inflexibility in the system does not account for the "normal" patient population seen on acute medical wards in whom the NEWS would recommend referral to critical care when their clinical condition is no different to their "normal" and does not require action.

It has contributed to the workload of already busy medical and nursing teams, resulting in apologetic phonecall exchanges. The category of bed and nursing ratios that in theory would be necessitated does not exist.

Competing interests: None declared

Ciarán P Trolan, ST6 Geriatric Medicine

Southern HSCT, 10 Disert Road, Draperstown, Co.Derry, BT45 7JN

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The Royal College of Physicians (RCP) should be praised for drawing national attention to the 6,000 avoidable deaths in English hospitals each year due to the failure to recognise and respond appropriately to signs of deterioration. Add the avoidable harm of patients admitted to intensive care for the same reason, and it is clear that the current system is both unsafe and expensive.

Standardisation is the friend of patient safety. Whilst McGinley and Pearse (1) rightly commend the RCP for proposing a standardised National Early Warning Score (NEWS), the recommendation to introduce a new design of paper observation chart is outdated, and does not address many of the underlying system failings. It is well documented that the inaccurate assignation of individual vital sign parameters to the correct EWS weighting group (2) and the calculation of the total EWS is prone to significant error (3). For EWS models based on five physiological parameters, over 40% of scores were inaccurately calculated in a classroom study, most commonly underestimating the patient’s level of risk (4). The proposed NEWS, using seven parameters, is likely to be even more error-prone if calculated manually.
Furthermore, the proposed escalation levels carry the risk of “alarm fatigue”. The NEWS is based on the published VitalPAC Early Warning Score (ViEWS) (5), already widely used in the UK. Our data show that for a typical 1,000 bed hospital, ViEWS/NEWS scores of five and seven (as proposed) will trigger escalations for about 17% and 7% of observation sets every day (about 500 and 200 escalations respectively) – many more than the MEWS systems that they will typically replace. Most hospitals using VitalPAC escalate instead at ViEWS scores of six and nine, generating about 330 and 90 escalations daily. Whilst the final decision to escalate must reflect patient need (and there is some evidence that lower thresholds are appropriate for specific diagnoses), the design of the system should also reflect the resources available. The RCP recommendations may not be sustainable.

The RCP Working Group chose not to consider how handheld devices such as iPod touches can improve the management of this vulnerable group of patients. Such devices can schedule, capture and accurately calculate Early Warning Scores. They can incorporate automatic messaging to senior colleagues (to overcome the occasional reticence of junior staff to escalate care when needed) and allow easy tailoring of hospital protocols to the needs of individual patients and specialties. They improve productivity of front-line clinicians (3, 4) and provide fully auditable data, underpinning effective improvement cycles.

By ignoring some of the reasons why paper-based systems fail, the RCP is promoting an approach in which patients will continue to suffer avoidable harm. The recommendation to adopt a redesigned paper observation chart, and the media’s subsequent focus on this detail (6), represents a missed opportunity to promote a truly innovative and standardisable approach to improving patient care.

References

1. McGinnley A, Pearse R. A national early warning score for acutely ill patients. BMJ 2012;345:e5310.

2. Edwards M MH, Van Leuvan C, Mitchell I. Modified Early Warning Scores: inaccurate summation or inaccurate summation of score? Crit Care (2010) 14, S88.

3. Prytherch D. Smith G, Schmidt P, Featherstone P, Stewart K, Knight D, Higgins B. Calculating early warning scores – A classroom comparison of pen and paper and hand-held computer methods. Resuscitation (2006) 70, 173—178.

4. Mohammed MA, Hayton R, Clements G, Smith G, Prytherch D. Improving accuracy and efficiency of early warning scores in acute care. BJN 2008, Vol 17, No 22.

5. Prytherch D, Smith G, Schmidt P, Featherstone P. ViEWS—Towards a national early warning score for detecting adult inpatient deterioration. Resuscitation 81 (2010) 932–937.

6. Triggle N. Call for national system for monitoring vital signs. BBC News 27 July 2012. http://m.bbc.co.uk/news/health-19001271

Competing interests: PG, RM and KB are Medical Director, Chief Executive and Nurse Director respectively of The Learning Clinic, a private company that produces VitalPAC, an electronic system for capturing and interpreting vital signs and which generated the dataset used to develop the ViEWS algorithm on which NEWS is based. PG works part time as Clinical Fellow in ED, Imperial College Healthcare NHS Trust. Kate Beaumont is former Head of Patient Safety (deterioration), National Patient Safety Agency.

Peter Greengross, Medical Director

Kate Beaumont Nurse Director, Roger Killen CEO

The Learning Clinic, 7 Lyric Square London W6 0ES

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Mc Ginlay and Pearce express appropriate cautions about the use of the National Early Warning Score in people recovering from brain injury. An even greater reason for concern lies in its potential application to people developing brain insults. For these its approach is extremely insensitive and risks inappropriate care and worse outcomes(1). There should be a very clear message that, as presently proposed, the NEWS is not suitable for patients with acute intracranial conditions. Until a valid, safe modification Is produced, existing well established systems should be continued.

(1)http://www.bmj.com/content/345/bmj.e5041?tab=response

Competing interests: Since the description in 1974 of the Glasgow practical scale for assessment of impaired consciousness and coma I have written and lectured widely on its use in the management of patients with acute brain damage. The scale and associated chart have always been available without charge to clinical and scientific users

Graham M Teasdale, Emeritus Professor of Neurosurgery

University of Glasgow, Ardgryffe, Duchal Road, Kilmacolm, PA27 8BZ

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Ann McGinley(1) points out that introducing a National Early Warning Score (NEWS)(2) system may lead to an increased workload on critical care outreach teams. However, using effective early warning systems to avoid ‘failure to rescue’ scenarios may reduce the need for escalation of care into critical care areas. These early interventions have the potential to reduce morbidity, length of patient stay, and increase patient survival.

Six months ago, we undertook an audit of 597 patients looking at the management of severe sepsis across our hospital (a large tertiary centre), using the local Modified Early Warning Score (MEWS) chart. Some scoring parameters in our MEWS charts differ from the scoring parameters implemented by other protocols, such as the Surviving Sepsis guidelines(3). For example, the Surviving Sepsis guidelines suggest that SIRS (systemic inflammatory response syndrome) occurs when a number of physiological criteria are met, one of which is a heart rate (HR)>90, whilst our local MEWS chart doesn’t trigger suspicion until HR is >100.

Junior doctors are expected to review patients, differentiate SIRS, sepsis and severe sepsis and implement immediate management. Our audit showed that our local MEWS score has the misleading potential for a patient with severe sepsis to have a MEWS of 1. One of our recommendations is to bring our MEWS more in line with SIRS criteria. The local implementation of NEWS would encompass this recommendation and therefore lower the threshold for alerting doctors when compared to our MEWS system. Whilst this will inevitably have the side effect of increasing the number of patients that trainees need to review, “failure to rescue” scenarios will often begin with only subtle physiological deteriorations. Our experience and audit outcomes support the Royal College of Physicians’ National Early Warning Score, and we commend its congruence with Surviving Sepsis guidelines.

References
1 McGinnley A, Pearse R. A national early warning score for acutely ill patients. BMJ 2012;345:e5310
2 Royal College of Physicians of London. National early warning score (NEWS): standardising the assessment of acute-illness severity in the NHS. 2012. www.rcplondon.ac.uk/resources/national-early-warning-score-news
3 Surviving Sepsis campaign. Surviving Sepsis guidelines 2008. www.survivingsepsis.org

Competing interests: None declared

Gregory A Moore, F2 Critical care

Denmade C (Registrar), Poole L (ITU Consultant)

Royal Liverpool Hospital, Prescott Street, Liverpool, L78XP

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Please may I as someone new to the profession and having only recently received the power of prescribing, plea to the powers that be to produce a national drug prescribing chart for hospital inpatients.

The EQUIP study published by the GMC in 2009 announced that the in hospital prescribing error rate was 8.9% and that foundation doctors, unsurprisingly, were primarily to blame. Perhaps this is because as medical students they have spent the last five years learning to prescribe on a completely different chart. I trained at Bristol and throughout my medical school career I came across, and had to master, 5 different formats of drug charts.

If a thoughtfully designed chart were to be made and distributed throughout the NHS I wonder how many errors would be prevented.

Competing interests: None declared

Katie Young, FY1

Southmead Hospital, Bristol, BS10 5NB

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The uniformity of a national early warning score system to identify patients with physiological deterioration is a positive step to improve patient safety [1,2]. The uniformity of a national system allows healthcare staff moving between, or temporarily working at different NHS hospitals to be instantly familiar with it. The same logic standardised the cardiac arrest telephone numbers across the NHS in 2004 [3]. What is more surprising is that there are not more similar initiatives to harmonise paperwork and systems in the NHS. In particular, the lack of a single national inpatient drug chart needs addressing.

It is an anomaly of the NHS that different NHS organisations have different prescription charts. There seems no argument for local chart design when prescription chart design has been identified as one of several contributors to hospital prescribing errors [4]. Although standards of drug chart design have been defined [5], the wider NHS should follow the lead of the NHS in Wales, which has for some years had a uniform inpatient drug chart.

1. McGinley A, Pearse RM. A national early warning score for acutely ill patients. BMJ2012;345:e5310 (Published 8 August 2012).

2. Royal College of Physicians of London. National early warning score (NEWS): standardising the assessment of acute-illness severity in the NHS—report of a working party. 2012. www.rcplondon.ac.uk/resources/national-early-warning-score-news.

3. Establishing a standard crash call telephone number in hospitals. National Patient Safety Agency 2004. http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59789

4. Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, Tully M, Wass V. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. London: General Medical Council; 2009.

5. Keogh B, Beasley C, Ridge K. Guidelines for design of in-patient prescription charts. 2011 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/di...

Competing interests: None declared

David A Gorard, Physician

Wycombe Hospital, Queen Aleaxandra Road, High Wycombe, HP11 2TT

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I read the editorial[1] on the Royal College of Physicians national early warning score (NEWS) with interest. The NEWS and classification of clinical risk table included contains a small error for low clinical risk. This should be a score of 1-4,[2] rather than 1-3.

Competing interests: None declared

Amit Patel, SpR in Haematology & Intensive Care Medicine

Imperial College London, Imperial College Healthcare NHS Trust, MRC Clinical Sciences Centre, Hammersmith Hospital, Du Cane Road, London, W12 0NN

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