Royal college recommends national system to recognise deteriorating patientsBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5041 (Published 26 July 2012) Cite this as: BMJ 2012;345:e5041
All acutely ill adult patients in NHS hospitals should be assessed by the same standardised clinical dataset to help detect those who are deteriorating rapidly and who need more intensive support, a working party from the Royal College of Physicians of London has recommended.
The national early warning score (NEWS) would be used to assess acute illness, detect deterioration in a patient’s condition, and prompt a timely and competent clinical response. Such a “track and trigger” system, implemented to a common pattern nationally, would make for a step change in the care of acute illness, said Richard Thompson, the college’s president.
Many hospitals already have such systems in place, admitted Bryan Williams, professor of medicine at University College London, who chaired the group responsible for the recommendation. These systems represent a lot of work, and their originators are firmly wedded to them, he said.
“Perhaps because this was not the area of my life’s work, I saw things a little differently,” Williams writes in the preface to a new report.1 “This was not just about ‘what is the best system,’ it was also about recognising the huge advantages of ‘everybody using the same system’ . . . Just like the highly effective simple surgical checklist, simple things done well can make a huge impact in healthcare and the NEWS has the potential to do the same.”
The NEWS score card is based on six physiological measurements that are already routinely made: respiratory rate, oxygen saturation, temperature, systolic blood pressure, pulse rate, and level of consciousness. Each is allocated a score from 1 to 3, reflecting variation from the norm (3 being the greatest variation), and the score is then aggregated. A further two points are added for patients requiring oxygen.
A low score (1-4) should prompt assessment by a competent registered nurse, who should decide whether more or less frequent monitoring or an escalation in clinical care is needed. A medium score (5-6), or a score of 3 on any one of the six measurements, should prompt an urgent review by a clinician experienced in the assessment of acute illness—a ward based doctor or acute team nurse—who should consider whether critical care skills are needed. A high score (≥7) should prompt assessment by a team with critical care competencies and would usually mean a transfer to a higher dependency care area.
The team responsible for NEWS said that its use would improve the assessment of illness, detect deterioration better, and ensure a timely clinical response. It is intended for use in patients 16 years or older, excluding pregnant women, and should be used to aid clinical assessment, not as a substitute for competent clinical judgment.
In some conditions, such as chronic obstructive pulmonary disease, the sensitivity of the system could be affected, and this should be taken into account when interpreting the NEWS in these patients. Concern about a patient’s condition should always override the NEWS score if the attending doctor or nurse thinks that care needs to be intensified. It may not be appropriate for patients nearing the end of life.
The working party said that a national system would avoid the risks of variation in local systems and enable standardised training for undergraduates and postgraduates. It added that few local systems have been formally evaluated and may be poorly defined and adhered to, without robust response systems in place.
These issues were recognised in 2007 by a report of the college’s acute medicine task force,2 which found no justification for the continued use of multiple early warning scores. A national system, it said, “would enhance good clinical practice, support standardised recording of clinical data, and provide an important source of documentation for audit of the quality of patient care.”
But the success of the scheme depends, said Thompson, on its being adopted by every hospital in the NHS and underpinned by education and training. “The RCP [Royal College of Physicians] is supporting such implementation by making the report and the associated charts free to use across the NHS and has co-developed an online training programme with the Royal College of Nursing and the National Outreach Forum. We hope to see the score adopted as soon as possible right across the NHS,” he said.
Cite this as: BMJ 2012;345:e5041