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A national early warning score for acutely ill patients

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5310 (Published 08 August 2012) Cite this as: BMJ 2012;345:e5310

Rapid Response:

Re: A national early warning score for acutely ill patients

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National Early Warning Score (NEWS), the recommendation to introduce a new design of paper observation chart is outdated, and does not address many of the underlying system failings.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.

20 August 2012
Peter Greengross
Medical Director
Kate Beaumont Nurse Director, Roger Killen CEO
The Learning Clinic
7 Lyric Square London W6 0ES