NEWS 2: an opportunity to standardise the management of deterioration and sepsisBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1260 (Published 20 March 2018) Cite this as: BMJ 2018;360:k1260
All rapid responses
We would like to thank the sender for the useful comments and for generating a debate about the use of NEWS in the community. This is exactly what the article was intended to do, and so we welcome his letter.
A Need for Validation
No one disputes the fact that NEWS validation in primary care is warranted. Though not validated in primary care, what NEWS offers is a prompt to encourage the reliable taking of physiological observations, an adjunct to clinical decision making and a very clear easily communicated and well understood physiological score that the rest of the care pathway understands.
A Need for Reliable Completion of Observations in Unwell Patients
The NCEPOD 2015 Just Say Sepsis report demonstrated that a complete set of observations was only taken in patients seen by GPs in a small fraction of patients that were later identified as having sepsis. GPs saw a significant proportion of the studied patients - 18.2% of the total (n=536). Self-presenters to ED constituted 12.5% of the total and Ambulance‘s 51.9%. Of note, the GP reviewers of the community sepsis cases found that physiological observations were only taken 1/3rd of the time.
Vital signs recorded GP (n=129) % Paramedic (n=163) %
Temperature 34 26.4 146 89.6
Blood pressure 32 24.8 157 96.3
Heart Rate 40 31.0 163 100
Respiratory Rate 8 6.2 159 97.5
AVPU 8 6.2 144 88.3
What NEWS is
NEWS has been validated in pre hospital and hospital settings when patients become acutely ill and its use should be tailored to this category of patient, so the track and trigger that is so helpful in determining which patients are at highest risk of death can be initiated at the earliest possible stage. There is a different dialect in the subjective terminology used in different settings: a patient identified as ‘sick’ in community settings is often not viewed as being ‘as sick’ as one in hospital settings. The only determinants that really stand the ‘test of a journey’ across a referral pathway is the physiology, past history and clinical impression.
We also acknowledge and stress the importance of clinical judgement in primary care. The idea that GPs don’t see sick patients should be challenged. As a GP in a previous life, home visits to some pretty unwell patients were not uncommon. Using a needle in a haystack analogy, the needle will be smaller and the haystack larger, but both will still be there in community settings.
NEWS is not a decision tool or test, it is an adjunct to decision making. When combined with clinical judgement and communicated across the care pathway, it becomes incredibly helpful to those ‘downstream’ & ‘upstream’ of the GP (and might even be useful for GPs as the NHS England sepsis definition is based on an aggregate NEWS of 5). We have an ‘ambulance stack’ that means that every bit of non-subjective information can improve the triage and guide the urgency of transportation and a front of house hospital “medical assessment stack” which benefit from as much ‘up front’ information as possible. We must remember these ‘stacks’ often rise to 20-30 urgent cases requiring transportation and medical assessment, and without full physiology how can a decision on prioritisation be made?
Regions of GPs (West of England, Liverpool and Wessex) have found the use of NEWS to be helpful as an adjunct to decision making, a prompt to do a complete set of observations (which NCEPOD showed was not done well in primary care in patients identified as being septic) and when communicating with the rest of the healthcare pathway about deteriorating patients.
I will quote Dr Simon Stockley, the RCGP sepsis clinical champion here, “Respiratory rate, low perfusion (BP) and altered cognition were probably the features that alarmed me most consistently and that their presence together multiplied my concern. I also knew that from NCEPOD that these were the least recorded elements of physiology in patients admitted from General practice with sepsis”
The prompt to do a NEWS is worry from the clinician that the patient might be unwell so it is not recommended for every patient. Where it really shines, is when multiple healthcare professionals are involved in the care of a patient during a single episode of deterioration. With the advent of NEWS implementation in all other community settings, and encouragement of SBAR communication to include NEWS in referrals, it would be a shame if GPs were not aware of what an elevated or low NEWS represents and how helpful that information can be.
GP referrals over recent times have been a non-standardised affair, often based on judgement alone, often with patchy and variable amounts of information and physiology. As Dr Usha Couderc, Primary Care Lead for Wessex Patient Safety Collaborative, states, “As GPs we have not had a standardised assessment method, transfer information, referral standard, physiological trigger guidance; leading to inappropriate transfers to the acute sector with under/over escalation and potentially poor outcomes” The better referrals that I have received over the years have included observations.
We must also consider what our patients would want . . .
to persist with a non-evidenced (in any setting), unvalidated subjective system of referral based on judgement or
to change to a non-GP evidenced (but strongly secondary care and ambulance evidenced), unvalidated objective system of referral based on physiology and judgement.
As favourable or unfavourable evidence on community NEWS implementation starts to be generated we will have a clearer idea of which of the options we should pick.
We should also pause and imagine the potential pan system gains through use of a single language of sickness and just how beneficial this could be.
Competing interests: No competing interests
Inada-Kim and Nsutebu (1) extol the health system to use the NEWS2 score in all healthcare settings. They state that "a score in one setting must mean the same in any other". The problem is that it doesn't.
Improved communication within health systems is to be encouraged, but as Bernard-Shaw (maybe) commented regarding the UK and USA, primary and secondary care will always be separated by the same language.
In common with any scoring system, diagnostic test or risk stratification tool, the predictive value is governed by the pretest probability as well as the characteristics of the test. A NEWS score of 4 in an emergency medical setting (2) does not mean the same thing in an ambulance call out (3), or in a GP surgery, for the simple reason that serious illness is not as common in these settings to begin with.
Clinicians should do observations on patients and be alert to the sick patient, but we should acknowledge that the NEWS score is not validated in primary care, let alone as a screening tool. Research is needed to establish what any warning score means in primary care, and until then, we need to face the facts that the NEWS score from primary care is spoken with a different dialect.
1. Inada-Kim Matt, Nsutebu Emmanuel. NEWS 2: an opportunity to standardise the management of deterioration and sepsis, BMJ 2018; 360 :k1260
2. Smith et al. The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death. Resuscitation 2013;84:465–70
3. D.J. Silcock et al. Validation of the National Early Warning Score in the prehospital setting. Resuscitation 2015;89 31–35
Competing interests: No competing interests