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
- Matt Inada-Kim, consultant acute physician and sepsis lead, national clinical advisor for sepsis and deterioration1,
- Emmanuel Nsutebu, consultant infectious diseases physician and sepsis lead, national clinical advisor for sepsis and deterioration2
- 1Royal Hampshire County Hospital, UK
- 2Tropical and Infectious Disease Unit, Royal Liverpool Hospital, UK
Currently, hospitals across England don’t use a standardised early warning system (EWS) to identify patients at risk of deterioration or sepsis, or in need of intervention. No other safety critical industry would tolerate this. The NHS has evolved into tribes who use different dialects to describe sickness.
Whatever the system, it must be usable and utilised in all settings. A score in one setting must mean the same in any other. Although doctors rarely use EWS when communicating with each other regarding a patient, they provide a safety mechanism to make sure that nurses flag up deteriorating patients on the ward, and that patients are prioritised based on their mortality risk.
National Early Warning Score (NEWS) is probably the best validated early warning score system and is used in the majority of UK hospitals to identify and respond to patients at risk of deterioration or sepsis.
A recent Patient Safety Measurement Unit survey showed that 64.6% of the 127 acute trusts who responded used an unmodified NEWS, 14.2% used a modified NEWS, and 19.7% used another early warning score. Potential harm could occur as a result of having variable scoring systems across regions, or even within the same organisation, and this is magnified when we consider how often staff and patients move around.
In December 2017, NEWS 2 (an updated version of NEWS) was published. It contains improvements on the previous version. For example, the chronic hypoxia sub chart helps to better tailor escalation to baseline oxygen levels in those with respiratory disease.
We must guard against blinkered, condition specific approaches in both assessment and measurement. When patients are admitted as emergencies, the cause of deterioration is often unclear. Diagnostic certainty only really comes at the end of an admission, once tests are back and the patient’s response to treatment is processed. There are no gold standard diagnostic tests for sepsis, and diagnosis is dependent on physiological observations (aggregate NEWS) and clinical judgment. For these reasons, there is an argument for us to use a proxy, such as emergency admissions with suspected infection or suspicion of sepsis, instead of trying to measure sepsis.
Separating the pathways for sepsis from other causes of deterioration is harmful, and sick patients (with elevated NEWS) without sepsis must be equally prioritised and managed as aggressively as those with suspected sepsis.
It is vital that national bodies, organisations, regions, and collaborators understand this and link sepsis improvement programmes to those focused on the management of deteriorating patients. NEWS2 (with its chapter on sepsis) coupled with the NHS sepsis guidance implementation advice for adults have shown the way for a potential combined all cause deterioration (including sepsis) pathway that will minimise the risks of a more blinkered approach.
With NEWS2, healthcare organisations in England are now able to use a single unadulterated score to describe the physiological sickness of patients in all care settings. If clinicians communicate using this score, the severity of illness, prioritisation, transportation, and placement of patients becomes clearer. Tracking NEWS from an established baseline enables us to understand whether patients are deteriorating and need prompt review and escalation.
Let’s make healthcare a truly safety critical industry and standardise to the best that’s currently out there. Let’s test the hypothesis that if everyone did the same thing then patient outcomes would improve.
And if, over time, there emerges a superior, tried and tested, single EWS that better enables deterioration and sepsis to be recognised and managed across all healthcare settings, then we will adopt that system. In the meantime, all hospitals and clinicians in England should use NEWS2.
Competing interests: M I-K received an honorarium for producing some educational slides for Relias.