Fine balance between pragmatism and rigidness in system approaches to acute careBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6226 (Published 31 October 2019) Cite this as: BMJ 2019;367:l6226
- Damian T Roland, honorary associate professor and consultant in paediatric emergency medicine1,
- Andrew Rowland, professor and consultant in children’s emergency medicine2,
- Sarah Cotterill, senior lecturer in health services research and statistics3,
- Calvin Heal, research associate3,
- Steve Woby, honorary professor and director of operations4,
- Natalie Garratt, research and innovation business development manager4,
- Stephen Brown, academic network manager4,
- Tony Long, professor of child and family health5
- 1Children’s Emergency Department, Leicester Royal Infirmary, Leicester LE1 5UE, UK
- 2Pennine Acute Hospitals NHS Trust, Emergency Department, Manchester M8 5RB, UK
- 3Centre for Biostatistics, Jean McFarlane, University of Manchester, Manchester M13 9PYL, UK
- 4Department for Research and Innovation, Northern Care Alliance NHS Group, Salford M5 5AP, UK
- 5Mary Seacole Building, University of Salford, Salford M6 6PU, UK
Reluctance of the Royal College of General Practitioners to endorse NEWS2 (the second iteration of the national early warning score) has surprised some and been supported by others.1 This dichotomy over what seems to be a proved safety measure shows the fine balance between pragmatism and rigidness in system approaches to acute care.
The predictive value of NEWS2 is well evidenced,2 and acting on a high score might prevent excess mortality, leading to calls for it to be used in primary care. The college’s concern about the unintended consequences of patients not being rapidly transferred to hospital because they have a low NEWS2 is genuine but must be balanced against the tangible communication advantages of alerting ambulance services to a patient with a high NEWS2.
There is currently no national paediatric equivalent of NEWS2. Paediatric early warning scores that have been investigated outside of wards have not shown benefit3; bespoke emergency department systems add more value.45 Enforcing an inpatient derived system for children in primary care as the next step would be unreasonable and illogical.
The effect of these systems must be investigated, as children are still dying of reversible pathologies, and there is little standardisation of practice. Opportunities for such studies exist, as large datasets (more than 30 000 patients) exploring the physiological characteristics of patients presenting to urgent and emergency care departments will shortly be available.6
How primary care scoring tools will be used must be determined before they are implemented. The pragmatic approach of aiding communication and standardisation will need to be balanced against using a tool that simply isn’t valid to detect the range of potential pathologies seen in both adults and children in primary care.
Competing interests: The authors are in receipt of National Institute for Health Research funds for a research for patient benefit study examining the use of PAT-POPS (Pennine Acute Trust paediatric observation priority score) on a cohort of children presenting to urgent and emergency care locations. DTR is the clinical lead of the NHS England/Royal College of Paediatrics and Child Health/Royal College of Nursing national paediatric early warning score project and chair of the Paediatric Emergency Medicine Advisory Group on NHS access standards.
Full response at: https://www.bmj.com/content/367/bmj.l5814/rr-0.