Louise Murphy RGN BSc

Developed by Morgan et al in 1997, The National Early Warning

Score is a bedside track and trigger scoring system used by staff

to calculate a total early warning score (EWS) from routinely

collected observations. It aims to indicate early signs of

deterioration in patients’ conditions and prompts more timely medical review and treatment of patients

(HSE 2013).

The NEWS, like many existing EWS systems, is based on a simple scoring system in which a score is allocated to physiological measurements already undertaken when patients present to, or are being monitored in hospital. Six simple physiological parameters form the basis of the scoring system: 1 respiratory rate 2 oxygen saturations 3 temperature 4 systolic blood pressure 5 pulse rate 6 level of consciousness. A score is allocated to each as they are measured, the magnitude of the score reflecting how extreme the parameter varies from the norm. The score is then aggregated. The score is uplifted for people requiring oxygen. It is important to emphasise that these parameters are already routinely measured in hospitals and recorded on the clinical chart.

The importance of early detection of patient deterioration, and

activating a medical response in acute hospitals, has

prompted health services in Canada, Australia and the UK to

implement early warning score systems. Although there are

many types of such systems, they share a common function

as a bedside tool to assess basic physiological parameters

and to identify patients ‘at risk’ or critically ill with associated

escalation and medical team activation protocols

(Patterson et al. 2011).

In Ireland, The Acute Medicine Programme in 2011 established a

NEWS project workforce to develop and nationally agree and

implement one NEWS system in the Irish healthcare system. This

was endorsed by the National Clinical Effectiveness Committee

(NCEC).

In 2011 the EWS was national implemented in response to a policy

initiative and patient safety programme from the Health Service

Executive (HSE) (Health Service Executive 2011). NEWS was

launched in 2013.

The NEWS in the Irish healthcare system is based on international

evidence incorporating the VitalPAC TM Early Warning Score

(ViEWS) parameters (HSE 2009)

1. Categorization of patients’ SEVERITY of illness

2. EARLY detection of patient deterioration

3. Use of a structured COMMUNICATION tool (ISBAR)

4. Promote an early medical review, prompted by specific TRIGGER points

5. Use a definitive ESCALATION plan

● Early Detection

● Early Intervention

● Common Language between Health Professionals

● Directs nurses to necessary action

● Directs nurse to frequency of observation

● Allows health professionals to prioritise patient care

● Framework for urgent medical review i.e. built in escalation protocol

● Allows standardisation of patient care.

Standardization and minimization of variables in practice are

important elements in reducing risks for patients.

• One NEWS

• One National Patient Observation Chart

• One Communication Tool

• One multi-disciplinary education programme

• One quality assured national clinical guideline which met the

criteria of the NCEC (National Clinical Effectiveness Committee)

National Clinical Effectiveness Committee (NCEC) Feb 2013 same update Aug 2015

National-Early-Warning-Score

1.NEWS Full Report (update 2014) 2.NEWS Summary (update 2014) 3.Other supporting documents

Acute illness in adults in hospital: recognising and responding to deterioration NICE guidelines [CG50

Patient safety first

Optimize patient care

Better management of healthcare resources

Improve patient healthcare outcomes

Reduce ITU admission and hospital length of stay

Reduced morbidity and mortality

Reduce healthcare cost

What the research says!!

● The 'sensitivity and specificity' of EWS allow’s the tool to

discriminate patients at risk of combined outcomes of cardiac arrest,

unanticipated intensive care unit (ITU) admission or even death

within 24 hours of a EWS value. Petersen et al. (2014).

• The true benefit of the EWS is its ability to allow nurses and doctors

recognise deteriorating patients who can have their outcomes changed with a timely intervention. Prytherch et al. (2010).

• EWS performance is superior to all other predecessors including

PARS and DTEWS.

• EWS can predict patient mortality. Smith et al. (2013).

According to McQuillan et al.,at least 39% of acute emergency patients admitted to the ITU are referred late in

the clinical course of the illness. Major causes of ‘suboptimal care’ prior to transfer from the ward in their study included

failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision and failure to seek advice.

J Gardner-Thorpe et al (2006)

• Ludikhuize et al. (2012) study found that, Nurse are failing to detect deteriorating patients. Netherlands

• Abbott et al. (2015) identified, High rate of inaccurate calculation of patients EWS, therefore patients are mismanaged. UK

• Abbott et al. (2015) Poor compliance with NEWS escalation protocol and ISBAR use. UK

• Kolic et al. (2015) Miscommunication between nurses &

doctors resulting in poor healthcare outcomes for patients. UK

Non-compliance with NEWS means Poor patient healthcare outcomes and high health-service cost.

No Rapid Response Team, or SHO/ Reg available to responded within the required time particularly at nights and weekends i.e. document parameters.

Lack of training and education, among nurses & doctors.

The sensitivity and specificity of NEWS means increase workload for nurses.

Staff desensitisation & alarm fatigue result in non-compliance of NEWS system.

Behaviour/ cultural change.

Inexperience/ lack of clinical knowledge among health professionals

EWS, NEWS, PEWS, MEWS, ViEWS…….

What NEWS can’t see!!!

Hypercapnia

Head injuries

Spinal Cord Injuries

etc.

The majority of patient adverse events occur on medical-surgical nursing wards and medical-

surgical nurses are frequently the first healthcare professionals to identify signs and symptoms of

clinical deterioration and initiate life-saving interventions.

(Cohn et al. 2004, Peters & Boyde 2007),

‘nurse’s attitudes towards patient care and the

standard of care given to patients is suboptimal at nights and weekends’

(Kolic et al. 2015).

‘Staff desensitisation, alarm fatigue and non-

compliance was commonly found when adverse

events occurred’

(Petersen et al. 2014)

The NCEPOD 2005 report identified that many

patient receive suboptimal care before ICU

admission either because of non-recognition of the

severity of the problem or inappropriate treatment.

Furthermore identifying that delayed recognition

and implementation of appropriate management for

acutely deteriorating patients as being key

contributors to patient morbidity and mortality

(Cullinane et al, 2005).

• NEWS COMPLIANCE, Recognizing when a patient’s condition is

deteriorating.

• EDUCATION, Promote nursing knowledge through regular education

including National guidelines, NCEC, Empirical Research etc.

• AWARENESS, Evaluate and address gaps in service through local

audits.

As nurses, the potential to save lives through the

NEWS compliance is enormous, according to Surviving

Sepsis Campaign (2016) we could save 400,000 lives

if we treat only half of the eligible patients with the

Surviving Sepsis Campaign Bundles which are

identified by the NEWS.

http://www.survivingsepsis.org/About-SSC

‘It must never be lost sight of what

observation is for. It is not for the sake of

piling up miscellaneous information or curious facts, but for the sake of saving life and

increasing health and comfort’

(Florence Nightingale 1859)

Abbott, T, Vaid, N, Ip, D, Cron, N, Wells, M, Torrance, H, & Emmanuel, J 2015, 'A single-centre observational cohort study of admission

National Early Warning Score (NEWS)', Resuscitation, 92, pp. 89-93.

Alam, N, Vegting, I, Houben, E, van Berkel, B, Vaughan, L, Kramer, M, & Nanayakkara, P 2015, 'Exploring the performance of the

National Early Warning Score (NEWS) in a European emergency department', Resuscitation, 90, pp. 111-115.

Allen A, McQuillan P, Taylor B, et al. (1994). Who sees the critically ill patient before ICU admission? Clin Intensiv Care 5: 152.

Badriyah, T, Briggs, J, Meredith, P, Jarvis, S, Schmidt, P, Featherstone, P, Prytherch, D, & Smith, G 2014, 'Decision-tree early warning

score (DTEWS) validates the design of the National Early Warning Score (NEWS)', Resuscitation, 85, 3, pp. 418-423.

Brain Injury Austrailia. 2015. 'About Acquired Brain Inury' Page. Accessed October 02, 2015. Hptt://braininjuryaustralia.org.au

Burchill, C, Anderson, B, & O'Connor, P 2015, 'Exploration o f Nurse Practices and Attitudes Related to Postoperative Vital Signs',

MEDSURG Nursing, 24, 4, pp. 249-255.

Capan, M, Ivy, J, Rohleder, T, Hickman, J, & Huddleston, J 2015, 'Individualizing and optimizing the use of early warning scores in

acute medical care for deteriorating hospitalized patients', Resuscitation, 93, pp. 107-112.

Fox, A, & Elliott, N 2015, 'EARLY WARNING SCORES: A SIGN OF DETERIORATION IN PATIENTS AND SYSTEMS', Nursing

Management - UK, 22, 1, pp. 26-31.

Jarvis, S, Kovacs, C, Briggs, J, Meredith, P, Schmidt, P, Featherstone, P, Prytherch, D, & Smith, G 2015, 'Are observation selection

methods important when comparing early warning score performance?', Resuscitation, 90, pp. 1-6.

Jarvis, S, Kovacs, C, Badriyah, T, Briggs, J, Mohammed, M, Meredith, P, Schmidt, P, Featherstone, P, Prytherch, D, & Smith, G 2013,

'Development and validation of a decision tree early warning score based on routine laboratory test results for the discrimination of

hospital mortality in emergency medical admissions', Resuscitation, 84, 11, pp.

Kellett, J, Wang, F, Woodworth, S, & Huang, W 2013, 'Changes and their prognostic implications in the abbreviated VitalPAC[TM] Early

Warning Score (ViEWS) after admission to hospital of 18,827 surgical patients', Resuscitation, 84, 4, pp. 471-476.

Kolic, I, Crane, S, McCartney, S, Perkins, Z, & Taylor, A 2015, 'Factors affecting response to National Early Warning Score (NEWS)',

Resuscitation, 90, pp. 85-90.

Kyriacos, U, Jelsma, J, & Jordan, S 2011, 'Monitoring vital signs using early warning scoring systems: a review of the literature', Journal Of

Nursing Management, 19, 3, pp. 311-330.

Ludikhuize, J, Borgert, M, Binnekade, J, Subbe, C, Dongelmans, D, & Goossens, A 2014, 'Standardized measurement of the Modified Early

Warning Score results in enhanced implementation of a Rapid Response System: A quasi-experimental study', Resuscitation, 85, 5, pp. 676-

682.

Ludikhuize, J, Smorenburg, S, de Rooij, S, & de Jonge, E 2012, 'Identification of deteriorating patients on general wards; measurement of vital

parameters and potential effectiveness of the Modified Early Warning Score', Journal Of Critical Care, 27, 4, pp. 424.e7-424.e13.

Odell, M 2015, 'Detection and management of the deteriorating ward patient: an evaluation of nursing practice', Journal Of Clinical Nursing, 24,

1-2, pp. 173-182.

M. Teasdale, G 2012, 'NEWS is not suitable for all patients...McGinlay A, Pearse RM. A national early warning score for acutely ill patients. BMJ

2012;345:e5310. (8 August.)', BMJ: British Medical Journal (Overseas & Retired Doctors Edition), 345, 7873, pp. 29-29 1p

Moon, A, Cosgrove, J, Lea, D, Fairs, A, & Cressey, D 2011, 'An eight year audit before and after the introduction of modified early warning score

(MEWS) charts, of patients admitted to a tertiary referral intensive care unit after CPR', Resuscitation, 82, 2, pp. 150-154.

Petersen, J, Mackel, R, Antonsen, K, & Rasmussen, L 2014, 'Serious adverse events in a hospital using early warning score - what went

wrong?', Resuscitation, 85, 12, pp. 1699-1703.

Prytherch, D, Smith, G, Schmidt, P, & Featherstone, P 2010, 'ViEWS--Towards a national early warning score for detecting adult inpatient

deterioration', Resuscitation, 81, 8, pp. 932-937.

Smith, GB 2013, 'Have we found the perfect early warning score? A view of ViEWS', Resuscitation, 84, 6, pp. 707-708.

Smith, G, Prytherch, D, Meredith, P, Schmidt, P, & Featherstone, P 2013, '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, 84, 4, pp. 465-470.

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