Recording and interpreting the National Early Warning ...

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Nima RobinsHead Nurse

Beckham & Victoria HospitalsNHS Trust NHS

The Nursing and Midwifery Council Code (NMC, 2018) requires nurses, midwives and nursing associates to accurately identify, observe and assess signs of normal or worsening physical health in the person receiving care. The thoughtful use of early warning scores can help healthcare professionals to appropriately respond to a patient’s condition and escalate to the medical team if indicated (Butler, 2020). Variations in practice and assessment can compromise the safety of patients (Grant & Crimmons, 2018; NHS Improvement, 2018; NCEPOD, 2012). The use and implementation of a standardised assessment tool could save an estimated 1,800 lives a year in hospitals in England (NHS England, 2020).

In 2007, the National Institute for Health and Care Excellence (NICE) recommended the use of track and trigger monitoring systems for all adult patients in acute hospital settings. These systems attach a numerical score to a patient’s vital signs, and trigger an escalation response if the patient’s condition deteriorates. In 2012, the Royal College of Physicians (RCP) developed the National Early Warning Score (NEWS) to standardise the assessment of, and response to, acute illness. In 2017, the RCP released NEWS2 to help detect deterioration in adults by triggering review, treatment and escalation of care where appropriate (NHS Improvement, 2018). It was created for use across all healthcare settings in England in all patients over 16 years old (RCP, 2017). NEWS2 includes the following improvements and updates (NHS Improvement, 2018; RCP, 2017):

• Restructured physical measurements to align with ABCDE assessment;• Improved identification of patients likely to have sepsis;• Improved scoring for patients with hypercapnic respiratory failure, i.e.

those patients with chronic obstructive pulmonary disease (COPD) who have high levels of carbon dioxide in their blood; and • Recognition of the importance of new-onset confusion or delirium.

The RCP published supplementary guidance to support the implementation of NEWS2 (RCP, 2019). This additional advice focuses on five categories: the assessment of new confusion; how frequently monitoring should take place for patients with a new elevated NEWS2 score; the use of the appropriate oxygen scale; the need to use NEWS2 scores when transferring patients between teams; and what to do if one of the NEWS2 measurements is incomplete.

NEWS2 is not used with patients with spinal cord injury, due to potential disturbance of the autonomic nervous system (Dean, 2018; RCP 2017), nor with pregnant women (RCP, 2017). (A modified early warning score system has been developed for use in obstetrics and maternal care [RCoA, 2018].) A national paediatric early warning system scoring tool is being developed to support the assessment of patients under the age of 16 years (RCPCH, 2019). Currently all ambulance trusts and more than 70 per cent of acute trusts are using NEWS2 (NHS, 2020). Due to the adoption of NEWS2 by ambulance trusts in England, GP and community services may be asked to provide a NEWS2 score when arranging an ambulance transfer.

NEWS2 is an assessment aid and does not replace or substitute experienced clinical judgement. If clinical staff are concerned about a patient’s condition, they should seek an urgent clinical review regardless of the patient’s NEWS2 score (Butler, 2020; Gerry et al., 2020; Grant & Crimmons, 2018; RCP, 2017). (See also Key reading.)

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ObservationsAdults

Recording and interpreting the National Early Warning Score 2 (NEWS2)

Demonstrated by Rebecca Craig, Senior Lecturer, and Edda Hensler, Senior Lecturer, both at University of Brighton

©2020 Clinical Skills Limited. All rights reserved

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

When patients start to deteriorate, they display common signs that represent failing respiratory, cardiovascular and nervous systems (RCUK, 2015). For the NEWS2 assessment, the healthcare professional takes six physiological measurements, which are routinely recorded in clinical practice, and gives each a score. The total score reflects the perfusion of vital organs, and aims to help detect deterioration in adults. High scores trigger review, treatment and escalation of care where appropriate (NHS Improvement, 2018). An important exclusion is urine output which is a key indicator of organ perfusion (UK Sepsis Trust, 2019).

Components of the National Early Warning Score 2 (NEWS2)

Respiration rate Oxygen saturation (SpO2) Systolic blood pressure

Pulse rate Level of consciousness and new confusion

Temperature

ObservationsAdults

Recording and interpreting the National Early Warning Score 2

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The individual scores are added up to provide a total score that can help guide ongoing patient management (RCP, 2017). A high score indicates potential deterioration in a patient’s condition.

NEWS2 has two oxygen saturation (SpO2) scoring scales. Scale 2 is used for patients with a target range of 88–92 per cent (e.g. in hypercapnic respiratory failure) (RCP, 2020). If no decision has been made about which scale to use, always choose scale 1 as the default. Record this in the patient’s notes. A competent clinical decision maker must make the decision to use scale 2. They must record this in the patient’s clinical notes. To avoid confusion, clearly cross out the scale not used (RCP, 2020).

Use the approved abbreviations to record aspects relating to air or oxygen delivery (see table below).

AirNasal cannulae (nasal specs)High-flow nasal cannulae (nasal specs)Venturi maskReservoir mask

ANHFNV + oxygen % (e.g. V24 for 24%)RM

Simple face maskHumidified oxygen Continuous positive airway pressureNon-invasive ventilationTracheostomy mask

SMH + oxygen % (e.g. H60 for 60%)CPAPNIVTM

Oxygen delivery device Approved abbreviations Oxygen delivery device Approved abbreviationsTable of abbreviations for oxygen delivery (O’Driscoll et al., 2017)

The chart uses a traffic light colour-coding system. Values that score zero are coloured white, a score of 1 is coloured yellow, a score of 2 is coloured orange and a score of 3 is coloured red.

The centre column denotes the scores awarded for the patient’s values. These scores are summed up on the NEWS TOTAL line at the foot of the chart.

The NEWS2 chart

Royal V&B HospitalAccount Red, Nurse V. Hemsworth

11:20

Location Location A - ZA - Z EWSEWS Obs dueObs due

Find PatientFind Patient

Applegate, John3 Elsea Grangerfm iC N Obs N fm iC O2

Harson, Jo5 Elsea Grangerfm iC 30 mins

Maudry, Lark2 Garald Fitzpatrickfm iCN Obs 44 minsfm iC O2

DeGray, Aubry2 Garald Fitzpatrickfm N 50 minsfm O2

Potter, Carli3 Elsea Grangerfm N 51 minsfm O2

Some healthcare organisations use an electronic NEWS2 recording and tracking system (NICE, 2020; RCP, 2019). Practitioners should follow local guidance about which recording method to use.

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Explain the procedure to the patient Gather your observations

Check the patient’s notes and select the SpO2 scale Fill in the chart: (a) Record respiratory rate

Decontaminate your hands (see clinicalskills.net procedure, “Routine hand hygiene”). Explain the procedure to the patient. Gain their consent to take and record physiological measurements (NMC, 2018). Add the patient’s details, and the date and time to the NEWS2 chart (NMC, 2018).

Measure and record the patient’s respiratory rate, SpO2, blood pressure, pulse rate, and temperature. (For more information refer to the Observations category of clinicalskills.net.) After taking each measurement, record it immediately on the NEWS2 chart (see below).

Record the respiratory rate on the NEWS2 chart. If the rate will go in a white, yellow or orange box, clearly mark the correlating box using a dot as shown. If the rate is in a red box, then state the number (inset).

Check the patient’s notes to see which SpO2 scale is being used (RCP, 2020). Cross out the section relating to the scale that is not being used.

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(c) Record air or oxygen(b) Record SpO2

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Record the SpO2 on the NEWS2 chart. If the SpO2 will go in a white, yellow or orange box, clearly mark the correlating box using a dot as shown. If the SpO2 is in a red box, then state the number (inset).

Record if the patient is receiving air or oxygen. If the patient is not receiving oxygen, record “A” for air in the A = Air white box. If the patient is receiving oxygen, add the oxygen delivery flow in L/min in the O2 L/min orange box (or the oxygen percentage if known), then the approved abbreviation for the oxygen delivery device in the Device box. For example: 2 = oxygen at 2 L/min N = Nasal cannulae (O’Driscoll et al., 2017).

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ObservationsAdults

CPulseBeats/min


Record the patient’s blood pressure on the NEWS2 chart using arrows as shown (or following local policy). Only the systolic recording (the upper arrowhead) triggers a NEWS2 score. The scoring system does not include the diastolic recording (the lower arrowhead) as it does not assist in early recognition of deterioration. Nevertheless, you should routinely record the diastolic reading on the NEWS2 chart, as it is relevant in some acute settings (RCP, 2017).

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(d) Record blood pressure (e) Record pulse rate

(f) Record the patient’s level of consciousness

Assess for new confusion (g) Record temperature

Record the patient’s pulse rate on the NEWS2 chart. If the rate will go in a white, yellow or orange box, clearly mark the corresponding box using a dot as shown. If the rate is in a red box, then state the number (inset). Note and escalate any new abnormal heart rhythm.

The ACVPU scale is a simple, rapid and effective method to assess consciousness (Lister et al., 2020). ACVPU forms part of the NEWS2 chart with the inclusion of C, for new confusion or delirium (RCP, 2017).

Record the patient’s conscious level on the NEWS2 chart. If the patient is alert, then mark an “A” in the correlating box. If the patient is assessed with new confusion/delirium, verbal, pain or unresponsive/unconscious, clearly mark the correlating red box (inset).

Record the patient’s temperature. If the temperature will go in a white or yellow box, clearly mark the correlating box using a dot as shown. If the temperature will go into an orange or red box, then state the number (inset). For example, clearly mark the red box for a temperature under 35.0°C, or the orange box for a temperature over 39.1°C. Be aware that some people will not develop a high temperature when they deteriorate (UK Sepsis Trust, 2019).

It is important to clarify if the patient has new confusion. Ask staff who may be familiar with the patient, or relatives, if they believe that the patient is more confused than usual or before. New-onset confusion is a sign of potentially serious clinical deterioration in patients and may be a sign of sepsis (RCP, 2017). If the patient is no more confused than usual, continue scoring using the ACVPU scale as normal. Assess the patient further to determine an appropriate threshold or trigger score, to detect if the patient’s confusion worsens or if they become less responsive (RCP, 2020).

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Only the systolic recording triggers a NEWS2 score; in this case, a NEWS2 score of 2

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ObservationsAdults

Alert: Spontaneous opening of eyes, responds to voice and has motor function.Confusion: New confusion or delirium. If you are unsure whether this is new confusion or the patient’s normal state, then assume confusion to be new until you can confirm otherwise.Verbal: The patient responds when you talk to them. This could be by opening their eyes, speaking or making a sound, or a motor response through limb movement.Pain: The patient responds to a painful stimulus. You can apply a painful stimulus with the trapezius squeeze: using the thumb and two fingers, hold 5 cm of the trapezius muscle, where the neck meets the shoulder, and twist the muscle (refer to local policy). Unresponsive or Unconscious: The patient gives no eye, voice or motor response to voice or pain (Lister et al., 2020; RCP, 2017).

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Assessment of consciousness using the ACVPU scale

This table shows which measurements would trigger a score on the NEWS2 chart (RCP, 2017). Note that a score of zero is not equivalent to normal values, specifically for systolic blood pressure and temperature, so further assessment of the patient, and escalation, may still be required. Equally, if urine output has reduced, this would need investigating.

Physiological parameter

Systolic blood pressure (mmHg)

Pulse (per minute)

Respiration rate (per minute)

Consciousness

Temperature (°C)

SpO2 Scale 1 (%)

Air or oxygen?

SpO2 Scale 2 (%)

3 2 1 0 1 2 3

≤8 9–11 12–20 21-24 ≥25

≤35.0 35.1–36.0 36.1–38.0 38.1–39.0 ≥39.1

Oxygen Air

Alert CVPU

≤91 92-93 94–95 ≥96

≤40 41–50 51–90 91–110 111–130 ≥131

≤90 91–100 101–110 111–219 ≥220

≤83 84–85 86–87 88–92≥93 on air

93–94 onoxygen

95–96 onoxygen

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Score

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CRYSTAL PEARL BATTON

If you cannot obtain one of the observations, maybe due to lack of equipment or because the patient does not consent, you should still document the score but mark it as incomplete. Clinical judgement will be particularly important here; you may want to escalate or trigger a response because this score is not available. If equipment used fails to record an observation, this should trigger an immediate response (RCP, 2020).

Once you have taken the full set of physical measurements, calculate the NEWS2 score for each measurement by reviewing the box in which you have recorded the measurement and attaching the appropriate score to it using the colour code and central column showing the score. Alternatively, obtain the score using the NEWS2 scoring system table at the top of this page (which is easier to read for some people). Add up these scores as you move down the chart and insert the aggregate score in the “NEWS TOTAL” box at the bottom of the chart. In the example shown, all the measurements are within NEWS2 defined normal ranges, so the NEWS2 score is zero.

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The NEWS2 scoring system

Calculate the NEWS2 score

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ObservationsAdults

The RCP (2017) recommends this guidance is followed to enable a safe clinical response to the NEWS2 trigger thresholds in the clinical setting. The frequency of monitoring recommended is a minimum standard, so always follow local policy, as this may differ.

NEWS key0 1 2 3

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≤91

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In this example, the blood pressure systolic measurement triggers a score of 3, but all other measurements are within the normal range, so the total NEWS2 score is 3 in a single parameter. This should trigger an urgent ward-based response (see below).

10/05/1955

YUSUF QAASIM

Scores 0

Scores 0

Scores 0

Total score = 3

Scores 3

Scores 0

Scores 0

Scores 0


Calculate the NEWS2 score triggers

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Move red box up to Air line

ObservationsAdults

0 • Continue routine NEWS2 monitoring

Minimum 4–6 hourly

Minimum 12 hourly

Minimum 1 hourly

Minimum 1 hourly

3 in single parameter

Total 1–4

Total 5 or moreUrgent response

threshold

Total 7 or moreEmergency response

threshold

• Inform registered nurse, who must assess the patient• Registered nurse decides whether increased frequency of monitoring and/or escalation of care is required

• Registered nurse to inform medical team caring for the patient, who will review and decide whether to escalate care

• Registered nurse to immediately inform medical team caring for the patient• Registered nurse to request urgent assessment by a clinician or team with core competencies in the care of acutely ill patients to provide clinical care in an environment with monitoring facilities

• Registered nurse to immediately inform medical team caring for the patient – this should be at least at specialist registrar level• Emergency assessment by a team with critical care competencies,including practitioner(s) with advanced airway management skills• Consider transfer of care to a level 2 or 3 clinical care facility, i.e. higher-dependency unit or ICU• Clinical care in an environment with monitoring facilities

NEWS2 score Frequency of monitoring Clinical response

Continuous monitoring of vital signs

Clinical response to the NEWS2 trigger thresholds

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You have received a handover for the day shift on an acute medical ward for Rose Summers. Rose is an 84-year-old patient admitted the previous day with a urine infection and reduced mobility. Your colleague informs you that Rose had a NEWS2 score of 2 overnight so was monitored by the ward staff. When you take a set of physiological measurements, you note that Rose is confused and disorientated. A colleague, who met Rose on admission, walks into the bay while you are assessing her and, on observing Rose and speaking to her briefly, informs you that she was not confused yesterday. So, you record Rose as having new confusion, which gives a score of 3 in an individual parameter, making it a NEWS2 trigger by itself. Additionally, one other parameter has changed since the last set of physiological measurements, so her NEWS2 score has now increased to 6.

When you check Rose’s physiological measurements since admission in the chart shown on the right, you can see how she has deteriorated gradually. Your current assessment shows that she is now in the category of medium clinical risk, requiring an urgent response from a clinician or team who can assess and treat acutely ill patients. You report to the nurse in charge and she agrees with your assessment that Rose’s treatment requires escalation to the medical team.

NEWS key0 1 2 3

DATETIME

≥2521-2418-2015-1712-14

9-11≤8

≥97 on O295-96 on O293-94 on O2

≥93 on air88-9286-8784-85≤83%

≥2521-2418-2015-1712-149-11≤8

≥9694-95 92-93

≤91

DATETIME


DATE OF BIRTH:

FULL NAME:

3

31

2

≥220201-219181-200161-180141-160121-140111-120101-11091-10081-9071-8061-7051-60

≤50

≥220201-219181-200161-180141-160121-140111-120101-11091-10081-9071-8061-7051-60≤50


3

3

12

≥131121-140111-120101-11091-10081-9071-8061-7051-6041-5031-40≤30

≥39.1°38.1-39.0°37.1-38.0°36.1-37.0°35.1-36.0°≤35.0°

≥39.1°38.1-39.0°37.1-38.0°36.1-37.0°35.1-36.0°

≤35.0°

≥131121-140111-120101-11091-10081-9071-8061-7051-6041-5031-40

≤30

CPulseBeats/min

3

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AlertConfusionVPU

AlertConfusion

VPU


3

A=AirO2L/min Device

3

12

3

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ETemperature°C

3

2

DATE OF ADMISSION:

≥97 on O295-96 on O293-94 on O2≥93 on air88-9286-8784-85≤83%

≥9694-95 92-93≤91

A=AirO2L/min Device


Air or oxygen?

SpO2 Scale 2†



2

NEWS TOTAL


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ROSE SUMMERS

1/2/19361/ 1/5 5 1/5 2/5 2/51500 1845 22000330 0830

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RCRC RCRCRC

Case study 1: The importance of recognising trends

ObservationsAdults


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You are working a night shift on a respiratory ward and have just received a 68-year-old patient, Donald Russell, from the emergency department who is being admitted with a severe chest infection that has exacerbated his chronic obstructive pulmonary disease (COPD). The nurse handing over informs you that the patient’s symptoms have worsened over the last 2 days, so he is being admitted for intravenous antibiotics and oxygen therapy. From Donald’s notes, you can see that, when recording physiological measurements on the NEWS2 chart, you must use SpO2 scale 2 and that his target oxygen saturation is 88–92 per cent because arterial blood gas has confirmed that he has hypercapnia (a high carbon dioxide level), and the medical team have confirmed that this is normal for Donald. The nurse tells you that his last NEWS2 score, recorded an hour ago, was 4. After you have settled Donald in, you record a set of physiological measurements and note that his NEWS2 score remains at 4, requiring a ward-based response, pending further blood gas analysis (he remains a high-risk patient). You decide to monitor his physiological measurements and NEWS2 score every 4 hours.

The NEWS2 chart shows that Donald has remained stable since administration of his first dose of intravenous antibiotics, oral prednisolone and paracetamol, and he has responded well to oxygen therapy.

Both case studies illustrate that trends are more important than a single reading. Clinicians must ascertain what is normal for each individual patient. Any patient with a chronic lung condition who scores below SPO2 scale 1 or scale 2 should have an individual threshold documented and assessed daily (RCP, 2017). Always check for environmental issues or patient factors that may impact on the physical measurements you take, including: • Comorbidities;• Pain;• Anxiety;• Medication, e.g. beta-blockers, digoxin, opiates, antipyretics or anti-inflammatories;• Caffeine/nicotine; and• Exercise.

NEWS key0 1 2 3

DATETIME

≥2521-2418-2015-1712-14

9-11≤8

≥97 on O295-96 on O293-94 on O2

≥93 on air88-9286-8784-85≤83%

≥2521-2418-2015-1712-149-11≤8

≥9694-95 92-93

≤91

DATETIME


DATE OF BIRTH:

FULL NAME:

3

31

2

≥220201-219181-200161-180141-160121-140111-120101-11091-10081-9071-8061-7051-60

≤50

≥220201-219181-200161-180141-160121-140111-120101-11091-10081-9071-8061-7051-60≤50


3

3

12

≥131121-140111-120101-11091-10081-9071-8061-7051-6041-5031-40≤30

≥39.1°38.1-39.0°37.1-38.0°36.1-37.0°35.1-36.0°≤35.0°

≥39.1°38.1-39.0°37.1-38.0°36.1-37.0°35.1-36.0°

≤35.0°

≥131121-140111-120101-11091-10081-9071-8061-7051-6041-5031-40

≤30

CPulseBeats/min

3

3

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AlertConfusionVPU

AlertConfusion

VPU


3

A=AirO2L/min Device

3

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3

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ETemperature°C

3

2

DATE OF ADMISSION:

≥97 on O295-96 on O293-94 on O2≥93 on air88-9286-8784-85≤83%

≥9694-95 92-93≤91

A=AirO2L/min Device


Air or oxygen?

SpO2 Scale 2†



2

NEWS TOTAL


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DONALD RUSSELL

20/3/19522/52/52/52/52/51800 1840 1945

2030 2145

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What is normal for the patient?

Case study 2: Assess what is normal for the individual patient

ObservationsAdults

Recording and interpreting the National Early Warning ...

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