The Royal College of Physicians of London, in its 2007 report “Acute Medicine: the right person, in the right setting – first time”, recognised that a standardised early warning score, used across the NHS could provide a step change in improving clinical outcomes in people with acute illness. Subsequent to this report, RCPL commissioned a group to develop an NHS Early Warning Score (NEWS), designed for use across the NHS.
The draft copy of this report has now been circulated, along with a draft NEWS chart. Stakeholder in acute care in the NHS were invited to give candid reviews and comments on the draft document. RCPL's intention is to review the comments of major stakeholders and then generate a pre-final draft document which will then be submitted to the RCPL's Council for further review prior to generating the final draft for publication.
The document will be supported by web-based educational materials, currently under development, to assist in the training and implementation of the NEWS. Additionally, downloads of the main document and charts will also be made available at the time of publication. RCPL's intention is to see NEWS widely adopted across the NHS, as the main early warning score. RCPL views the establishment of a single EWS, i.e. the NEWS as being key to the standardising assessment and response to acutely ill patients, as well as facilitating education and training in the management of the acutely ill patient, wherever they might be.
COMMENTS ON ROYAL COLLEGE OF PHYSICIANS OF LONDON
NHS EARLY WARNING SCORE (NEWS)
The Royal College of Physicians of Edinburgh has contributed to the development of this very positive initiative through membership of the design and implementation steering group. The College is supportive of the proposals and we would be happy to take the finalised version through our own Council with a view to a formal endorsement of the report and resulting NEWS tool once the final version is available. The College also believes that patient safety across the UK would be improved if a similar approach could be adopted in the devolved administrations, and would be pleased to contribute to the promotion of a UK-wide implementation strategy.
We have a few questions/comments from some of our non-physician Fellows, who are also broadly supportive of the initiative. If these points have been discussed previously by the working group, it may be useful to incorporate this into the final document to inform others who may raise them again:
- It may help readers if the order of the parameters in the explanatory document matches the proposed order in the observation chart.
- Wider adoption of the score chart may be supported by ensuring that zero values reflect the normal ranges for each parameter. The respiratory ranges may merit review in this regard. Also, it has been suggested that lower pulse rates may merit a higher score than proposed; namely 41-50 scoring 2, and 51-60 scoring 1, leaving 61-90 as the 0 score.
- Should blood sugar levels be included with a suggested interval of <4->14 mmol/l?
- It would be helpful to understand why pain, although recorded as a symptom by clinical teams, is not felt appropriate for inclusion within the NEWS scoring system other than as part of the consciousness level. Also, our anaesthetist colleagues suggest that the presence of pain (or lack of response to pain) should always score 3 in an early warning system.
- It would also be helpful to understand how this scorecard can be used consistently in pre- hospital care, and the team reviewing the final version may find a recent commentary in the Journal of Emergency Medicine helpful (Emerg Med J 2011;28:263 doi:10.1136/emj.2010.106104).
Finally, we understand that despite the wide use of score charts it has been difficult to demonstrate an improvement in patient outcomes following their introduction, and that the proposed chart has itself been evaluated retrospectively rather than prospectively. An editorial article in the Journal of Anaesthesia supports this point (British Journal of Anaesthesia 98 (6) 704-6 (2007)). Again, would further piloting and prospective evaluation support the case for national adoption?