Using NEWS2: an essential component of reliable clinical assessment

How NEWS2 is used in practice in the UK

NEWS2 uses respiratory rate, oxygen saturation, need for oxygen therapy, heart rate, blood pressure, level of consciousness/confusion and temperature in an ‘airway, breathing, circulation, disability and exposure’ framework. It can be used in all adults over 16 years of age, though more specific scoring systems should be used in pregnancy. It is a general assessment for all clinical scenarios. Changes or stability of measures and scores over time are particularly helpful to understand the patient's condition, risk, recovery, stabilisation or deterioration.

It is essential that NEWS2 informs and is part of the clinical judgement of a patient's condition, risk and illness course. Many other factors will be involved in that clinical assessment. A high combined NEWS2 or individual parameter red scores should trigger escalation (patients are sometimes said to be ‘NEWS-ing’). Condition-specific observations should be used alongside NEWS2 that might also trigger escalation. Escalation trigger points are for more detailed clinical assessments because of illness severity, risk of deterioration or change in condition. Patients should be informed and involved in assessments and decisions.

NEWS was initially validated for use on general medical and surgical wards before it spread to emergency departments and then pre-hospital services as evidence and experience in these areas developed.^5,6 The National Institute for Health and Care Excellence (NICE) recommends that these parameters are recorded at the time of hospital admission or initial assessment; a recent audit of 156 hospitals showed that this was achieved within 30 minutes in 77% of patients.^7,8 NEWS2 values guide frequency of ongoing observations, and the need for escalation (Table 1).⁹

Standardised charts should be used, with associated training, as these will ensure consistency and familiarity of use across care settings and organisations (Scenario 1).⁹

The response to escalation requires a structured review that includes time of escalation, time and grade of clinical response, clinical assessment, and plan (including a treatment plan and an individualised trigger score (threshold) for further escalation). Modifications to escalation thresholds are needed with particular diagnoses, prognosis, comorbidities, patient's wishes and treatment limitation plans (including do not attempt cardiopulmonary resuscitation and end-of-life pathways). These situations, therefore, require an appropriately competent clinical decision maker, and clear documentation and communication with the care team and patient (Scenario 2).

In practice, use of NEWS2 is variable. One ethnographic study found that 42% of behaviours were not as expected when ward staff measured and recorded vital signs (on paper or in an electronic health record (EHR)), calculated NEWS2 or escalated care.¹⁰ Examples included respirations counted without sight of a clock, oxygen saturation measured on patients’ ears with devices designed for fingers, poor practice in the assessment of consciousness and vital signs written on paper towels before transcription into the EHR sometime later. Moreover, the recorded NEWS2 was usually lower than that calculated by the researcher; the accurate assessment would have upgraded the associated risk level and actions required in 27% of cases. EHRs, however, increase accuracy of calculations of scores and alerts to trigger a response.¹¹

High patient acuity, dependency or throughput (or reduced staffing levels) make effective monitoring, recognition of deterioration, appropriate escalation and timely response less likely.¹² Poor team-working and hierarchical structures also contribute to suboptimal processes.

Clinicians and managers should work to understand the barriers and enablers that affect best use of the NEWS2 system and ensure that local structures and processes demonstrably protect patients at risk of deterioration.¹³ Critically, any early warning score only has value if there is a reliable, timely and effective response: a dependable whole rapid response system is required.^13,14 Most acute hospitals now have medical emergency, rapid response or critical care outreach teams who act as the experts in responding and supporting deteriorating patients who are triggering on NEWS2.

Limitations of NEWS2

Many acutely unwell patients are elderly with multiple, interacting, complex long-term conditions. Clinical history, examination and investigations are all crucial, and ongoing measurement of the NEWS2 will be enhanced by other routine assessments to effectively monitor the patient (Table 2). While NEWS2 scores discriminate patients most and least likely to deteriorate (and to die) within 24 hours, facilitating rapid escalation, completion of all assessments or investigations must not delay lifesaving treatment.¹⁵ Clinical judgement and any concerns about a patient's condition should override the NEWS2 if the attending healthcare professional thinks that it is necessary to escalate.⁹ In practice, such indicators as pallor, breathing pattern, bleeding, ‘personality change’, patient complaint, peripheral temperature and patient fatigue are used to both supplement and sometimes take precedence over NEWS2 (Scenario 3).¹² This is also important if any NEWS2 parameters have not been captured.

The recent Academy of Medical Royal Colleges sepsis guidance emphasises the value of NEWS2 in assessing acuity of illness, but recommends that if there are ‘concerns about the patient's condition ... the severity status and accompanying actions should be upgraded according to patient need, and at least to the next NEWS band.’¹⁶

NEWS2 scoring for oxygen supplementation is binary (yes/no). In patients with COVID-19 needing oxygen therapy, oxygen requirements can rapidly increase if respiratory function deteriorates. This may not cause an additional rise in the NEWS2 value. Therefore, increasing oxygen requirements in patients with COVID-19 should trigger escalation to a competent decision maker.⁹ It is logical to apply this to other causes of respiratory failure (Scenario 4).

Patients’ self-reported and/or relatives’ view of how the patient is compared with their normal state are important elements of assessment. The patient should be asked how they feel when vital signs are measured or if there are any concerns or other adverse signs. The reasons for the patient's distress must be clarified, any changes in physical or mental state or behaviour noted and escalated for clinical assessment. Creating reliable means for patients or their families/carers to escalate worries and concerns about their illness and deterioration when standard care is inadequate can provide an invaluable safety net.¹⁷

Using NEWS in context

NEWS2 will be measured in hospitals on initial assessment at presentation, continued at an appropriate frequency throughout the hospital stay in most adult patients and, as noted earlier, it should always be seen as part of a clinical assessment. The main inappropriate use of NEWS2 is when it is looked at either as an overall score in isolation or without considering the overall clinical context.

On initial assessment in hospital, any measures prior to attendance should be sought to understand any changes, and it must be set in the context of the presenting problems. Frequency of repeated measures will be determined by the initial assessment, but can be modified following full clinical assessment if there are other indications of disease severity despite a normal or low NEWS2, or if the patient has levels that they live with that may be persistently raised. It is also important to understand which of the measures is contributing to the score, and what individual parameters are abnormal even if they are not themselves ‘scoring’ (eg pulse rate with blood pressure or respiratory rate). Therefore, a single NEWS2 score, if raised without clinical context or component parts, is an inadequate assessment. Treatments should target the underlying cause and not just ‘correcting the numbers’.

As illustrated in Scenario 2, a high NEWS2 score can indicate that someone is nearing the end of their life. If persistently raised and treatment of causes are not proving effective, consideration of palliation must be part of the plan if further treatment escalation is not possible or desirable, and measuring NEWS2 components discontinued.

Clinical assessment incorporating NEWS2 should result in a monitoring plan that includes the escalation thresholds for the individual patient. Local systems must, therefore, be able to record when escalation thresholds and monitoring frequency change for the individual patient beyond the generic approach.

Automated alerting systems also need to be configured appropriately to prevent ‘alert fatigue’, so that a ‘new’ score at the agreed individual threshold should create an alert, but continued scores at this level without recovery should not automatically trigger. Ongoing clinical review and trigger thresholds should be established following the initial triggered review.

As illustrated in Scenarios 3 and 4, a normal or mildly raised NEWS2 score, does not exclude severe illness, or the need to trigger a clinical review. Patients may be assessed to have severe illness on initial or subsequent clinical assessment. Their underlying or acute condition may have other elements of monitoring (eg capillary blood glucose or oxygen requirements), which in themselves should have thresholds that trigger further clinical assessment.

Future opportunities

A NEWS2 value is simply calculated from just seven easily obtained measures. Early warning scoring systems that use NEWS2 parameters but also many more variables including combinations of vital signs, laboratory datasets, patient age, comorbidities and frailty have been shown to have greater predictive accuracy than NEWS2, although they require that data to be available and significant processing power to compute.^18,19 On a less sophisticated level, more detailed analysis of NEWS2 at particular time points, and its trends and changes over time may yield greater predictive power too.²⁰

Other technological advances include wireless wearable patient monitors that provide continuous or semi-continuous vital-sign data that can enable much more frequent calculation of the NEWS2. One recent before–after study with medical and surgical patients suggested that use of such a system reduced the number of escalations required and unplanned admissions to critical care.²¹ Wireless wearable systems to monitor patients at home that will allow earlier discharge from hospital and reduction of preventable admissions are under investigation.

On a more human level, NHS England is supporting a national programme to develop, test and evaluate reliable methods for patients (or their families/carers) to routinely input their views (especially regarding their wellness/illness and trajectory) as well as their worries and concerns into the health record, with evidence that those views and concerns are considered and acted on by the healthcare team. It is hypothesised that these approaches will supplement NEWS2 monitoring and enhance more reliable, earlier detection of deterioration.²²

Summary and conclusion

NEWS2 is a well-established, validated, easy to use track and trigger system for illness severity and the risk of deterioration. While used throughout the NHS, research suggests that it is not always used accurately, and there are risks that less experienced clinicians might place an over reliance on its measures without considering its limitations or the wider clinical context.

Digitisation of measurement and the use of AI give opportunities for more accurate measurement and triggering of response, and also the addition of other measurements that can assess illness severity, deterioration, risk and recovery.

Emphasis should be given to the consistent and accurate use of NEWS2 within and across pathways of care and care settings as part of clinical assessment. Clinical judgement remains paramount. Patient, clinician and family concerns can add significantly to assessment. Other measures that are disease specific should be used alongside NEWS2. The response to a trigger must be a detailed clinical assessment that can determine intervention, ongoing monitoring and escalation requirements for the individual patient, and sometimes palliation with cessation of measuring NEWS2.