Using NEWS to identify patient deterioration

Emergency departments (EDs) and acute medical units (AMUs) are coming under increasing strain, due to the rising number of patients being assessed and admitted. This has added to the pressure on quickly moving patients out of the ED and into beds on wards throughout the hospital. However, The Royal College of Physicians (RCP) recommends that patients admitted as emergencies should only be transferred out of the acute medical unit to a ward area that has the facilities to meet their clinical needs. This recommendation forms part of the Acute Care toolkit which also advises the use of the National Early Warning Score (NEWS),1 launched by the RCP in 2012 to rapidly identify patients who are severely ill or at risk of sudden deterioration. The acute care toolkit 6 – The medical patient at risk: recognition and care of the seriously ill or deteriorating medical patient – says that all patients admitted to an AMU should have their physiological status defined by a validated trackand- trigger tool as part of their reception to the unit2,3 to facilitate the rapid recognition of more severely ill patients. Commenting on the toolkit, Dr Rhid Dowdle, lead author said: “One of the major drivers for this toolkit was the identification of shortcomings in the care of seriously unwell medical patients by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). I hope the recommendations we have made will, if implemented, improve the care of this vulnerable group of patients.” After identifying their initial NEWS score, repeated NEWS values allows clinicians to track the progress of a patient and, in the event of a deterioration, should trigger an escalation in medical and nursing care. The NEWS score also guides the intensity of care required and matches the patient to the clinical area and staffing levels that are best able to provide the care needed at any point during a hospital stay. NEWS was introduced to offer a standardised mechanism for the indentification of critically ill patients in the acute setting to replace the many, disparate, early warning systems used in hospitals across the UK which have resulted in a lack of consistency, between Trusts, and in some cases even wards, in detecting deterioration in patients. The RCP believes that the wider adoption of NEWS in the NHS, including the emergency department and the prehospital sector, is key to standardising the assessment of, and response to, acute illness.

Clinical red flags

The toolkit highlights the importance of recognising certain clinical situations that define a patient at high risk. These have been termed clinical ‘red flags’4 which are not always associated with altered physiology. Red flag scenarios can be a collection of symptoms and signs suggestive of clinical risk to the patient, but which are not necessarily associated with altered physiology. Failure to recognise the significance of the following scenarios can have serious adverse clinical consequences for the patients: • Cardiac chest pain at rest lasting longer than 20 minutes. • Headache of dramatically sudden onset. • Recent onset headache with scalp tenderness and/or jaw claudication. • Palpitations associated with syncope. • Cauda equina syndrome. • Painful swollen calf. The RCP has also voiced concern about patients identified as requiring an intensity of monitoring and care greater than that available on a standard medical ward, stating that more enhanced care beds, with higher nurse to patient ratios, should be available on acute medical units. In addition, it says, hospitals should designate enhanced care beds on selected medical wards that are able to better manage acutely ill patients. The toolkit explains that, with reducing length of stay and the increasing development of alternatives to hospital admission, the acuity and complexity of illness in medical inpatients has increased, with implications for the provision of level 1-3 care. A population-based survey of critical care needs in 2000, for example, reported shortfalls, particularly of level 2 beds.5 Changes to clinical referral practices, including referral fatigue, where previous experiences of rejection alters the threshold for referral,6 can obscure the clinical need for level 2 critical care beds. Following initial and formal assessments, and the delivery of any immediate treatment, the newly admitted patient’s subsequent inpatient care should occur on a ward that has facilities appropriate to their clinical condition.2,7 While many patients with a NEWS score of 1-2 can be managed safely on an ordinary medical ward, patients with a NEWS score of 3-4 would qualify for level 1 care, as would all patients with medium scores. The RCP says that, with the help of critical care outreach services, a medical ward should be able to support a few patients needing level 1 care for a short period of time. However, this is dependent on the nursing skills and the skill mix of staff on a ward. Although patients with organ-specific illnesses benefit from care on specialty wards, the creation of level 1 beds on such wards is demanding of nurse and medical staffing. It was the strategy of co-locating patients needing intense monitoring and treatment that led to the development of critical care. There is merit to a crossspecialty approach to provision of level 1 beds, pooling resources and expert staff, says the RCP. It believes that the provision of level 1 beds on every AMU would enhance the ability to monitor and treat acutely ill patients and would also embed collaborative working with critical care staff on the AMU and highlight a cohort of medical patients at risk of requiring level 2-3 care. A final recommendation in the toolkit relates to ‘ceilings of care’ and advises that any patient who is terminally ill, or who has endured a prolonged period of documented illness not responding to treatment where it is agreed CPR would be futile, should not have to suffer the indignity of an inappropriate cardiopulmonary resuscitation (CPR) attempt.