“I think one of our challenges sometimes is to know firstly does someone need to go to hospital, and secondly how urgently do they need to go in and how do we communicate that to the hospital – how worried we are about this patient when they can’t see them for themselves? That’s where I found the NEWScore so helpful. It immediately clarified in my mind that there was no doubt (this patient) needs to be in hospital. There was no doubt he needed 999, and as soon as I rang 999 it was clear from the other end that they knew they needed to respond quickly.”
Dr Jonathan Rees, GP, Brockway Medical Centre, Nailsea
Overview

Since 2015, all organisations within the West of England Patient Safety Collaborative (PSC) have been involved in a major programme to introduce the National Early Warning Score (NEWS) at all handovers of patient care – primary care, ambulance, hospital, community, and mental health.

Building on the successful outcomes of this work in the West of England, the National Quality Board has endorsed the adoption of NEWS across all NHS acute care, and NEWS2 has now spread into non-acute settings too. This is a key clinical priority for NHS England, and one of the workstreams supported by Patient Safety Collaboratives in the National NHS Patient Safety Strategy.

Background

NEWS and NEWS2 (updated with improvements identified during the implementation and evaluation of NEWS) are fully endorsed by NHS England and NHS Improvement and has become the national early warning system for identifying acutely ill patients – including those with sepsis – in hospitals in England. In April 2018 new CQUIN indicator guidance was produced which includes NEWS/NEWS2 relating to reducing the impact of serious infections, and CQUINs continue to highlight the importance of deterioration, with a CQUIN for deterioration in relation to unplanned critical care admissions in the 2022/23 planning guidance.

Structured observations, or early warning scores (EWS) had been used for some time to recognise deterioration in the acute hospital setting. In 2015, The Royal College of Physicians (RCP) introduced the National Early Warning Score (NEWS) to standardise the approach across England. The NHS alert NHS/PSA/RE/2016/005 requires all acute providers to standardise their approach to deterioration [1].

In 2015, approximately 7% of patient safety incidents reported to the National Reporting and Learning System (NRLS) as death or severe harm were related to a failure to recognise or act on deterioration [2]. Sepsis kills around 44,000 people per year in the UK [3]. NEWS was recommended by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) as a tool to enable early detection and treatment of sepsis [4].

The aim of this which started in 2015 was to standardise to NEWS across all acute trusts in the West of England AHSN West of England and to move the use of NEWS scores into pre-hospital care. By agreeing escalation triggers the aim was to facilitate early recognition of acute illness including sepsis. This also enabled standardised communication across the system so that acutely unwell patients could be seen at the right time in the right place by the right grade of clinician.

The Institute for Health Improvement’s Breakthrough Collaborative Approach was used to influence change across a whole system. This was supplemented by local health community meetings which met under existing NHS structures. This led to trusts and community providers using a standardised approach to recognising and responding appropriately to the deteriorating patient.

Following the success of the collaborative in acute settings, targeted communities of practice have been supporting the adoption and spread of NEWS2 into settings, including care homes, providers and care workers caring for people with a learning disability, and other non-acute settings, such as prisons. Learning from the NEWS2 collaborative and the Learning from Deaths mortality reviews, highlighted an opportunity to improve communication to enable clinical decision-making in emergency situations, and this led to our collaborative to implement ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) across our three ICS (integrated care systems).

Aims, objective and scope

The aim was for NEWS to be used at the point of a referral of acutely unwell patients and throughout their entire journey into secondary care. The use of NEWS is not recommended in children under the age of 16 and pregnant women was outside the scope of the project. Patient Safety Collaboratives are supporting the development and adoption of national PEWS (paediatric) and MEWS (maternity) early warning scores to complement NEWS2.

Using NEWS/2 at each handover of care as a standardised communication tool enables the sickest patients to be seen at the right time, in the right place by the right grade of clinician. The West of England Patient Safety Collaborative (PSC) wanted to show that NEWS/2 could be successfully used to identify sick patients, both inside and outside of secondary care settings.

Following the Royal College of Physicians (RCP) updated to NEWS2, we supported the region-wide transition to NEWS2.

Method and approach

The Institute for Healthcare Improvement’s breakthrough collaborative model was used. It is designed to close the gap between what is known and what is done by creating a structure in which interested organisations can easily learn from each other and from recognised experts in topic areas where they want to make improvements.

Teams from across the healthcare system met every six months at collaborative events. In addition, health community task groups met more frequently to lead the work where teams met under existing NHS structures. This was supported by the introduction of an emergency department collaborative and a primary care collaborative.

The approach included direct support in the form of project management support to standardise NEWS in the two Bristol hospitals, financial support to introduce NEWS into the electronic patient clinical record system for the ambulance service, and funding to enable data collection within emergency departments. The collaborative developed several resources to support implementation include training and communication materials, prompt cards, patient stories and videos.

Measurement plan

Measurement was built into the project approach, including local quality improvement measures collected on number and accuracy of NEWS/2 scores as process measures – presented on run charts at individual trust and aggregate level, and local audits. These were shared through the collaborative. The Suspicion of Sepsis dashboard developed by Imperial AHSN provided a way to measure and compare outcome metrics, and showed that the West of England was a positive outlier for mortality through early adoption of NEWS/2 at a system level, in comparison to other regions in the country.

Results and evaluation
  • Year 1 – all acute hospitals standardised to NEWS and NEWS was introduced to pre-hospital settings.
  • Year 2 – focused on NEWS at handover of care.
  • Year 3 – focusing on data measurement, evaluation and sustainability.
  • Year 4 – focus on supporting transition to NEWS2 and spreading use of NEWS2 into wider community settings, including care homes and learning disability settings.
  • All acute trusts, community services, mental health and ambulance services have now implemented NEWS.
  • NEWS/2 has been introduced to GP practices and some care homes.
  • The benefits of NEWS/2 to track patient deterioration can be demonstrated at handover of care.
  • A national survey has recently shown that all acute trusts, as well as the ambulance service, are using NEWS2.
  • The ambulance service have recorded NEWS scores for over 700,000 patients since April 2016.
  • All emergency departments now measure NEWS on arrival.
  • A rapid response team has used NEWS to avoid admission for patients in care homes.
  • Patient contributors continue to be involved and a patient video story has been shared.
  • We have performed qualitative and quantitative analysis of the programme which has been submitted for publication.
  • Early data using suspicion of sepsis codes suggests that WofE AHSN is a positive outlier for mortality from suspicion of sepsis and this has reduced since the start of the project in 2015.
Learning points

There was significant enthusiasm for the project as evidenced by the positive feedback forms received following each event. This enthusiasm was harnessed by the collaborative to push forward the project as most people understood the case for change and were keen to make it happen.

Some parts of the pathway were less familiar and less confident to standardise their approaches as their perception was that their own system/approach had worked to date and questioned the need to standardise. The response to this was to emphasise the clinical evidence, focus on the value of addressing human factors in designing safe systems of care, exploring at all time differences of opinion, and creating a coaching culture so ‘all learn, all teach.’

Implementing change in a complex system is difficult, and organisations were at different starting points in terms of Quality Improvement (QI) experience and knowledge of NEWS. The breakthrough model alone was not enough, and this was supplemented with meetings using traditional NHS structures, meetings, and project planning. The QI Academy at the West of England AHSN was also utilised to support QI training.

There was some reluctance to use NEWS2 at handover in the emergency department. An Emergency Department (ED) collaborative was set up to spread use of an ED checklist which included NEWS. By allowing EDs to modify the checklist and discuss the issues related to ED, this also engaged this group of clinical staff.

There was also a big advantage in having a single ambulance trust covering the region. This is because any handover between the ambulance service and another provider would use NEWS, meaning others began to adopt to share a common language.

Evidence from the qualitative analysis suggests digital enablers made NEWS2 easier to adopt. NEWS2 templates were put into GP IT systems such as EMIS and Adastra and SystmOne, and many organisations have or are in the process of implementing e-observation systems to enable easier recording and calculation of observations and NEWS2 scores.

Plans for spreading learning and encouraging adoption

Following implementation of NEWS at a system-level, the collaborative continued to support development aligned to the national CQUINs, as well as the transition to NEWS2. Targeted communities of practice looked at patient groups and pathways, including the West of England Learning Disability Collaborative, and the system-wide implementation of ReSPECT process (Recommended Summary Plan for Emergency Care and Treatment). Find out more, and watch our two animations developed with the support of the Resus Council, for patients and healthcare professionals at www.weahsn.net/respect

Start and end dates

March 2015 – ongoing

Contact us for help and advice
References

[1] The Royal College of Physicians. 2015. https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news (accessed 05 Sep 2017)
[2] NHS Improvement. 2014. https://improvement.nhs.uk/resources/learning-from-patient-safety-incidents/ (accessed 05 Sep 2017)
[3] The UK Sepsis Trust. 2014. https://sepsistrust.org/
[4] The National Confidential Enquiry into Patient Outcome and Death 2015.  http://www.ncepod.org.uk/2015report2/downloads/JustSaySepsis_FullReport.pdf

Publications

BMJ Emergency Medicine Journal: Prognostic value of National Early Warning Scores (NEWS2) and component physiology in hospitalised patients with COVID-19: a multicentre study

BMJ Emergency Medicine Journal: Distributions of the National Early Warning Score (NEWS) across a healthcare system following a large-scale roll-out

Resuscitation: Can early warning scores identify deteriorating patients in pre-hospital settings? A systematic review

BMJ Open: Using the National Early Warning Score (NEWS) outside acute hospital settings: a qualitative study of staff experiences in the West of England.

British Journal of General Practice: Implementation of the National Early Warning Score in patients with suspicion of sepsis: evaluation of a system-wide quality improvement project

British Journal of General Practice: Association between National Early Warning Scores in primary care and clinical outcomes: an observational study in UK primary and secondary care

BMJ Emergency Medicine Journal: NEWS used without clinical judgement is of limited value (A response to the Finnikin paper ‘Are referrals to hospital from out-of-hours primary care associated with National Early Warning Scores?’