What’s behind the NEWS? National Early Warning Scores in primary care

Samuel Finnikin; Veronica Wilke

doi:10.3399/bjgp20X709361

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Changes in posture may help NEWS2 detect sepsis.
Stephen J. Katona

Published on: 10 November 2023
NEWS2: Unvalidated for primary care
Tom Mallinson

Published on: 07 September 2020
What’s behind the NEWS? National Early Warning Scores in primary care
Alex P. Burns

Published on: 28 June 2020
National Early Warning scores in primary care
Janet P. Watters

Published on: 25 June 2020

Published on: (10 November 2023)
Page navigation anchor for Changes in posture may help NEWS2 detect sepsis.
Changes in posture may help NEWS2 detect sepsis.
Stephen J. Katona, GP OOH, GTD Healthcare
Finnikin and Wilke¹ rightly conclude we cannot send every feverish patient to hospital to detect every case of sepsis. Deciding who to send might be easier if NEWS2 used systolic blood pressure (SBP) and heart rate (HR) readings from two postures², either lying flat (L) or tilted, sitting legs down or horizontal (SIT or SLH) or standing (S).

SBP and HR readings in 75 out-of-hours patients with postural changes L/S (n=17), L/SLH (n=3), L/SIT (n=1) and SIT/S (n=54) were converted to a single score using the formula:

(SBP^LP/SBP^HP) x (HR^HP/HR^LP)
where LP = lowest posture and HP = highest posture

I refer to this score as the mnemonic ABCDS³ to remind me high values can be due to anaphylaxis⁴, autonomic dysfunction⁵, bleeding^6,7, cardiac dysfunction^8,9, dehydration^6,7 and sepsis¹⁰.

NEWS2 scores were adjusted by adding ((10* (ABCDS – 1) – 1) if the postural change was lying to standing or (10* (ABCDS – 1)) for lesser changes in posture.

Adjustments for 15 patients assessed by telephone calls to paramedics were -1 (n=5), 0 (n=3), +1 (n=6) and +3 (n=1). Adjustments for the other 60 were -1 (n=13), 0 (n=11), +1 (n=10), +2 (n=12), +3 (n=3), +4 (n=4), +5 (n=4) and >5 (n=3). 4/60 patients were identified as having probable sepsis, A and D seen as home visits and B and C assessed...
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Finnikin and Wilke¹ rightly conclude we cannot send every feverish patient to hospital to detect every case of sepsis. Deciding who to send might be easier if NEWS2 used systolic blood pressure (SBP) and heart rate (HR) readings from two postures², either lying flat (L) or tilted, sitting legs down or horizontal (SIT or SLH) or standing (S).

SBP and HR readings in 75 out-of-hours patients with postural changes L/S (n=17), L/SLH (n=3), L/SIT (n=1) and SIT/S (n=54) were converted to a single score using the formula:

(SBP^LP/SBP^HP) x (HR^HP/HR^LP)
where LP = lowest posture and HP = highest posture

I refer to this score as the mnemonic ABCDS³ to remind me high values can be due to anaphylaxis⁴, autonomic dysfunction⁵, bleeding^6,7, cardiac dysfunction^8,9, dehydration^6,7 and sepsis¹⁰.

NEWS2 scores were adjusted by adding ((10* (ABCDS – 1) – 1) if the postural change was lying to standing or (10* (ABCDS – 1)) for lesser changes in posture.

Adjustments for 15 patients assessed by telephone calls to paramedics were -1 (n=5), 0 (n=3), +1 (n=6) and +3 (n=1). Adjustments for the other 60 were -1 (n=13), 0 (n=11), +1 (n=10), +2 (n=12), +3 (n=3), +4 (n=4), +5 (n=4) and >5 (n=3). 4/60 patients were identified as having probable sepsis, A and D seen as home visits and B and C assessed by telephone.

Patient A: SaO2 90%, (L) SBP112 HR66 NEWS2=3, (SLH) SBP82 HR134 NEWS2=8, ABCDS 2.8, Adjustment +18

Patient B: (L) SBP150 HR72 NEWS2=0, (S) SBP=111 HR98 NEWS2=1, (L) SBP161 HR68, (S) SBP109 HR100, ABCDS 1.8 and 2.2, Adjustment +7 or +11

Patient C: Temp 37.5, (SIT) SBP128 HR100 NEWS2=1, (S) SBP100 HR116 NEWS2=4, (L) SBP154 HR98 NEWS2=1, (S) SBP110 HR114, ABCDS 1.6 and 1.8, Adjustment +5 or +7

Patient D: Temp 39.0, (L) SBP 116 HR125 NEWS2=3, (SLH) SBP74 HR108 NEWS2=6, ABCDS=1.4, Adjustment +4

The NEWS2 scores were increased in four patients with probable sepsis. Studies are needed to confirm whether ABCDS scores can help us detect more cases of sepsis without sending more patients to hospital.

References

1. Finnikin S, Wilke V. What's behind the NEWS? National Early Warning Scores in primary care. Br J Gen Pract. 2020; 70(695):272-273. doi: 10.3399/bjgp20X709361
2. Phipps D, Butler E, Mounsey A, Dickman MM, Bury D, Smith A, Bennett N, Arthur B, Marshall B. PURL: Best timing for measuring orthostatic vital signs? J Fam Pract. 2019; 68(9):512-514.
3. Katona SJ. JSCalc.io http://www.abcds.co.uk.
4. Brown SG. The pathophysiology of shock in anaphylaxis. Immunol Allergy Clin North Am. 2007; 27(2):165-75.
5. Purewal TS, Watkins PJ. Postural hypotension in diabetic autonomic neuropathy: a review. Diabet Med. 1995; 12(3):192-200. doi: 10.1111/j.1464-5491.1995.tb00458.x.
6. McGee S, Abernethy WB 3rd, Simel DL. The rational clinical examination. Is this patient hypovolemic? JAMA. 1999; 281(11):1022-9. doi: 10.1001/jama.281.11.1022.
7. Witting MD. When and how to use orthostatic vital signs. J Emerg Med. 2022; 63(3):460-466. doi: 10.1016/j.jemermed.2022.09.007.
8. Ruwald MH. Syncope and orthostatic hypotension: early markers of cardiac disease in the general population. Heart. 2018; 104(6):456-457.
9. Ho CH, Wu YC, Lin YY, Hsu CW, Tsai SH. Postural hypotension as the initial presentation of fulminant right ventricular myocarditis. Am J Emerg Med. 2010; 28(6):708-10.
10. Jacobi J. The pathophysiology of sepsis - 2021 update: Part 2, organ dysfunction and assessment. Am J Health Syst Pharm. 2021; zxab393. doi: 10.1093/ajhp/zxab393.
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Competing Interests: The domain name www.abcds.co.uk is owned by the author.
Published on: (7 September 2020)
Page navigation anchor for NEWS2: Unvalidated for primary care
NEWS2: Unvalidated for primary care
Tom Mallinson, Prehospital Care Doctor, BASICS Scotland
While it is interesting to discuss the use of the NEWS2 tool in the community, it is worth noting, as NHS England have, that "there is currently limited evidence for the predictive value of NEWS2 in the community or a primary care setting"¹ and that its use in this setting is unvalidated. Furthermore, the clinical response guidance attached to the various NEWS2 scores appear to be totally inappropriate and unachievable in primary care, which is unsurprising as the document was written for an in-patient population. To explore the lack of usefulness of NEWS2 to the primary care population, a small audit was undertaken.

The author undertook convenience sample of 20 consecutive patient contacts seen as acute same-day home visits by a rural general practice team.² The consultation notes and outcomes within 5 days were reviewed. Out of the 20 home visit case records audited, fifty five percent (n=11) had a NEWS2 score of zero, ten percent (n=2) had a score of 1, five percent (n=1) had a score of 2, and twenty five percent (n=5) had a score of 3. One patient (5%) had a NEWS2 score of 9 and none had a NEWS2 score above 9. NEWS2 scores did not appear to correlate to patient outcome, with only two admissions to hospital occurring within five days (scoring zero and 1). In this small data set, NEWS2 did not predict patient outcome within five days. The highest scoring patient, with a NEWS2 score of 9, was...
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While it is interesting to discuss the use of the NEWS2 tool in the community, it is worth noting, as NHS England have, that "there is currently limited evidence for the predictive value of NEWS2 in the community or a primary care setting"¹ and that its use in this setting is unvalidated. Furthermore, the clinical response guidance attached to the various NEWS2 scores appear to be totally inappropriate and unachievable in primary care, which is unsurprising as the document was written for an in-patient population. To explore the lack of usefulness of NEWS2 to the primary care population, a small audit was undertaken.

The author undertook convenience sample of 20 consecutive patient contacts seen as acute same-day home visits by a rural general practice team.² The consultation notes and outcomes within 5 days were reviewed. Out of the 20 home visit case records audited, fifty five percent (n=11) had a NEWS2 score of zero, ten percent (n=2) had a score of 1, five percent (n=1) had a score of 2, and twenty five percent (n=5) had a score of 3. One patient (5%) had a NEWS2 score of 9 and none had a NEWS2 score above 9. NEWS2 scores did not appear to correlate to patient outcome, with only two admissions to hospital occurring within five days (scoring zero and 1). In this small data set, NEWS2 did not predict patient outcome within five days. The highest scoring patient, with a NEWS2 score of 9, was managed in the community with no need for admission, and was alive five days later. The only patient to die within five days scored 3, and this was an expected death.

As others have noted, using an unvalidated tool to guide decision-making and resource allocation is not without risks, and it appears significant modifications are likely to be needed before formal validation can be attempted in relation to the use of NEWS2 in primary care.

References
1. NHS England. NEWS frequently asked questions, 2019. Available: www.england.nhs.uk/ourwork/clinical-policy/sepsis/nationalearlywarningscore/news-frequently-asked-questions [Accessed 20 01 2020].
2. Mallinson, T. NEWS2 Audit Data: Table 1 - Case Analysis Data. 2020. Available: http://dx.doi.org/10.13140/RG.2.2.19132.05762 [Accessed 07 09 2020].

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Competing Interests: None declared.
Published on: (28 June 2020)
Page navigation anchor for What’s behind the NEWS? National Early Warning Scores in primary care
What’s behind the NEWS? National Early Warning Scores in primary care
Alex P. Burns, GP, Three Spires Medical Practice
Finnikin et al¹ rightly urge caution before widespread roll out of the NEWS2 score. We must acknowledge the NEWS’ successful use in communication but demand better evidence before adopting it as a diagnostic score.

Scott et al ² describe the reluctance from GPs to use the NEWS score in clinical reasoning, and offer “preference for observing symptoms, clinical instinct, and a lack of validated studies conducted in primary care” as reasons. A low predictive value might be added to this list.

NEWS scores are validated in secondary care^3-6 and it should not surprise us that NEWS may have validity in patients who are being sent to secondary care: they should be, after all, similar populations. To assume the same applies in the general primary care population is a Bayesian “base rate neglect”.

Bayes theorem tells us that the predictive value of scores, as with other tests, changes with the probability of the target disorder in the population it is applied to. The lower the disease probability, the lower the positive predictive value.

The proponents of NEWS2 argue that it “assists but does not replace clinical judgement”, ⁷ but the accompanying example invariably features the astute clinician admitting/escalating despite a low score, and rarely the cou...
Show More

Finnikin et al¹ rightly urge caution before widespread roll out of the NEWS2 score. We must acknowledge the NEWS’ successful use in communication but demand better evidence before adopting it as a diagnostic score.

Scott et al ² describe the reluctance from GPs to use the NEWS score in clinical reasoning, and offer “preference for observing symptoms, clinical instinct, and a lack of validated studies conducted in primary care” as reasons. A low predictive value might be added to this list.

NEWS scores are validated in secondary care^3-6 and it should not surprise us that NEWS may have validity in patients who are being sent to secondary care: they should be, after all, similar populations. To assume the same applies in the general primary care population is a Bayesian “base rate neglect”.

Bayes theorem tells us that the predictive value of scores, as with other tests, changes with the probability of the target disorder in the population it is applied to. The lower the disease probability, the lower the positive predictive value.

The proponents of NEWS2 argue that it “assists but does not replace clinical judgement”, ⁷ but the accompanying example invariably features the astute clinician admitting/escalating despite a low score, and rarely the counterfactual. In primary care, where the majority have minor illness (or no illness at all), the positive predictive value of any score is lower than in secondary care, and clinical judgement overriding concerning observations is thus the norm, and not the exception.

We should heed Finnikin et al’s warning about “systematising NEWS”. By using it in communication we may “interfere with clinical decision making” and create an unevidenced “cognitive shortcut”.

George Orwell⁸ would agree: “...language can also corrupt thought”

References
1. Finnikin S, Wilke V, What’s behind the NEWS? National Early Warning Scores in primary care. Br J Gen Pract 2020; 28;70(695):272-273.
2. Scott LJ, Redmond NM, Tavare A, et al. Association between National Early Warning Scores in primary care and clinical outcomes. Br J Gen Pract 2020; 70 (695): e374-e380.
3. Fernando SM, Fox-Robichaud AE, Rochwerg B, et al. Prognostic accuracy of the Hamilton Early Warning Score (HEWS) and the National Early Warning Score 2 (NEWS2) among hospitalized patients assessed by a rapid response team. Crit Care 2019; 21;23(1).
4. Nannan Panday RS, Minderhoud TC, Alam N, et al. Prognostic value of early warning scores in the emergency department (ED) and acute medical unit (AMU): A narrative review. Eur J Intern Med 2017; 45 p. 20–31.
5. Redfern OC, Smith GB, Prytherch DR, et al. A comparison of the Quick sequential (Sepsis-related) Organ failure assessment score and the National early warning score in non-ICU patients with/without infection. Crit Care Med 2018; 46(12):1923–33.
6. Pimentel MAF, Redfern OC, Gerry S, et al. A comparison of the ability of the National Early Warning Score and the National Early Warning Score 2 to identify patients at risk of in-hospital mortality: A multi-centre database study. Resusc 2019; 1; 134:147–56.
7. NHS England. NEWS frequently asked questions. www.england.nhs.uk/ourwork/clinical-policy/sepsis/nationalearlywarningscore/news-frequently-asked-questions/
8. Orwell, G. 1984. New York, NY: Published by Signet Classic, 1977.

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Competing Interests: None declared.
Published on: (25 June 2020)
Page navigation anchor for National Early Warning scores in primary care
National Early Warning scores in primary care
Janet P. Watters, GP OOH, BELFAST HEALTH AND SOCIAL CARE TRUST
I first heard of National Early Warning Scores (NEWS)¹via an article in the BMJ in 2012,² and went on to read about it via other websites. It immediately struck me that the baseline observations should start when a patient is first seen, i.e. in general practice. Thus, I started routinely recording the recommended observations. I did not add up a formal score, but found that conscious thought about the normality/abnormality of clinical observations was immensely helpful to my decision making, particularly taking the time to formally record respiratory rate and oxygen saturation. These recordings are slightly more time consuming than 'gut feeling', but enable a conscious consideration of 'How sick is this patient?' My change in practice made me consider sepsis earlier, than I had before starting to use these observations routinely. If the observations were normal but I was still unhappy with a patient's clinical status, I would still refer, especially young children, where a drop in respiratory rate and oxygen saturation comes later in illness. I would wholeheartedly recommend the use of NEWS 2 in primary care based on my own experience. The new guidelines re hypercapnic respiratory failure are a welcome addition.

References

1. Finnikin S, Wilke V. What's behind the NEWS? National Early Warning Scores in primary care....
Show More

I first heard of National Early Warning Scores (NEWS)¹via an article in the BMJ in 2012,² and went on to read about it via other websites. It immediately struck me that the baseline observations should start when a patient is first seen, i.e. in general practice. Thus, I started routinely recording the recommended observations. I did not add up a formal score, but found that conscious thought about the normality/abnormality of clinical observations was immensely helpful to my decision making, particularly taking the time to formally record respiratory rate and oxygen saturation. These recordings are slightly more time consuming than 'gut feeling', but enable a conscious consideration of 'How sick is this patient?' My change in practice made me consider sepsis earlier, than I had before starting to use these observations routinely. If the observations were normal but I was still unhappy with a patient's clinical status, I would still refer, especially young children, where a drop in respiratory rate and oxygen saturation comes later in illness. I would wholeheartedly recommend the use of NEWS 2 in primary care based on my own experience. The new guidelines re hypercapnic respiratory failure are a welcome addition.

References

1. Finnikin S, Wilke V. What's behind the NEWS? National Early Warning Scores in primary care. Br J Gen Pract 2020; 70(695):272-273. doi:10.3399/bjgp20X709361.

2. McGinnley A, Pearse R. A national early warning score for acutely ill patients. BMJ 2012; 345. DOI: 10.1136/bmj.e5310 (Published 08 August 2012).

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Competing Interests: None declared.