Acta Anaesthesiol Scand 2014; 58: 377–379 Printed in Singapore. All rights reserved
© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/aas.12296
Editorial
Choose the NEWS you like? Reliable identification of risk necessary first step to safer systems C. P. Subbe1 and J. Sabin2 1
School of Medical Sciences, Bangor University, Bangor, Gwynedd, UK and 2Medicine, Ysbyty Gwynedd, Bangor, Gwynedd, UK
H
ospitals are dangerous places at best of times, even for patients who are not seriously ill.1 For those who develop critical illness after admission, recognition and treatment are often significantly worse than for those who are already critically ill on admission in the emergency department.2 This has led to the development of medical emergency teams (METs) for non-critical care areas to establish more reliable timely escalation.3–5 In 2007, the Royal College of Physicians in London published a document proposing the standardisation of the assessment of vital signs at the bedside in the form of a National Early Warning Score (NEWS). The document was the result of a working party that looked into the safety of acute hospitals services.6 The resulting working group met over 2 years to review the existing evidence and published a recommendation on NEWS in 2012.7 There were several reasons why we felt that this document on NEWS was needed. We saw overwhelming evidence that many opportunities to rescue deteriorating patients on our hospital wards were missed every day. We regarded the data on sensitivity and specificity of alert criteria as sufficient to recommend the usage of a scoring system that does not just allow for alerting health-care professionals to the potential for deterioration but additionally facilitates the monitoring of response to treatment. There were lively discussions on the choice of the score8 that were helped by the publication of a model based on a large database by Professors David Prydderch’s and Gary Smith’s group.9 Most of all, we felt that the standardisation of assessment tools was a sine qua non for safer health care. We wanted to be sure that nursing and medical students would leave their training with the same
understanding of the measures of critical illness and that patients would not be subjected to the risk of staff being unfamiliar with a local system because they worked in several different facilities previously. The Welsh deanery was the first to complete implementation of the new system in all hospitals in 2012. Since then, the roll-out has progressed throughout the UK. In 2013, the Irish Health Service Executive agreed the introduction of a national early warning score with a standardised chart to record vital signs.* At the same time, the related ViEWS9 is trialled by groups of Danish and Dutch hospitals following the same idea – that standardisation of safety systems is a crucial building block in building safer reliable health care for patients.10 In this context, the present paper by Tirkkonen et al.11 is a welcome piece of evidence to confirm that NEWS predicts adverse incidents in a different cohort of patients in a different health-care system. The authors show that in a group of unselected patients from a number of specialties that there is a significant association with high NEWS and patient in-hospital adverse events and mortality risk, suggesting that NEWS should be incorporated into protocols for escalation of patients to METs. The use of dichotomised activation criteria in the same paper appeared to only identify patients who have highly abnormal observations and did not pick up on the early decline towards this extreme – therefore potentially missing the window of opportunity to intervene in good time, potentially resulting in patients suffering cardiac arrests or being admitted
*http://www.hse.ie/eng/about/Who/clinical/natclinprog/ acutemedicineprogramme/ewsguidel.pdf (accessed 26 January 2014)
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C. P Subbe and J. Sabin
to intensive care more unwell than they might have been otherwise had the decline been picked up in a timely fashion. The increase in workload for METs would need to be considered if NEWS scores are utilised as it is worth noting that over twice as many patients would have triggered for escalation when NEWS scores were applied when compared with the existing set of criteria used at Tempere University Hospital (176 patients compared with 72 patients). The higher rate of trigger events with NEWS might create additional opportunities for rescue of sick patients, but it has implications for the workload of teams. This could in parts be regulated by determining the trigger threshold for a call-out: at a NEWS of 5 or more 22% of patients triggered, this is a high proportion of patients and MET teams in most hospitals would struggle to see all of them in a timely manner. In comparison at a NEWS of 7, only 6.5% triggered. This might allow a sustainable and reliable service. Of the 72 patients who had ‘positive’ MET activation criteria, only 10 actually had a MET activation. This would seem to suggest that even the current protocols are not being used optimally and that there are other factors influencing decisions to escalate a patient’s care. The reasons for this can only be speculated on – for example, it is possible that observations were subsequently repeated, possibly after intervention, and showed improvement or the patients in question may have always chronic physiological abnormalities such as those found in chronic obstructive pulmonary disease.12 The trend of observations can often be more significant than simply using one off-readings.13 It does however raise the important point that whichever scoring system is in place, it still requires the staff to have knowledge and understanding of the scoring implications in order for them to make a decision whether to act upon them. As a caveat, it is worth mentioning that a system with superior statistical properties does not necessarily result in better clinical outcomes in a complex system. Clinical studies need to examine the impact on reduction of adverse events and demonstrate how NEWS affects clinical practice. We need to also bear in mind that this study excluded patients who had do-not-attemptresuscitation decisions in place as they would not be suitable for escalation to critical care. It is reasonable to assume that many in this cohort of patients would probably have had high NEWS scores at some point and, even though they were not for escalation
378
beyond ward level, might still be suitable for treatment and intervention at ward level with potentially useful intervention by a MET or ward team to prevent clinical deterioration.14 After the present article, it is probably safe to say that the NEWSs has superior statistical properties to dichotomised call-out criteria. Human factors aspects of their implementation need to be the subject of further work. Conflict of interest: Neither of the authors has any conflict of interest to declare in relation to this manuscript.
References 1. Vlayen A, Verelst S, Bekkering GE, Schrooten W, Hellings J, Claes N. Incidence and preventability of adverse events requiring intensive care admission: systematic review. J Eval Clin Pract 2012; 18: 485–97. 2. Simpson HK, Clancy M, Goldfrad C, Rowan K. Admissions to intensive care units from emergency departments: a descriptive study. Emerg Med J 2005; 22: 423–8. 3. Winters BD, Pham JC, Hunt EA, Guallar E, Berenholtz S, Pronovost PJ. Rapid response systems: a systematic review. Crit Care Med 2007; 35: 1238–43. 4. Esmonde L, McDonnell A, Ball C, Waskett C, Morgan R, Rashidian A, Bray K, Adam S, Harvey S. Investigating the effectiveness of critical care outreach services: a systematic review. Intensive Care Med 2006; 32: 1713–21. 5. Tobin AE, Santamaria JD. Medical emergency teams are associated with reduced mortality across a major metropolitan health network after two years service: a retrospective study using government administrative data. Crit Care 2012; 16: R210. 6. Royal College of Physicians. Acute medical care: the right person, in the right setting – first time. London: RCP, 2007. 7. Royal College of Physicians. National Early Warning Score (NEWS): standardising the assessment of acute illness severity in the NHS. Report of a working party. London: RCP, 2012. 8. Gao H, McDonnell A, Harrison DA, Moore T, Adam S, Daly K, Esmonde I, Goldhill DR, Parry GJ, Rashidian A, Subbe CP, Harvey S. Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward. Intensive Care Med 2007; 33: 667–79. 9. Prytherch DR, Smith GB, Schmidt PE, Featherstone PI. ViEWS – towards a national early warning score for detecting adult inpatient deterioration. Resuscitation 2010; 81: 932– 7. 10. Rozich JD, Howard RJ, Justeson JM, Macken PD, Lindsay ME, Resar RK. Standardization as a mechanism to improve safety in health care. Jt Comm J Qual Saf 2004; 30: 5– 14. 11. Tirkkonen J, Olkkola KT, Huhtala H, Tenhunen J, Hoppu S. Medical emergency team activation: performance of conventional dichotomized criteria versus National Early Warning Score. Acta Anaesthesiol Scand 2014; 58: 411–9. 12. Eccles SR, Subbe C, Hancock D, Thomson N. CREWS: improving specificity whilst maintaining sensitivity of the National Early Warning Score in patients with chronic hypoxaemia. Resuscitation 2014; 85: 109–11. 13. Kellett J, Woodworth S, Wang F, Huang W. Changes and their prognostic implications in the abbreviated Vitalpac™
Choose the NEWS you like? early warning score (ViEWS) after admission to hospital of 18 853 acutely ill medical patients. Resuscitation 2013; 84: 13–20. 14. Pattison N, Ashley S, Farquhar-Smith P, Roskelly L, O’Gara G. Thirty-day mortality in critical care outreach patients with cancer: an investigative study of predictive factors related to outreach referral episodes. Resuscitation 2010; 81: 1670–5.
Address: Christian Subbe School of Medical Sciences Bangor University 21 Menai Quays Menai Bridge LL59 5DB UK e-mail: [email protected]
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© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/aas.12296
Editorial
Choose the NEWS you like? Reliable identification of risk necessary first step to safer systems C. P. Subbe1 and J. Sabin2 1
School of Medical Sciences, Bangor University, Bangor, Gwynedd, UK and 2Medicine, Ysbyty Gwynedd, Bangor, Gwynedd, UK
H
ospitals are dangerous places at best of times, even for patients who are not seriously ill.1 For those who develop critical illness after admission, recognition and treatment are often significantly worse than for those who are already critically ill on admission in the emergency department.2 This has led to the development of medical emergency teams (METs) for non-critical care areas to establish more reliable timely escalation.3–5 In 2007, the Royal College of Physicians in London published a document proposing the standardisation of the assessment of vital signs at the bedside in the form of a National Early Warning Score (NEWS). The document was the result of a working party that looked into the safety of acute hospitals services.6 The resulting working group met over 2 years to review the existing evidence and published a recommendation on NEWS in 2012.7 There were several reasons why we felt that this document on NEWS was needed. We saw overwhelming evidence that many opportunities to rescue deteriorating patients on our hospital wards were missed every day. We regarded the data on sensitivity and specificity of alert criteria as sufficient to recommend the usage of a scoring system that does not just allow for alerting health-care professionals to the potential for deterioration but additionally facilitates the monitoring of response to treatment. There were lively discussions on the choice of the score8 that were helped by the publication of a model based on a large database by Professors David Prydderch’s and Gary Smith’s group.9 Most of all, we felt that the standardisation of assessment tools was a sine qua non for safer health care. We wanted to be sure that nursing and medical students would leave their training with the same
understanding of the measures of critical illness and that patients would not be subjected to the risk of staff being unfamiliar with a local system because they worked in several different facilities previously. The Welsh deanery was the first to complete implementation of the new system in all hospitals in 2012. Since then, the roll-out has progressed throughout the UK. In 2013, the Irish Health Service Executive agreed the introduction of a national early warning score with a standardised chart to record vital signs.* At the same time, the related ViEWS9 is trialled by groups of Danish and Dutch hospitals following the same idea – that standardisation of safety systems is a crucial building block in building safer reliable health care for patients.10 In this context, the present paper by Tirkkonen et al.11 is a welcome piece of evidence to confirm that NEWS predicts adverse incidents in a different cohort of patients in a different health-care system. The authors show that in a group of unselected patients from a number of specialties that there is a significant association with high NEWS and patient in-hospital adverse events and mortality risk, suggesting that NEWS should be incorporated into protocols for escalation of patients to METs. The use of dichotomised activation criteria in the same paper appeared to only identify patients who have highly abnormal observations and did not pick up on the early decline towards this extreme – therefore potentially missing the window of opportunity to intervene in good time, potentially resulting in patients suffering cardiac arrests or being admitted
*http://www.hse.ie/eng/about/Who/clinical/natclinprog/ acutemedicineprogramme/ewsguidel.pdf (accessed 26 January 2014)
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C. P Subbe and J. Sabin
to intensive care more unwell than they might have been otherwise had the decline been picked up in a timely fashion. The increase in workload for METs would need to be considered if NEWS scores are utilised as it is worth noting that over twice as many patients would have triggered for escalation when NEWS scores were applied when compared with the existing set of criteria used at Tempere University Hospital (176 patients compared with 72 patients). The higher rate of trigger events with NEWS might create additional opportunities for rescue of sick patients, but it has implications for the workload of teams. This could in parts be regulated by determining the trigger threshold for a call-out: at a NEWS of 5 or more 22% of patients triggered, this is a high proportion of patients and MET teams in most hospitals would struggle to see all of them in a timely manner. In comparison at a NEWS of 7, only 6.5% triggered. This might allow a sustainable and reliable service. Of the 72 patients who had ‘positive’ MET activation criteria, only 10 actually had a MET activation. This would seem to suggest that even the current protocols are not being used optimally and that there are other factors influencing decisions to escalate a patient’s care. The reasons for this can only be speculated on – for example, it is possible that observations were subsequently repeated, possibly after intervention, and showed improvement or the patients in question may have always chronic physiological abnormalities such as those found in chronic obstructive pulmonary disease.12 The trend of observations can often be more significant than simply using one off-readings.13 It does however raise the important point that whichever scoring system is in place, it still requires the staff to have knowledge and understanding of the scoring implications in order for them to make a decision whether to act upon them. As a caveat, it is worth mentioning that a system with superior statistical properties does not necessarily result in better clinical outcomes in a complex system. Clinical studies need to examine the impact on reduction of adverse events and demonstrate how NEWS affects clinical practice. We need to also bear in mind that this study excluded patients who had do-not-attemptresuscitation decisions in place as they would not be suitable for escalation to critical care. It is reasonable to assume that many in this cohort of patients would probably have had high NEWS scores at some point and, even though they were not for escalation
378
beyond ward level, might still be suitable for treatment and intervention at ward level with potentially useful intervention by a MET or ward team to prevent clinical deterioration.14 After the present article, it is probably safe to say that the NEWSs has superior statistical properties to dichotomised call-out criteria. Human factors aspects of their implementation need to be the subject of further work. Conflict of interest: Neither of the authors has any conflict of interest to declare in relation to this manuscript.
References 1. Vlayen A, Verelst S, Bekkering GE, Schrooten W, Hellings J, Claes N. Incidence and preventability of adverse events requiring intensive care admission: systematic review. J Eval Clin Pract 2012; 18: 485–97. 2. Simpson HK, Clancy M, Goldfrad C, Rowan K. Admissions to intensive care units from emergency departments: a descriptive study. Emerg Med J 2005; 22: 423–8. 3. Winters BD, Pham JC, Hunt EA, Guallar E, Berenholtz S, Pronovost PJ. Rapid response systems: a systematic review. Crit Care Med 2007; 35: 1238–43. 4. Esmonde L, McDonnell A, Ball C, Waskett C, Morgan R, Rashidian A, Bray K, Adam S, Harvey S. Investigating the effectiveness of critical care outreach services: a systematic review. Intensive Care Med 2006; 32: 1713–21. 5. Tobin AE, Santamaria JD. Medical emergency teams are associated with reduced mortality across a major metropolitan health network after two years service: a retrospective study using government administrative data. Crit Care 2012; 16: R210. 6. Royal College of Physicians. Acute medical care: the right person, in the right setting – first time. London: RCP, 2007. 7. Royal College of Physicians. National Early Warning Score (NEWS): standardising the assessment of acute illness severity in the NHS. Report of a working party. London: RCP, 2012. 8. Gao H, McDonnell A, Harrison DA, Moore T, Adam S, Daly K, Esmonde I, Goldhill DR, Parry GJ, Rashidian A, Subbe CP, Harvey S. Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward. Intensive Care Med 2007; 33: 667–79. 9. Prytherch DR, Smith GB, Schmidt PE, Featherstone PI. ViEWS – towards a national early warning score for detecting adult inpatient deterioration. Resuscitation 2010; 81: 932– 7. 10. Rozich JD, Howard RJ, Justeson JM, Macken PD, Lindsay ME, Resar RK. Standardization as a mechanism to improve safety in health care. Jt Comm J Qual Saf 2004; 30: 5– 14. 11. Tirkkonen J, Olkkola KT, Huhtala H, Tenhunen J, Hoppu S. Medical emergency team activation: performance of conventional dichotomized criteria versus National Early Warning Score. Acta Anaesthesiol Scand 2014; 58: 411–9. 12. Eccles SR, Subbe C, Hancock D, Thomson N. CREWS: improving specificity whilst maintaining sensitivity of the National Early Warning Score in patients with chronic hypoxaemia. Resuscitation 2014; 85: 109–11. 13. Kellett J, Woodworth S, Wang F, Huang W. Changes and their prognostic implications in the abbreviated Vitalpac™
Choose the NEWS you like? early warning score (ViEWS) after admission to hospital of 18 853 acutely ill medical patients. Resuscitation 2013; 84: 13–20. 14. Pattison N, Ashley S, Farquhar-Smith P, Roskelly L, O’Gara G. Thirty-day mortality in critical care outreach patients with cancer: an investigative study of predictive factors related to outreach referral episodes. Resuscitation 2010; 81: 1670–5.
Address: Christian Subbe School of Medical Sciences Bangor University 21 Menai Quays Menai Bridge LL59 5DB UK e-mail: [email protected]
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