The updated National Early Warning Score and its use with suspected Sepsis

Dr Rachel Marsden, RCGP Clinical Support Fellow for Sepsis

The National Early Warning Score (NEWS) is relevant in the management of patients in whom Sepsis is suspected. NHS England's document, Sepsis Guidance Implementation Advice for Adults, provides an operational definition of Sepsis that fits with the use of the National Early Warning Score in assessing patients who are acutely unwell2. Meanwhile the NICE Sepsis Quality Standard QS161 Standard One asks that patients in whom sepsis is suspected are risk assessed using a structured set of observations3.

NEWS is an aggregate score made up of six physiological parameters, with the aim of improving detection and response to clinical deterioration in acutely unwell patients. Parameters measured are:

  • Respiratory Rate
  • Oxygen saturations
  • Systolic BP
  • Pulse rate
  • Level of consciousness (AVPU score)
  • Temperature 

NEWS (2) provides an updated version of this score. As before, scores range from 0-20, with a higher score representing further removal from normal physiology and a higher risk of morbidity4. Based on feedback from users, attention during the review was paid to four themes:

  • Determining how NEWS could be used in the assessment of patients with or at elevated risk of sepsis 
  • Highlighting that NEWS of 5 or more is a key threshold for urgent clinical review
  • Improving recording of 02 sats in patients on supplemental oxygen or those with hypercapnic respiratory failure (such as those with COPD) 
  • Recognising the importance of new onset confusion, disorientation and delirium as a sign of potentially serious clinical deterioration

The NEWS (2) chart highlights that patients on supplemental oxygen score an additional 2 points, and holds a separate section for scoring O2 saturations in patients with hypercapnic respiratory failure, in whom O2 sats of 88-92% are recommended. 

Nice Guidance NG515 and the Sepsis -3 groups q SOFA6 include altered mentation as a high-risk sign in patients with Sepsis. New confusion, C, which includes disorientation, delirium or any new alteration to mental state, has been added to the AVPU score in NEWS (2), which now reads ACVPU. In instances where it is unclear if confusion is new or long standing, it is to be considered new until proven otherwise.

The NEWS review group also made recommendations within its report aimed at Sepsis. They felt that Sepsis should be considered in any patient with a NEWS score of ≥ 5 in the presence of known infection, signs or symptoms of infection, or who are at elevated risk of infection. Furthermore, it was felt that pts with suspected infection, and a NEWS score of ≥5, where escalation of care is appropriate, require urgent assessment and intervention by a clinical team competent in the management of sepsis. 

Whilst NEWS has yet to be validated in primary care, its use in assessing patients with, or at risk of Sepsis in Secondary care is well evidenced 1,7-10 NEWS (2) provides an updated score with recommendations of its use in the assessment of suspected Sepsis. NEWS2 does not replace clinical judgement but can be used as an adjunct to patient assessment in general practice. It also provides a common language for expressing concern between GPs, Ambulance and secondary care colleagues, allowing for deterioration to be tracked and resources prioritised.  

References

1 Royal College of Physicians. National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. In: RCP, editor. London: RCP; 2017.
2 NHS England. Sepsis Guidance implementation advice for adults: NHS England, Sept 17
3 National Institute for Health and Care Excellence. Sepsis Quality Standard [QS161]. Published September 2017 
4 Smith GB, Prytherch DR, Meredith P, Schmidt PE, Featherstone PI. The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death. Resuscitation 2013; 84(4): 465-70.
5 National Institute for Health and Care Excellence. Clinical Guidance CG51 Sepsis: recognition, diagnosis, and early management: Published July 2016 
6 Angus DC, Seymour CW, Coopersmith CM, Deutschman CS, Klompas M, Levy MM, Martin GS, Osborn TM, Rhee CV. A Framework for the Development and Interpretation of Different Sepsis Defninitions and Clinical Criteria. Critical Care Medicine, 44(3)  
7 Corfield AR, Lees F, Zealley I, et al. Utility of a single early warning score in patients with sepsis in the emergency department. Emergency medicine journal : EMJ 2013.
8 Geier F, Popp S, Greve Y, et al. Severity illness scoring systems for early identification and prediction of in-hospital mortality in patients with suspected sepsis presenting to the emergency department. Wiener klinische Wochenschrift 2013; 125(17-18): 508-15.
9 Corfield AR, Lees F, Zealley I, et al. Utility of a single early warning score in patients with sepsis in the emergency department. Emergency medicine journal : EMJ 2014; 31(6): 482-7.
10 Silcock DJ, Corfield AR, Gowens PA, Rooney KD. Validation of the National Early Warning Score in the prehospital setting. Resuscitation 2015; 89: 31-5.

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