Abstract
BackgroundThe National Early Warning Score (NEWS) calculated from physiological observations provides a simple away to identify and respond to the deteriorating patient. There is increasing interest in the application of NEWS to facilitate referrals from the community.AimTo establish whether elevated NEWS are associated with adverse outcomes at 5 and 30 days when obtained in a community setting at the time of transfer to an acute setting.Design & settingA retrospective service evaluation was undertaken using a database of emergency admissions to secondary care from two NHS district general hospitals within the South of England between January 2018 and April 2019.MethodThe performance of NEWS recorded in a community setting to predict death or critical care admission at 5 and 30 days was calculated using established thresholds.Results2786 referrals from primary care were analysed. The 5 day and 30 day mortality was 2.2% (1.7 to 2.8) and 7.1% (6.2 to 8.1). The prevalence of the composite outcome was 3.4% (2.8 to 4.2) at 5 days and 8.5% (7.5 to 9.6) at 30 days. The risk of adverse outcomes increased incrementally with increasing NEWS. When calculated at the point of referral from primary care the positive predictive value of death at 5 and 30 days was 15% (95% confidence intervals [CI] = 12 to 19) and 23% (95% CI = 17 to 30) in the high-risk NEWS group.ConclusionElevated NEWS obtained in the community during the process of emergency admission are associated with adverse outcomes. Communicating NEWS may allow downstream care to be better calibrated to risk.
Highlights
The number of emergency admissions to hospitals has increased by 40% over the last decade.[1]
National Early Warning Score (NEWS) were recorded by the admitting clinician at the point of referral in 33.5% (n = 2522); by the ambulance service in 15.0% (n = 1126) referrals; and 7.8% (n=592) referrals had a NEWS recorded initially at the point of referral and subsequently by the ambulance on conveyance to hospital (Figure 1)
The median monthly proportion of patients with a NEWS recorded at the point of referral was 30.6%
Summary
The number of emergency admissions to hospitals has increased by 40% over the last decade.[1]. Warning scores (EWS) are calculated from routine physiological observations to provide a single aggregated value representing the risk of future deterioration. EWS have been shown to predict a range of clinical outcomes including death, cardiac arrest, and critical care admission within the inpatient population.[5,6,7] NHS England currently mandates the use of National Early Warning Score 2 (NEWS2), a specific EWS, in all acute hospital and ambulance trusts but use in primary care is not compulsory.[8] NEWS2 has been advocated as a tool to facilitate planning, preparation, and prioritisation when acute illness requires escalation of care from the community to the hospital, but concerns have been raised regarding the absence of validation studies in the primary care population.[9,10] NICE recommends that people with suspected sepsis in the community have a complete set of observations recorded but does not currently support converting the observations to a NEWS to guide care, due to an absence of evidence in support of this approach.[11,12] A better understanding of the prognostic value of NEWS obtained in the primary care setting is required before widespread implementation can be advocated with confidence. Communicating NEWS may allow downstream care to be better calibrated to risk
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