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Are referrals to hospital from out-of-hours primary care associated with National Early Warning Scores?
  1. Samuel Finnikin1,
  2. Gail Hayward2,
  3. Fay Wilson3,
  4. Daniel Lasserson1,4
  1. 1 Institute of Applied Health Research, University of Birmingham, Birmingham, UK
  2. 2 Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  3. 3 Bader Group, Birmingham, UK
  4. 4 Department of Acute Medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
  1. Correspondence to Dr Samuel Finnikin, University of Birmingham, Birmingham B15 2TT, UK; finniksj{at}


Background The National Early Warning Scores (NEWS) is used in various healthcare settings to augment clinical decision making, and there is growing interest in its application in primary care. This research aimed to determine the distribution of NEWS among patients in UK out-of-hours (OOH) general practice and explore the relationship between NEWS and referral of patients to hospital.

Methods A historical cohort study using routinely collected data from the Birmingham Out-of-hours general practice Research Database. This includes patients who attended a large out-of-hours general practice provider in the West Midlands, UK, between July 2013 and July 2018. All adults who were seen face to face who had a full set of physiological observations recorded were included. NEWS was calculated post hoc, and subsequent hospital referral was the outcome of interest.

Results A NEWS was calculated for 74 914 consultations. 46.9% of patients had a NEWS of 0, while 30.6% had a NEWS of 1. Patients were referred to hospital in 8.5% of all encounters. Only 6.9% (95% CI 6.3% to 7.5%) of the 6878 patients referred to hospital had a NEWS of ≥5. Of the 1509 patients with a NEWS ≥5, 68.6% (95%CI 66.2% to 70.9%) were not referred to hospital. When considering how NEWS was related to hospital referral, the area under the receiver operating characteristic (AUROC) for patients seen in their own home was 0.731 (95%CI 0.681 to 0.787). For patient seen in treatment centres, the AUROC was 0.589 (95% CI 0.582 to 0.596).

Conclusions Patients seen in out-of-hours general practice have low physiological acuity. Those referred to hospital have a slightly higher NEWS overall. NEWS is poorly associated with hospital referral, although the association is stronger for patients seen in at home compared with patients seen in treatment centres. Implementing NEWS-based referral from OOH general practice is likely to increase hospital admissions.

  • clinical assessment
  • emergency care systems, primary care
  • primary care

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  • Correction notice This paper has been updated since first published with an update in figure 1.

  • Contributors SF and DL designed the study. Data collection and analysis was performed by SF. All authors contributed to data interpretation and writing of the manuscript. The lead author (SF) affirms that the manuscript is an honest, accurate and transparent account of the study being reported and that no important aspects of the study have been omitted.

  • Funding This research was unfunded, but the authors would like to acknowledge the West Midlands Clinical Research Network whose funding allowed the creation of BORD. GH and DSL are funded by the NIHR Community Healthcare Medtech and IVD Cooperative.

  • Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care.

  • Competing interests SF is a fellow in Evidence and Values at the RCGP and a senior clinical tutor at the University of Birmingham. He receives income from freelance writing, lecturing and book authorship and does consultancy work for EBSCO industries. FW is the medical director of Badger Group.

  • Patient consent for publication Not required.

  • Ethics approval This research was carried out under the ethical approval for the BORD, which was granted by the West Midlands – South Birmingham Research Ethics Committee on the 22 January 2019 (reference 19/WM/0010).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request.