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Finnikin and colleagues describe a large data set of retrospectively calculated National Early Warning Scores (NEWS) in a system that was not using or responding to NEWS. Understanding the relationship between NEWS and referral practices is an important area of research which could help shed some light on the impact of introducing NEWS into primary care.
The first important point is that only 31% (74,992/242,451) of patients who had face-to-face encounters had a full set of observations and the clinical characteristics of the 69% excluded from the study are unknown. In our experience, GPs tend to perform a full set of observations on patients who appear more unwell so it is possible that the population studied may not be representative.
Finnikin and colleagues found that only 6.9% of patients referred to hospital had a NEWS≥5 and 69% with a NEWS ≥5 were not referred. There is emerging evidence that NEWS calculated by GPs at referral correlates with mortality (data from West of England accepted for publication) so the fact that it did not correlate with referral is of concern. Scott et al in the West of England (1, 2) and Inada Kim et al in Wessex (unpublished data) have demonstrated that the higher the NEWS on referral or arrival, the more likely the patient is to be admitted and the more likely the patient is to die.
The lack of linkage to any outcomes is a major weakness of this work. While an increase in admissions of 16.2% is not ideal in an alr...
The lack of linkage to any outcomes is a major weakness of this work. While an increase in admissions of 16.2% is not ideal in an already extremely busy system, if those patients require acute attention it is important that they are appropriately referred. Similarly, there may be a number of patients with NEWS<5 who were unnecessarily referred to hospital; without outcomes data, conclusions about appropriateness of referrals cannot be drawn. In addition, in the West of England, where NEWS is used by GPs, admissions did not increase at any greater rate than elsewhere (3).
It is also suggested in the paper that a NEWS cut off of <5 could be used to reduce ‘low acuity admissions’; however, it is often appropriate to admit a patient irrespective of NEWS, for example someone with a stroke or crushing central chest pain. The Royal College of Physicians is clear that ‘NEWS should be used as an aid to clinical assessment- it is not a substitute for competent clinical judgement’ (4). Using NEWS promotes a full assessment of the patient and, if used at referral, is also a useful communication tool which helps the receiving hospital to recognise the patients that are deteriorating in the time frame between referral and arrival.
GPs have to make important and challenging decisions in a short time frame and formal actions should not be ascribed to NEWS in the community but instead there should be increased awareness that the higher the NEWS the more likely the patient is to be sick. Before NEWS, GPs would admit a patient and highlight the most extreme observations; perhaps the learning from this analysis could be that simply measuring observations is of limited value in identifying who needs admission and the aggregate nature of NEWS is better suited to identifying potential deterioration than high scores for a single vital sign(5).
1. Scott LJ, Redmond NM, Garrett J, et al. Distributions of the National Early Warning Score (NEWS) across a healthcare system following a large-scale roll-out. Emergency Medicine Journal 2019; 36:287-292.
2. Scott LJ, Redmond NM, Tavaré A, et al. National Early Warning Scores in primary care are associated with clinical outcomes. BJGP 2020, In press.
3. Pullyblank A, Tavaré A, Little H, et al System Wide Implementation of the National Early Warning Score Reduces Mortality in Patients with Suspicion of Sepsis. BJGP 2020, In press.
4. Royal College of Physicians. National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. London: RCP, 2017.
5. Jarvis S, Kovacs C, Briggs J, et al. Aggregate National Early Warning Score (NEWS) values are more important than high scores for a single vital signs parameter for discriminating the risk of adverse outcomes. Resuscitation 2015, Volume 87, 75 – 80.