Understanding and Using the National Early Warning Score (NEWS/NEWS 2)

The NEWS score was originally developed as a way to standardize patient assessment, especially for acute illnesses where time is paramount, and a common communication paradigm between caregivers could potentially save lives. Since its introduction in 2012, the score has gained worldwide popularity and has proven useful in hospitals and other care settings in Europe, the USA (including the US Naval and Air Forces) and India. This popularity can be attributed to the score's high accuracy in predicting mortality. ^[7] It takes into account both extremes of the parameters it measures; for example, high as well as low blood pressure, can raise the score depending on the values.

The predictive power of the NEWS & NEWS 2 Scores is practically indistinguishable between the two. In some studies, the original is slightly better at predicting IHCA events or need for ICU care, the difference is statistically insignificant. However, for both parameters, overall results are still poor, and the use of more specialized scores is advised. The small differences between the scores are probably due to the fact that HRCF (Hypercapnic Respiratory Failure) is sometimes not confirmed before utilizing the second O2 table provided in the new score, an error that would result in lower scores for some more severe patients ^{[2], [3]}.

In recent years, numerous studies have been conducted to validate the predictive power of the new score and its use in the emergency department. For example, a study released in 2021, involving 3986 patients, successfully confirmed the score's accuracy in predicting mortality rates and challenged other studies' results. It showed that the score was even successful at predicting the need for ICU (Intensive Care Unit) management, which was correlated with mortality (AUC of 0.97-0.92) ^[4]. The mean NEWS-2 Score for patients who were eventually transferred to the ICU was 7. Only 2% of all patients required ICU care, but 41% of those who died. ^[4] Among patients with a NEWS-2 score higher than 10, 38.6% died, suggesting a high correlation ^[4]

Another study on 39,470 admissions (of which 2,361 had AECOPD - acute exacerbation of chronic obstructive pulmonary disease - with a median age of 74 years) found that the sensitivity of the NEWS-2 Score was merely 28%, compared to the original score's 50%. However, specificity was higher at 93% (vs. 80%). ^[5]

While results have been mixed, as with any score, the NEWS & NEWS 2 scores should offer reasonably good mortality prediction values and be a reasonable pillar in the management of acutely ill patients.

The main updates that were made to the NEWS score were an improvement of the chart used to record patient data over time. The change was made to conform to the ABCDE approach that is recommended by the UK Resuscitation Council. In the new score, the temperature stands for Exposure ^[2].

A new addition to the NEWS 2 Score was a secondary chart/scale for recording the evolution of the respiratory system in patients with hypercapnic respiratory failure, who usually have lower O₂ Saturation recommendations of 88-92% (which have been shown to lower mortality rates in COPD patients). ^{[1][2], [6]}

While there weren't any major changes made between the scores, it is important to keep in mind that these scores were specifically designed by the Royal College of Physicians (RCP) as a way to standardize the assessment and management of patients across all the UK's Acute Care Facilities. With the introduction of the new score and chart, the RCP recommends switching over to the new chart when recording vital sign or other observation charts ^[2].

• Still, calling out the fact that the changes to the new score, albeit small, were not validated on a large dataset of patients before release, a study on 39,470 admissions (of which 2,361 had AECOPD - exacerbation of chronic obstructive pulmonary disease - with a median age of 74 years) found that the sensitivity of the NEWS-2 Score was merely 28%, compared to the original score at 50%. Still, specificity was higher, at 93% (vs. 80%) ^[5]

A download of the RCP publication about the NEWS 2 Score, including the chart (at page 58/77), can be downloaded here.

Several other tools similar to the NEWS score are used for patient assessment and prediction of clinical outcomes. Some notable ones include:

1. MEWS (Modified Early Warning Score): MEWS is another early warning scoring system that uses vital signs such as heart rate, blood pressure, respiratory rate, temperature, and level of consciousness to assess the severity of a patient's condition. It assigns scores to each parameter, and a higher total score indicates a higher risk of clinical deterioration.
2. qSOFA (Quick Sequential Organ Failure Assessment): qSOFA is a simplified scoring system used to identify patients at risk of sepsis outside of the intensive care unit (ICU). It includes three criteria: altered mental status, systolic blood pressure ≤100 mmHg, and respiratory rate ≥22 breaths per minute. A qSOFA score of 2 or higher suggests a higher risk of poor outcomes.
3. EWS (Early Warning Score): EWS is a general early warning scoring system that assesses a patient's vital signs and other clinical parameters. It varies in its specific parameters and scoring thresholds depending on the institution or healthcare setting where it is used.
4. ROSIER (Recognition of Stroke in the Emergency Room): ROSIER is a tool specifically designed to aid in the recognition of stroke in the emergency room. It evaluates symptoms, risk factors, and signs of stroke to help healthcare providers make prompt and accurate decisions regarding stroke management.

These tools, including the NEWS score, serve as valuable aids in the assessment and management of patients, allowing healthcare providers to identify those at higher risk of clinical deterioration and make timely interventions.