NATIONAL EARLY WARNING

SCORES (NEWS):
A QUALITY IMPROVEMENT PROJECT

SREEDEVI S. WARRIER, DNP, RN, MA, CNS

MARGARET BRADY, PhD, RN, CHAIR

JOY R. GOEBEL, PhD, RN, COMMITTEE MEMBER,
SAVITRI SINGH-CARLSON, PhD, APHN-BC, COMMITTEE MEMBER
 NEWS
Background

 Research suggests that patients transferred from medical/surgical

wards to intensive care units experience higher mortality rates when
compared to patients admitted from emergency or operating
rooms
 Patients suffering from a cardiac and/or respiratory arrest usually
exhibit physiological deviations, such as changes in vital signs
and/or mental status, at least eight hours prior to their need for
more intensive care
 Several studies suggest the use of early warning scores (EWS) in
different patient care settings within acute care hospitals are
effective in the identification and initiation of early intervention for
patients who present with or develop acute illness

(Stenhouse, Coates, Tivey, Allsop, & Parker, 2000 & Royal College of Physicians, 2015)
 NEWS
Background
 Several bedside tools are available for nurses to identify patients
experiencing clinical deterioration
 National Early Warning Scores (NEWS) is an EWS prediction tool
 NEWS focuses on a simple scoring system in which physiological
measurements are assigned a predetermined score, which is then applied
to a patient’s physiological measurements (vital signs)
 Six simple physiological parameters form the basis of the scoring system:
respiratory rate, oxygen saturation, temperature, systolic blood pressure,
heart rate, and level of consciousness.
 A specific NEWS value is designated to each physiological measurement
and the aggregated score from all six parameters and the use of oxygen
are used to predict the magnitude of variation from the norm

(Royal College of Physicians, 2015)

 NEWS
Background
 An initial pilot study was conducted at the project site in one
medical/surgical unit to evaluate the effectiveness of the NEWS and the
results of early interventions if needed
 The outcome of interest in this NEWS pilot study was the number of Rapid
Response (RRT) and Code Blue activations from the pilot unit vs. other
medical/surgical units
 The study was conducted over 26-days in one 50-bed unit (February 2014)
 40-patients were identified who meet NEWS alert criteria
 14-patients were transferred to a higher level of care and 26-patients
stayed in the unit with some type of bedside intervention
 The decision was made to implement a Phase 2 NEWS study in 6
medical/surgical unit
 NEWS
Comparison of 2014 Pilot Study
 NEWS
Scoring Criteria
 Scoring Guidelines and Clinical Risk Assessment
 NEWS
Review of Literature
 Evidence based articles were used to examine the efficacy,
specificity, sensitivity, validity and reliability of using a NEWS
tool in different clinical settings
 Multiple search methods were used to access the following
databases
 Cumulative Index to Nursing and Allied Health (CINAHL)
 Oxford Journals
 PubMed
 Medical Subject Heading (MeSH)
 Medline
 Cochrane Library
 Google Scholar
 NEWS
Framework

 Plan-Do-Study-Act
(PDSA)
 Focuses on real-time
changes
 Action oriented
 Developed by Best
and Newhauser
(2006)
 PDSA can guide a
process change with
measurable outcome

Adapted from NHS-Institute for innovation and Improvement. Retrieved from

www.ihi.org/resources/pages/Healthimprove/default.aspx
 NEWS
Purpose
 Early identification of clinical deterioration in
patients, so that nurses and providers could initiate
an immediate intervention(s) ensuring appropriate
use of RRT and/or Code Blue activations and
preventing further clinical decline
 NEWS
Aims
1) Compare the number of RRT/Code Blue calls in six
medical/surgical units before and after NEWS
implementation (November/December 2014 vs.
November/December 2015)
2) Explore the number of RRT/Code Blue activations
based on NEWS and nursing judgment
3) Identify demographic and/or clinical factors
associated with RRT/Code Blue activation
 NEWS
Aims

4) Describe the characteristics of patients who were transferred

to a higher level of care with patients who remained in the
unit with a reportable NEWS. What was the patient’s
subsequent clinical condition after receiving an
intervention?
5) Describe the clinical condition(s) of patients who received a
NEWS of 5 or greater or 3 in any single parameter
6) Identify the number of patients who did not receive
interventions despite a NEWS scores of 5 or greater or 3 in
any single parameter
 NEWS
Methods
 Six adult non-monitored medical surgical units in a Level
1 trauma center in a Southern California Academic
Medical Center
 Inclusion criteria
 Age 18 or older
 Hospitalized in one of the six designated pilot unit
 Any medical or surgical diagnosis
 Exclusion criteria
 Under 18 years of age
 Pregnancy
 Repeated, unchanged NEWS
 Receiving active palliative/comfort care
 NEWS
Procedures
 Conducted a pilot test of the NEWS using the Electronic Health
Record (EHR)
 Pilot testing helped to identify the issues with EHR
 Approval from nursing and medical administration
 Institutional Review Board (IRB) approval from CSULB and the pilot
hospital
 Developed NEWS manual documentation form
 PowerPoint presentation was developed and reviewed by the team
 In-service provided for over 500 nursing staff and 250 providers
 NEWS
Data Collection
 Started November 10, 2015 to December 9, 2015
 Information includes:
 Date
 Patient identification code
 Demographic information (age, race, and gender)
 Diagnosis
 Routine vital signs and NEWS scores (every 4-hours = 6 times in a
24 hour period)
 Level of care/intervention(s)
 NEWS
Results
 Data cleaning
 Total number of patients in the initial data set was 3,154
 Anticipated data collection points were 113,536
 Available data points were 102,473
 9.7% of the data were missing from the total data set (90.3%
complete)
 Late admission
 Discharge
 Off unit (procedure/surgery)
 Refusal
 NEWS
Data Distribution
Summary of Missing Data Across Six Measures by Cause,
Aggregate Data from Six Time-Points (N = 3,154 patients)
Respiratory Oxygen Oxygen Systolic Blood Level of
Temperature Heart Rate
Rate Saturation Supply Pressure Consciousness

Data

Available 17096 (90.3%) 17073 (90.2%) 17124 (90.5%) 17058 (90.1%) 17056 (90.1%) 17066 (90.2%) 17180 (90.8%)

Unavailable 1826 (9.7%) 1847 (9.8%) 1799 (9.5%) 1866 (9.9%) 1867 (9.9%) 1858 (9.8%) 1780 (9.2%)

Reason Unavailable

Missing 1417 (7.5%) 1418 (7.5%) 1422 (7.5%) 1430 (7.6%) 1424 (7.5%) 1426 (7.5%) 1416 (7.5%)

*D/C (555) 167 (0.9%) 167 (0.9%) 167 (0.9%) 167 (0.9%) 167 (0.9%) 165 (0.9%) 164 (0.9%)

*No V/S (666) 7 (0.0%) 7 (0.0%) 8 (0.0%) 5 (0.0%) 14 (0.1%) 5 (0.0%) 0 (0.0%)

Refused (777) 133 (0.7%) 153 (0.8%) 99 (0.5%) 162 (0.9%) 160 (0.8%) 160 (0.8%) 56 (0.3%)

*OR (888) 12 (0.1%) 12 (0.1%) 12 (0.1%) 12 (0.1%) 12 (0.1%) 12 (0.1%) 11 (0.1%)

Off Unit (999) 90 (0.5%) 90 (0.5%) 91 (0.5%) 90 (0.5%) 90 (0.5%) 90 (0.5%) 90 (0.5%)
 NEWS
Comparison of RRT and Code Blue
 Aim # 1: Comparison of RRT, and RRT/Code Blue activations before and
after NEWS implementation (Pre-NEWS – Nov/Dec 2014 and NEWS Nov/Dec
2015)
 NEWS
Comparison of RRT and Code Blue

 Results revealed that the number of RRT, and RRT/Code

Blue calls decreased (x1, 000 patient days):
 November 2014/2015 = 11/5
 December 2014/2015 = 9/7
 Values are not statistically significant (p =>0.05)
 Clinically significant
 Small numbers can affect statistical testing sensitivity
 NEWS
RRT/Code Blue Calls
 Aim # 2: RRT/Code Blue calls based on NEWS vs. nursing
judgment
 Total number of RRT calls during the pilot period was 91
 17 from the pilot unit
 16 RRT were activated by using NEWS (94.7%)
 1 alert was called because of nursing clinical judgment (5.3%)
 2 Code Blue Activations
 Nursing judgment (100%)
 NEWS
Demographic Data

 AIM # 3: Demographic and clinical factors associated with

RRT/Code Blue activations during this project period
 Total number of patients 3,154 patients
 After data cleaning selected 2,667 patients (met all 6 time points with a
complete NEWS value)
 1,611 males and 1,056 females
 Race and ethnicity
 Hispanic 48.4%
 Black/African American 23.4%
 White/Caucasians 18.2%
 Asians 9.2%
 NEWS
Demographic Data Distribution
NEWS Score

5-6

Overall 0-4 (or 3 in any parameter) 7+ p*

N 2667 2634 32 1

Mean (SD)

Age, in years 52.89 (15.27) 52.83 (15.28) 57.53 (14.14) 73.00 (n/a) .08

Frequency (valid %)

Gender .40

Male 1611 (60.4) 1594 (60.5) 17 (53.1) 0 (0)

Female 1056 (39.6) 1040 (39.5) 15 (46.9) 1 (100)

Race .05

Asian 245 (9.2) 240 (9.1) 5 (15.6) 0 (0)

Black/African American 625 (23.4) 618 (23.5) 7 (21.9) 0 (0)

Hawaiian/Pacific Islander 5 (0.2) 5 (0.2) 0 (0) 0 (0)

Hispanic 1279 (48.6) 13 (40.6) 0 (0)

1292 (48.4)

Native American 6 (0.2) 5 (0.2) 1 (3.1) 0 (0)

White 486 (18.2) 479 (18.2) 6 (18.8) 1 (100)

Other 4 (0.1) 4 (0.2) 0 (0) 0 (0)

Unknown 4 (0.1) 4 (0.2) 0 (0) 0 (0)

* Due to the limited sample size of NEWS Scores of 7+ formal comparisons via hypothesis testing included only the first two groups
* Presented for Independent Samples t-tests and Chi-Square tests of Independence
 NEWS
Score 5-6 or 3 in Any Single Criteria
 AIM # 4: Compare the number of patients who had a
high NEWS and transferred to a higher level of care with
patients with similar scores who remained on the unit
 Total of 122 patients received a score of 5-6 or 3 in any single
parameter
 48 patients missed interventions or were not timely identified
 74 patients received some type of intervention(s)
 63 remained in the unit after an intervention
 11 patients transferred to a higher level of care
 NEWS
Score 7 or Greater
 16 patients received a score of 7 or greater
 5 patients remained in the unit
 11 patients transferred either with NEWS score or by initiation
of RRT
 2 patients received a higher NEWS that was not reported due
to unchanged NEWS (benign hypertension; COPD;
asymptomatic atrial fibrillation)
 2 patient placed on comfort/palliative care
 1 patient with a high NEWS score was acknowledged by the
provider and specific parameters written for RRT activation
(Dx: s/p lobectomy; small cell lung cancer; interstitial lung
disease)
 NEWS
Intervention(s)Distribution Table
Number of Patients Who remained in Unit After Receiving Intervention

Intervention Stayed in
Employed Unit
Score Time N n (valid %)
0-4 1 9 7 (77.8)
2 5 5 (100)
3 9 9 (100)
4 5 4 (80.0)
5 20 17 (85.0)
6 16 10 (62.5)

5-6, or 1 18 16 (88.9)
3 in any single 2 11 10 (90.9)
parameter 3 10 8 (80.0)
4 8 6 (75.0)
5 8 7 (87.5)
6 19 16 (84.2)

7+ 1 1 0 (0)
2 2 1 (50.0)
3 4 2 (50.0)
4 1 1 (100)
5 4 0 (0)
6 4 1 (25.0)
 NEWS
Post-Intervention Distribution

 Efficacy of the tool

 The efficacy of interventions for patients who remained in the
unit was analyzed using a repeated measures of ANOVA that
tracked scores across 24 hours
 Results showed a statistically significant NEWS over time
 Statistically significant reductions were seen between baseline
and 8-24 hours
 For patients who stayed in the unit with a high NEWS score, their
subsequent scores decreased significantly after receiving an
intervention
 NEWS
Post-Intervention Distribution
 Mean NEWS Scores at Post -Intervention Timeframes for Patients Remaining
in Unit
 NEWS
Clinical conditions & Missed Interventions

 Aim # 5: Clinical condition of patients who received a high NEWS score

 Data retrieval included information about the clinical diagnosis of all patients
 Multiple comorbidities along with the admitting diagnosis made analysis
inconclusive. The project investigator was unable to extract a specific diagnosis

 Aim # 6: Number or patients with missed intervention(s)

 48 patients with a NEWS of 5 or greater or 3 in any single parameter experienced
missed intervention
 Majority of patients missed intervention during the 0200 vital sign time period
followed by the time periods of 0600, 1000, 2200
 NEWS
Intervention(s) Distribution Table
 Intervention Rate by NEWS Score Category
n (valid %)
Score Time Total Intervention Intervention
Sample Employed* Missed
0-4 1 2634 9 (0.3)
2 2672 5 (0.2)
3 2785 9 (0.3)
n/a
4 2861 5 (0.2)
5 2980 20 (0.7)
6 2990 16 (0.5)

5-6, or 1 32 18 (56.3) 14 (43.8)

3 in any single parameter 2 19 11 (57.9) 8 (42.1)
3 18 10 (55.6) 8 (44.4)
4 14 8 (57.1) 6 (42.9)
5 13 8 (61.5) 5 (38.5)
6 26 19 (73.1) 7 (26.9)

7+ 1 1 1 (100) 0
2 2 2 (100) 0
3 5 4 (80.0) 1 (20.0)
4 1 1 (100) 0
5 5 4 (80.0) 1 (20.0)
6 4 4 (100) 0
*
 NEWS
Summary of Results
 The results did not show statistically significant
differences related to the use of NEWS; nevertheless, the
trend analysis is encouraging
 Sensitivity of statistical testing can be affected with small
subject numbers
 In dealing with issues related to a patient’s clinical
condition, any downward trend showing a decrease in
the number of missed opportunities to intervene in
situations of clinical deterioration is clinically significant
for the patient, family and providers
 NEWS
Discussion
 Appropriate level of admission in medical/surgical units
 2% clinical deterioration and mortality rate
 Number of RRT, and RRT/Code Blue pre-NEWS and with
NEWS
 Use of clinical judgment and high NEWS values
 Demographic data (age and race has clinical
significance)
 NEWS
Discussion
 Delay in implementing the NEWS tool in other units after
the pilot study in 2014
 Missed interventions especially at 0200
 Other reasons for missing data
 Timely documentation and acceptance of the call by
the provider
 Provider and nursing education
 NEWS
Limitations
 Missing data from the total data set
 Unavailability of the NEWS tool in EHR
 Provider education (Nursing 95% complete)
 Motivation to use the tool
 NEWS
Conclusion
 NEWS helps to identify clinical deterioration and outcome
improvement
 Value in using PDSA framework, allowing real time feedback
 Scores are readily available for nurses and providers that will
enhance the initiation of an intervention
 NEWS provides a realistic tool for clinical decision -making
because the score includes a single physiological measure of
extreme value in addition to aggregate scores that activate
interventions
 Plans to implement the NEWS tool in all DHS hospitals
 Initiating pilot study in one step-down unit
Acknowledgements
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 NEWS
(National Early Warning Scores)
 Questions?