Digitising the National Early Warning Score NEWS2

NEWS2 is the latest version of the National Early Warning Score (NEWS), first produced in 2012 and updated in December 2017, which advocates a system to standardise the assessment and response to acute illness.

Digital NEWS2 Chart

This blog discusses our journey to develop and implement a digital NEWS2 chart. This covers some of the design decisions we made in implementing the national guidance and lessons learned along the way.

I have made the digital NEWS2 chart available as an open source project on Github should others wish to contribute to the project (further details below) and implement it in their own electronic patient record EPR.

Digital NEWS2 chart

Digital NEWS2 is one component of a full suite of electronic clinical nursing assessments we have developed as part our clinical web portal EPR.

How NEWS2 works

The NEWS2 is based on a simple aggregate scoring system in which a score is allocated to physiological measurements, already recorded in routine practice, when patients present to, or are being monitored in hospital.

Six simple physiological parameters form the basis of the scoring system:

  1. respiration rate
  2. oxygen saturation
  3. systolic blood pressure
  4. pulse rate
  5. level of consciousness or new confusion
  6. temperature.

A score is allocated to each parameter as they are measured, with the magnitude of the score reflecting how extremely the parameter varies from the norm. The score is then aggregated and uplifted by 2 points for people requiring supplemental oxygen to maintain their recommended oxygen saturation.

This is a pragmatic approach, with a key emphasis on system-wide standardisation and the use of physiological parameters that are already routinely measured in NHS hospitals and in prehospital care, recorded on a standardised clinical chart – the NEWS2 chart.

The full Royal College of Physicians NEWS2 report, executive summary, observation chart, and clinical response triggers can be found on the RCP website.

National Early Warning Score (NEWS) 2

Reproduced from: Royal College of Physicians. National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. Updated report of a working party. London: RCP, 2017.

Digitalisation plan

At the time NEWS2 guidance was published, we had already piloted digital eOBS based on our local MEWS standard, and were using paper MEWS charts on our other wards. The digitisation was put in hold until it was agreed how the NEWS2 would be implemented.

We had a number meetings with our nursing and clinical outreach team leads to agree how to implement the new guidance. The team were keen to deploy the paper NEWS2 charts initially to ensure compliance with national standards. We would switch the current eMEWS to digital NEWS2 and complete the digital roll once we had embedded the new system. This approach was endorsed by the trust patient safety committee.

NEWS2 form eOBS data capture

For our initial MEWS pilot we had developed an eform that can capture the clinical observations (eOBS), calculate the aggregate score and display the clinical guidance.

As our in-house eforms solution is fully configurable, it was a relatively simple process to update the eform to the NEWS2 standard, without requiring further code development.

The eOBS data and scores are automatically recorded in our structured EPR and can be retrieved on demand via an API call.

For details of the safety considerations and design principles that underpin the eforms calculator, please see my separate blog.

Clinical calculators (design principles and implementation)

Digital NEWS 2 Chart design

The digital NEWS2 chart was developed in parallel to support the transition from the paper NEWS2 charts to a fully digital system.

The objective was to mirror the official NEWS2 chart as closely as possible to enable users to make the switch seamlessly and minimise the risk to patients.

The sequence of recording physiological parameters has been reordered on the NEWS2 chart to reflect the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) sequence used to assess the acutely ill patients.

Official NEWS2 Observation Chart (pdf)

The redesigned NEWS2 chart posed a number of development challenges. For example the scales are non linear. Observation values above and below the maximum and minimum chart ranges are displayed at the limits. The official NEWS2 training advises placing the actual value above the points plotted on the chart to compensate for this.

The NEWS2 “chart” is actually a “table” into which the user plots the values in the table cells and then joins up the dots to show the trends more clearly.

To replicate this we create a dedicated NEWS2 table and overlaid a chart to plot the eOBS values. The result is an almost exact replica of the official chart. We omitted the scoring column as the chart is designed to calculate the scores automatically.

Digital NEWS2 chart

The official NEWS2 chart contains several new features compared to the original NEWS.

Oxygen saturation scales

A new scale has been included for patients with type II hypercapnic respiratory failure as a result of chronic hypoxia. Administering too much oxygen to these patients can lower the patient’s respiratory rate and cause potentially lethal metabolic acidosis. A qualified medical practitioner should determine whether to use this scale 2 or the standard oxygen saturation scale 1.

Our NEWS2 eform asks whether the patient has chronic hypoxia and we record this and the qualified clinician authorising the diagnosis and use of scale 2 as part of the form record.

It is possible this diagnosis can be made in retrospect however. To address this, we included a switch on the chart to toggle between the 2 scales, or to display the data on both scales if required. In practice we chart the data as it was recorded at the time and allow qualified staff to access the toggle button for comparison if needed. The NEWS2 score and guidance can vary depending on which scale is used.

NB The official NEWS2 guidance is only one oxygen saturation scale should be used and the other crossed out (on the paper chart). On the digital version we hide the chart that is not being used to save space.

If changing the scale results in a different calculated score from the original assessment, we indicate that with an asterisk and tooltip on the recalculated score. By toggling the charts you can see any change and the impact on the score. This is also potentially useful for incident investigation.

As the chart calculates the NEWS2 score, this also provides a useful safety check as any variance with the original calculated score is flagged for review.

Supplemental oxygen and delivery

The oxygen saturation scale2 includes a top section for patients on supplemental oxygen. This makes the scale non linear and the plotting of values should take this into account.

The NEWS2 chart has also been updated to ensure the device delivery codes for face masks, nasal cannula etc. are recorded alongside the flow rate. The BTS device codes vary according to the percentage of oxygen given. For example a Venturi face mask set at a flow rate to give 28% oxygen has the BTS device code V28.

As these codes are potentially confusing we included a tooltip on the charts to provide further explanation. This includes the name of the device, the flow rate in litres/min and the oxygen percent. Please see the demonstration video and sample chart for examples of these.

There is a full description of the design principles and changes specific to the NEWS2 in the Royal College of Physicians report.

RCP NEWS2 Working Party Final Report 2017 (pdf)

NEWS 2 ward lists

The NEWS2 observations and scores are recorded in our EPR. We use these data to show ward lists including the latest scores and when the next set of observations are due. We also indicate if the nurse is concerned or has overridden the guidance and the reason why.

The NEWS2 ward lists and charts can support remote monitoring and a ‘safety huddle’ meeting where outreach and ward staff can review the NEWS2 scores and nursing/medical records across the hospital to ensure we are delivering the optimal care. An ‘all wards’ filter gives clear visibility of the patients with the highest scores at most risk.

Implementation and Devices

The digital NEWS2 went through our standard development and testing quality assurance processes including a hazard assessment and clinical safety sign off. All staff were trained in the use of NEWS2 and the digital implementation.

The digital solution is designed to work on desktop and mobile devices down to a resolution of an iPad mini. The forms and charts resize dynamically to accommodate different screen sizes and portrait orientation.

On mobile devices the form sliders and buttons are rendered larger to support touch. The NEWS2 chart is designed to fill the screen in portrait. In landscape it automatically scrolls on moving the mouse to the bottom of the screen or using the keyboard down button.

On desktops the data can be entered via the key board and tab between fields. In practice the staff tend to prefer a combination of the sliders and key pad. Sliders are helpful when using a mouse and on touch. They will move to any position clicked on the scale (see sample videos below)

The demonstration digital NEWS2 chart will displays on smart phone devices but the resolution is considered too small to be practical for everyday clinical use. While there would be some advantages in having a standalone form for data entry, the benefits of being able to see the charts and other nursing assessments all on the same device probably out weigh these. These risks are covered in the separate blog on clinical calculators.

Sample videos

The following videos demonstrate use of the NEWS2 form and chart integrated into our clinical web portal.

On the form you will note the scoring changes dynamically as the form is completed. We also include a number of additional non-scoring observations (pain score, chest pain etc) which are configurable by ward. Once the requisite fields are completed the NEWS2 guidance is displayed. The user is asked to confirm they agree with the recommendation and follow up interval, or use their clinical judgement to override, adding an explanatory comment.

On submission of the the user is shown the NEWS2 chart and guidance. The form can be figured to automatically send a notification by email and/or SMS message to the clinical outreach team, dependent on the score and escalation.

in our clinical web portal EPR, we display the NEWS2 chart alongside the latest set of observations and guidance. We include tooltip on all data points which are visible in hover or touch.

In addition to the default NEWS2 chart, our nursing and medical teams were keen to retain options to view the data on individual graphs and tables that we had developed for the initial eOBS pilot. These graphs have the advantage of a linear time X axis to more easily see changes in frequency of monitoring and the corresponding rate of change. These are illustrated in the video.

Open source project

I have made the chart available as an open source project should other teams wish to collaborate on this and potentially implement it in their solutions.

The chart render and display are encompassed within a single JavaScript (TypeScript) file and css stylesheet. The observation data are Json sourced by an Ajax call. The demo includes a sample static Json file.

I would welcome support to develop this as an Angular and React component, and to provide a NEWS2 FHIR alternative to the source data Json encoding. I have posted further details on this on the github wiki.

NEWS2 Repository Github

End Note

I would like to thank all the people and teams that helped us implement Digital NEWS2. I hope this blog helps provide some insight into this and how we addressed some of the challenges in digitising the chart.

Please feel free to contact me via github or through Twitter @RhidianB

©️Rhidian Bramley 2019

Author: Rhidian Bramley

Chief Clinical Information Officer (CCIO) and Associate Medical Director at the Christie NHS trust. Clinical directorate consultant at NHS Wales Informatics Service (NWIS).

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