European Journal of Cardiovascular Medicine

When a critically ill patient presents to a healthcare facility or when a stable patient becomes critically ill, swift, planned and effective management of the situation is needed for a favorable outcome. Current evidence suggests that the triad of i) early detection, ii) timeliness of response and iii) competency of the clinical response determines the final clinical outcome. [1-5]

The importance of a systematic approach and the use of "EWS" (Early Warning Scores), also known as "track-and-trigger systems," have been emphasized in a number of British national reports, including those from the NICE (National Institute for Health and Clinical Excellence) and the RCP's acute medicine task force. [6,7] These systems are designed to efficiently identify and respond to patients who present with or develop acute illnesses.

In order to identify patients who are deteriorating or who are presenting with an acute illness, it is necessary to: i) measure basic physiological parameters in all patients in a systematic manner; and ii) define the appropriate urgency and scope of the clinical response that is necessary, taking into account the severity of the acute illness.

The first evaluation and measurement of the severity of acute sickness must be straightforward. The technique has to be more realistic, viable, and sufficient if it is to be used by all healthcare professionals and applied throughout all healthcare systems. Simple physiological characteristics that are easily measured during normal patient assessments, such as respiration rate, oxygen saturations, temperature, systolic blood pressure, pulse rate, and state of consciousness, can be used to quantify the severity of an illness. Numerous "early warning scores" or "track-and-trigger systems" are currently in use across the world, based on these basic physiological data.[8–10] These range in complexity from aggregate-weighted, single physiological parameter scores to multiple physiological parameter systems.

A 2007 report by the NCEPOD (National Confidential Enquiry into Patient Outcome and Death) advises that each patient should have a specific physiological monitoring strategy that is appropriate for their clinical situation. The standard operating procedures for the vitals monitoring plan, which are meant to be a crucial component in facilitating education and training in the initial evaluation and ongoing monitoring of critical patients in hospitals, were not highlighted in the NCEPOD report.[11]

Hospitals have previously created and widely adopted a variety of EWS systems. However, the thorough Acute Medicine Task Force report from the RCP in 2007 acknowledged the shortcomings of current clinical practice, noting that "there is no justification for the continued use of multiple different early warning scores to assess illness severity" and that "a number of basic assessment tools or "early warning scores" are currently in use nationwide."[10] Therefore, the NEWS was created to offer a standardized nationwide platform for documenting predetermined levels of illness severity. This would make it easier to create basic acute-illness severity profiles, which would help with (i) capacity and human resource needs audit and planning and allocation to match illness severity, and (ii) a potent research tool to evaluate the effectiveness of interventions, the standard of care, and clinical outcomes.

We intended to implement NEWS in a tertiary care centre in an Indian setting as a pilot project to assess the feasibility of implementing it at the national level.

The study was conducted from July 2020 to September 2021 at AIG Hospital, Hyderabad, Telangana, involving 270 patients of either sex or age greater than 16 years presenting to the emergency department, selected by a simple random sampling technique. Patients with COPD, acute MI, and pregnant females were excluded. The NEWS, as depicted in the figure below, was used to collect the data.

The data was expressed as a percentage and mean ± S.D. Kolmogorove-Smirnove analysis was performed to check the linearity of the data. Fischer’s exact test, or chi square test, was used to analyse the significance of the difference between the frequency distribution of the data. A student’s unpaired t test was used to assess the significance of the difference between means. The ROC curve was plotted to check the prognostic significance of PI. A p-value of <0.05 was considered statistically significant. SPSS© for Windows™ Vs. 17, IBM™ Corp. NY, and Microsoft Excel™ 2007, Microsoft® Inc. USA, were used to perform the statistical analysis.

The mean age was found to be 56.4 ± 16.9 years. The age and sex distribution of the study population is shown in Table 1.

A comparison of various parameters between study subjects with different outcomes was performed using the student's unpaired t test. Two groups were found to be age-matched. Further, no significant difference was found between the two groups regarding respiratory rate, SPO2, temperature, heart rate, blood sugar level, and pain score. Systolic blood pressure was, however, found to be significantly higher (p<0.0001) and urine output significantly lower (p<0.0001) in subjects who died compared to those who were discharged. The mean NEWS scores were 7.10±3.38 and 6.28±2.79, respectively, in outcomes of death and discharge, respectively. The difference was, however, not statistically significant (p = 0.09) (Table 2).

The ROC curve was plotted to assess the prognostic efficacy of the NEWS score in predicting death. The area under the curve was found to be 56%, indicating low prognostic accuracy. With a cutoff value of 7.5, we can predict death with 63.4% sensitivity and 49.2% specificity (Table 3 and Figure 2).

parameters (p = 0.36).

The association between outcome and level of consciousness was assessed using the chi-square test. A significant association was noted between two parameters, indicating a higher rate of discharge in subjects with alert consciousness (p<0.0001).

The association between outcome and NEWS colour coding was assessed using a chi-square test. No significant association was noted between the two parameters.

A number of factors, including a lack of accessible EWS, individual preferences, clinical expertise, or the fact that the specific EWS now in use was created locally, have contributed to the failure to adopt a standard EWS. Another barrier has been the scarcity of data and the difficulty in obtaining advanced data analysis tools that allow for system comparison. Consequently, there is a need for the creation of a national EWS that is standardized, validated, and benefits patients by bringing about a substantial shift in practice, policy, and mentality. With the same intent, we implemented NEWS in a tertiary referral centre in India to assess its feasibility in an Indian setting.

Two hundred and seventy subjects reporting to the emergency department were recruited for the study and monitored for all NEWS parameters. Healthcare staff, including the nursing staff, was primed with training on NEWS and its implementation. The implementation was followed by assessment in the form of morbidity and mortality outcomes.

Demographic Data

In our study, the majority (33% of subjects) belonged to the seventh decade, followed by the sixth decade (19.3%). The least number of subjects was in the fifth decade of life (12.6%). The mean age was found to be 56.4 ± 16.9 years. The gender distribution was almost equal, with 53.7% male and 46.3% female.

Vitals

The respiratory rate was found to be moderately raised in 42.2% and severely raised in 33.3%. The mean respiratory rate was found to be 25.0 ± 6.0 per minute. SPO2 was <91% in 29 subjects (10.7%). The mean SPO2 was 96.9 ± 3.8%. The majority (87.4%) of subjects had a body temperature between 36.1 and 380C. Body temperature was found to be lower in 1.5% and higher in 11.1% of subjects. The mean body temperature was found to be 37.3 ± 0.70C. The mean heart rate was found to be 94.3 ± 25.8. Random blood sugar was found to be normal in 39.6% of subjects. RBS was in the range of impaired glucose tolerance in 29.6% of subjects, and frank hyperglycemia was detected in 30.7%. The mean RBS was 189.4 ± 120.6 mg/dl.

NEWS Score

Based on the vitals, the NEWS was calculated. NEWS was 1-4 in 25.9% of subjects. 5-6 in 28.1% subjects and >/=7 in 45.9% subjects. The mean NEWS was 6.5 ± 2.9. Indicative news color coding was done. Accordingly continuous monitoring was performed in 45.9% of subjects. Hourly monitoring was provided to 33.3 subjects, and 20.7% of subjects received 4-6 hours of hourly monitoring. Escalation was performed in 16.3% of subjects.

Outcome

The outcome at the end of the hospital stay was noted: mortality was 22.6%, 75.9% of subjects were discharged, and 1.5% were referred.

Outcome Prediction

In the present study, apart from blood pressure and urine output, none of the parameters were found to be significantly different, including NEWS, between subjects with outcomes of death and discharge. The NEWS cutoff of 7.5 was found to predict mortality with 63.4% sensitivity and 49.2% specificity.

The level of consciousness was found to have a significant association with mortality. Gender, NEWS, monitoring, and escalation failed to reach a statistically significant association with outcome. The insignificant association of NEWS with outcome indicates that the NEWS-directed note of the subject's status prompted timely intervention, reducing mortality in subjects with a higher NEWS score too.

It has been demonstrated that the use of EWS in conjunction with quick response teams lowers the incidence of cardiac arrests and unplanned ICU admissions.[11] Numerous research endeavours have been carried out to examine the significance of early warning scores in discerning individuals who are susceptible to decline, their impact on medical results, and their capacity to forecast medical outcomes. [12-16] Utilizing early warning scores might have a beneficial impact on therapeutic results. However, various EWS scores have been employed in different research conducted so far, which makes it challenging to draw broad generalizations about the usefulness of these scores. [17,18] To the best of our knowledge, no research has been done to support the use of EWS in an Indian setting.

Previous investigations have shown that elevated NEWS is connected with a higher mortality risk using established grading standards. NEWS may also serve as a further means of evaluating the effectiveness of medical therapies. Compared to the majority of systems currently in use, NEWS is expected to offer a more sensitive and adaptable tool. Emergency medical and nursing personnel will find that NEWS helps them prioritize their patients and gives them the courage to seek professional counsel, when necessary, when caring for these patients.

Groarke et al. [19] conducted an early NEWS study in which they tracked 225 hospital medical admissions in a row and categorized patients into four groups according to their NEWS score. The length of hospital stays, admission to the ICU (Intensive Care Unit) or the CCU (Cardiac Care Unit), cardiac arrest, and mortality were the primary outcomes. Regardless of the patient's age, a correlation between higher admission scores and the last three objectives was discovered. Additionally, they discovered that an improvement in score within four hours of hospital presentation was predictive of a better result.

Data for 274 patients were gathered by Alam et al,[20] at admission at the ED (Emergency Department), as well as an hour later and upon transfer to the general ward or intensive care unit. The NEWS score "was significantly correlated with patient outcomes, including 30-day mortality, hospital admission, and length of stay at all-time points," according to the study's authors. In order to "longitudinally monitor patients throughout their stay in the ED and in the hospital," the authors came to the conclusion that the method was beneficial.

Research has also been done on the NEWS score's application in the prehospital context. For instance, research by Silcock et al. [21] looked at how well the NEWS system performed in the prehospital scenario in relation to the major outcomes of ICU admission, 48-hour and 30-day mortality, and all of these were linked to higher NEWS ratings.

Even if the research mentioned above and many more are positive, there are a few warning signs that should be mentioned. For instance, Kolic et al.'s research [22] examined the possibility of variations in NEWS compliance for detecting patient deterioration after hours. The authors discovered that 18.9% of patients in their sample of 370 had their scores computed inaccurately.

Also, NEWS refers patients with scores more than 4 to a physician or when the sum of all parameter values is 3. Still, not everyone thinks this makes sense. In an analysis of workload, Jarvis et al. [23] discovered that aggregate NEWS values are more significant in predicting unfavorable outcomes than high single parameter scores. They noted that "escalating care to a doctor when any single component of NEWS scores 3 compared to when aggregate NEWS values ≥5, would have increased doctors' workload by 40% with only a small increase in detected adverse outcomes from 2.99 to 3.08 per day (a 3% improvement in detection)." The authors also issued a warning, pointing out that an escalation strategy of this kind runs the danger of creating alert fatigue in addition to warping the emphasis on patient safety.

According to research evaluating the NEWS score's capacity, while statistical analysis shows that NEWS outperforms competing EWS systems for the outcomes examined, there is no assurance that this will remain the case should NEWS be extensively deployed in an operational setting. When calculating the total EWS and allocating individual vital sign parameters to the appropriate EWS weighting group, EWSs with fewer parameters than NEWS is more likely to make mistakes.

Therefore, it stands to reason that NEWS would be more likely to have operational error than EWS with fewer parameters; nevertheless, this theory has to be verified. In addition, further research must be done on how successful it is operationally for any EWS, including NEWS, in comparison to less complex methods (such as single calling criteria or subjective criteria) for activating a fast reaction team.[24] The aforementioned study also indicated that a NEWS value was superior to other EWSs in terms of death within 24 hours.

A number of factors, including a lack of accessible EWS, individual preferences, clinical expertise, or the fact that the specific EWS now in use was created locally, have contributed to the failure to adopt a standard EWS. Another barrier has been the scarcity of data and the difficulty in obtaining advanced data analysis tools that allow for system comparison. Consequently, there is a need for the creation of a national EWS that is standardized, validated, and benefits patients by bringing about a substantial shift in practice, policy, and mentality. With the same intent, we implemented NEWS in a tertiary referral centre in India to assess its feasibility in an Indian setting.

Two hundred and seventy subjects reporting to the emergency department were recruited for the study and monitored for all NEWS parameters. Healthcare staff, including the nursing staff, was primed with training on NEWS and its implementation. The implementation was followed by assessment in the form of morbidity and mortality outcomes.

Demographic Data

In our study, the majority (33% of subjects) belonged to the seventh decade, followed by the sixth decade (19.3%). The least number of subjects was in the fifth decade of life (12.6%). The mean age was found to be 56.4 ± 16.9 years. The gender distribution was almost equal, with 53.7% male and 46.3% female.

Vitals

The respiratory rate was found to be moderately raised in 42.2% and severely raised in 33.3%. The mean respiratory rate was found to be 25.0 ± 6.0 per minute. SPO2 was <91% in 29 subjects (10.7%). The mean SPO2 was 96.9 ± 3.8%. The majority (87.4%) of subjects had a body temperature between 36.1 and 380C. Body temperature was found to be lower in 1.5% and higher in 11.1% of subjects. The mean body temperature was found to be 37.3 ± 0.70C. The mean heart rate was found to be 94.3 ± 25.8. Random blood sugar was found to be normal in 39.6% of subjects. RBS was in the range of impaired glucose tolerance in 29.6% of subjects, and frank hyperglycemia was detected in 30.7%. The mean RBS was 189.4 ± 120.6 mg/dl.

NEWS Score

Based on the vitals, the NEWS was calculated. NEWS was 1-4 in 25.9% of subjects. 5-6 in 28.1% subjects and >/=7 in 45.9% subjects. The mean NEWS was 6.5 ± 2.9. Indicative news color coding was done. Accordingly continuous monitoring was performed in 45.9% of subjects. Hourly monitoring was provided to 33.3 subjects, and 20.7% of subjects received 4-6 hours of hourly monitoring. Escalation was performed in 16.3% of subjects.

Outcome

The outcome at the end of the hospital stay was noted: mortality was 22.6%, 75.9% of subjects were discharged, and 1.5% were referred.

Outcome Prediction

In the present study, apart from blood pressure and urine output, none of the parameters were found to be significantly different, including NEWS, between subjects with outcomes of death and discharge. The NEWS cutoff of 7.5 was found to predict mortality with 63.4% sensitivity and 49.2% specificity.

The level of consciousness was found to have a significant association with mortality. Gender, NEWS, monitoring, and escalation failed to reach a statistically significant association with outcome. The insignificant association of NEWS with outcome indicates that the NEWS-directed note of the subject's status prompted timely intervention, reducing mortality in subjects with a higher NEWS score too.

It has been demonstrated that the use of EWS in conjunction with quick response teams lowers the incidence of cardiac arrests and unplanned ICU admissions.[11] Numerous research endeavours have been carried out to examine the significance of early warning scores in discerning individuals who are susceptible to decline, their impact on medical results, and their capacity to forecast medical outcomes. [12-16] Utilizing early warning scores might have a beneficial impact on therapeutic results. However, various EWS scores have been employed in different research conducted so far, which makes it challenging to draw broad generalizations about the usefulness of these scores. [17,18] To the best of our knowledge, no research has been done to support the use of EWS in an Indian setting.

Previous investigations have shown that elevated NEWS is connected with a higher mortality risk using established grading standards. NEWS may also serve as a further means of evaluating the effectiveness of medical therapies. Compared to the majority of systems currently in use, NEWS is expected to offer a more sensitive and adaptable tool. Emergency medical and nursing personnel will find that NEWS helps them prioritize their patients and gives them the courage to seek professional counsel, when necessary, when caring for these patients.

Groarke et al. [19] conducted an early NEWS study in which they tracked 225 hospital medical admissions in a row and categorized patients into four groups according to their NEWS score. The length of hospital stays, admission to the ICU (Intensive Care Unit) or the CCU (Cardiac Care Unit), cardiac arrest, and mortality were the primary outcomes. Regardless of the patient's age, a correlation between higher admission scores and the last three objectives was discovered. Additionally, they discovered that an improvement in score within four hours of hospital presentation was predictive of a better result.

Data for 274 patients were gathered by Alam et al,[20] at admission at the ED (Emergency Department), as well as an hour later and upon transfer to the general ward or intensive care unit. The NEWS score "was significantly correlated with patient outcomes, including 30-day mortality, hospital admission, and length of stay at all-time points," according to the study's authors. In order to "longitudinally monitor patients throughout their stay in the ED and in the hospital," the authors came to the conclusion that the method was beneficial.

Research has also been done on the NEWS score's application in the prehospital context. For instance, research by Silcock et al. [21] looked at how well the NEWS system performed in the prehospital scenario in relation to the major outcomes of ICU admission, 48-hour and 30-day mortality, and all of these were linked to higher NEWS ratings.

Even if the research mentioned above and many more are positive, there are a few warning signs that should be mentioned. For instance, Kolic et al.'s research [22] examined the possibility of variations in NEWS compliance for detecting patient deterioration after hours. The authors discovered that 18.9% of patients in their sample of 370 had their scores computed inaccurately.

Also, NEWS refers patients with scores more than 4 to a physician or when the sum of all parameter values is 3. Still, not everyone thinks this makes sense. In an analysis of workload, Jarvis et al. [23] discovered that aggregate NEWS values are more significant in predicting unfavorable outcomes than high single parameter scores. They noted that "escalating care to a doctor when any single component of NEWS scores 3 compared to when aggregate NEWS values ≥5, would have increased doctors' workload by 40% with only a small increase in detected adverse outcomes from 2.99 to 3.08 per day (a 3% improvement in detection)." The authors also issued a warning, pointing out that an escalation strategy of this kind runs the danger of creating alert fatigue in addition to warping the emphasis on patient safety.

According to research evaluating the NEWS score's capacity, while statistical analysis shows that NEWS outperforms competing EWS systems for the outcomes examined, there is no assurance that this will remain the case should NEWS be extensively deployed in an operational setting. When calculating the total EWS and allocating individual vital sign parameters to the appropriate EWS weighting group, EWSs with fewer parameters than NEWS is more likely to make mistakes.

Therefore, it stands to reason that NEWS would be more likely to have operational error than EWS with fewer parameters; nevertheless, this theory has to be verified. In addition, further research must be done on how successful it is operationally for any EWS, including NEWS, in comparison to less complex methods (such as single calling criteria or subjective criteria) for activating a fast reaction team.[24] The aforementioned study also indicated that a NEWS value was superior to other EWSs in terms of death within 24 hours.

Our study successfully implemented NEWS in a tertiary level reference center in Telangana. NEWS effectively identifies those subjects in need of immediate medical attention. Implementation at the national level will provide an objective score for indicating and conveying the seriousness of critically ill subjects to referral centers. NEWS is not an end point but a beginning to the development of a nationally validated scoring system to assess and convey the condition of subjects at intra and inter hospital facilities.

1. Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified early warning score in medical admissions. QJM 2001;94(10):521-6.
2. Smith GB, Prytherch DR, Schmidt P, Featherstone PI, Knight D, Clements G, et al. Hospital-wide physiological surveillance – a new approach to the early identification and management of the sick patient. Resuscitation 2006;71(1):19-28.
3. Gao H, McDonnell A, Harrison DA, Moore T, Adam S, Daly K, et al. Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward. Intensive Care Med 2007;33(4):667-79.
4. Groarke JD, Gallagher J, Stack J, Aftab AR, Dwyer C, McGovern R, et al. Use of an admission early warning score to predict patient morbidity and mortality and treatment success. Emerg Med J 2008;25(12):803-6.
5. Australian Commission on Safety and Quality in Healthcare. Recognising and responding to clinical deterioration: use of observation charts to identify clinical deterioration. Australian Commission on Safety and Quality in Healthcare 2009.
6. Jansen JO, Cuthbertson BH. Detecting critical illness outside the ICU: the role of track and trigger systems. Curr Opin Crit Care 2010;16(3):184-90.
7. National Institute for Health and Clinical Excellence. Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital. NICE clinical guideline 50. London: NICE 2007.
8. Patterson C, Maclean F, Bell C, Mukherjee E, Bryan L, Woodcock T, et al. Early warning systems in the UK: variation in content and implementation strategy has implications for a NHS early warning system. Clin Med 2011;11(5):424-7.
9. Smith GB, Prytherch DR, Schmidt P, Featherstone PI. Review and performance evaluation of aggregate weighted ‘track and trigger’ systems. Resuscitation 2008;77(2):170–9.
10. Royal College of Physicians. Acute medical care: the right person, in the right setting – first time. London: RCP 2007.
11. Moon A, Cosgrove JF, Lea D, Fairs A, Cressey DM. An eight year audit before and after the introduction of modified early warning score charts, of patients admitted to a tertiary referral intensive care unit after CPR. Resuscitation 2011;82(2):150-4.
12. Reini K, Fredrikson M, Oscarsson A. The prognostic value of the Modified Early Warning Score in critically ill patients. European Journal of Anaesthesiology 2012;29(3):152-7.
13. Armagan E, Yilmaz Y, Olmez O, Simsek G, Gul C. Predictive value of the modified Early Warning Score in a Turkish emergency department. European Journal of Emergency Medicine 2008;15(6):338-40.
14. Carle C, Alexander P, Columb M, Johal J. Design and internal validation of an obstetric early warning score: secondary analysis of the Intensive Care National Audit and Research Centre Case Mix Programme database. Anaesthesia 2013;68(4):354-67.
15. Burch V, Tarr G, Morroni C. Modified early warning score predicts the need for hospital admission and inhospital mortality. Emergency Medicine Journal 2008;25(10):674-8.
16. Merz T, Etter R, Mende L, Barthelmes D, Wiegand J, Martinolli L, et al. Risk assessment in the first fifteen minutes: a prospective cohort study of a simple physiological scoring system in the emergency department. Critical Care 2011;15(1):R25.
17. Subbe C, Williams E, Fligelstone L, Gemmell L. Does earlier detection of critically ill patients on surgical wards lead to better outcomes? Annals of The Royal College of Surgeons of England 2005;87(4):226-32.
18. Alam N, Hobbelink EL, van Tienhoven AJ, van deVen PM, Jansma EP, Nanayakkara PW. The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review. Resuscitation 2014;85(5):587–94.
19. Groarke JD, Gallagher J, Stack J, Aftab A, Dwyer C, McGovern R, et al. Use of an admission early warning score to predict patient morbidity and mortality and treatment success. Emerg Med J 2008;25(12):803-6.
20. Alam N, Vegting IL, Houben E, Van Berkel B, Vaughan L, Kramer MH, et al. Exploring the performance of the National Early Warning Score (NEWS) in a European emergency department. Resuscitation 2015;90:111-5.
21. Silcock DJ, Corfield AR, Gowens PA, Rooney KD. Validation of the National Early Warning Score in the prehospital setting. Resuscitation 2015;89:31-5.
22. Kolic I, Crane S, McCartney S, Perkins Z, Taylor A. Factors affecting response to National Early Warning Score (NEWS). Resuscitation 2015:90:85-90.
23. Jarvis S, Kovacs C, Briggs J, Meredith P, Schmidt PE, Featherstone PI, 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;87:75-80.
24. Smith G, Prytherch D, Meredith P, Schmidt P, Featherstone P. The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death. Resuscitation 2013;84(4):465-70.