Download News2 Chart

Automatic capture of physiological measurements could lead to fewer data input errors to the NEWS2 algorithm than manual recording and fewer calculation errors, giving a more accurate NEWS2 alert. The technology can address issues such as illegible written observations on paper charts.

The integrated electronic EWS systems in the scope of this briefing may be used in place of the manual recording of NEWS2 parameters on paper charts, and manual calculation, to trigger alerts for appropriate clinical response.

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Standard care is manually recording physiological parameters on NEWS2 paper-based charts, and manual calculation to trigger alerts for the appropriate clinical response. A series of standardised NEWS2 charts can be downloaded for free from the Royal College of Physicians website, which includes:

Wong et al. (2017) found the mean time taken for nursing staff to capture and record the 6 physiological parameters on paper-based charts and manually calculate the EWS was 3 minutes, 35 seconds (95% confidence interval: 2 minutes 57 seconds to 4 minutes 22 seconds) for 577 nurse events across 3 wards in 1 NHS trust (in 2 university teaching hospitals).

The cost of a nurse on band 4 of the NHS payscale per working hour is 28 (Personal Social Services Research Unit, 2018). Assuming a time of 3 minutes, 35 seconds for a band 4 nurse to manually capture and record the 6 physiological parameters on the chart and calculate the NEWS2, this costs an estimated 1.67 per patient, per observation set (assuming the cost of printing a NEWS2 chart is negligible).

The scores are calculated using the NEWS2 observation chart (Fig. 1). A score is allocated to each of the physiological measurements (Box 1); the higher the score, the more abnormal the measurement.3 The score is aggregated and, if the patient requires supplementary oxygen, it is increased. An elevated NEWS score doesn't provide a diagnosis, but helps to identify patients who are sick, requiring urgent clinical review following a standardised approach.3

NEWS2 observation chart (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)2

The NEWS thresholds and triggers chart (Fig. 2) can then prompt an appropriate response. Another chart providing guidance on the recommended clinical responses to NEWS trigger thresholds is available, particularly for use in hospital settings.

NEWS thresholds and triggers chart (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)2

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 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.

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 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.

The first author registered all data used in this analysis by review of clinical scoring charts and patient records. Clinical scores were based on the first recorded vital signs after admission, documented on charts or in the records.

NEWS2 is a standardised clinical scoring system developed to improve detection of deterioration in acutely ill patients (Fig. 1) [8]. It is based on aggregate scoring of six physiological parameters; respiratory rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new confusion, and body temperature. In addition, two points are added for patients requiring supplementary oxygen treatment. A NEWS2 score of 5 or 6 is considered a key threshold that may indicate clinical deterioration and should prompt urgent response by a clinician or a team with competence in assessment and treatment of acutely ill patients [8]. The NEWS2 scoring chart is utilised as part of routine patient care practice at our hospital.

The RCP is keen to encourage as many people as possible to use NEWS, so there is no copyright restriction on the NEWS2 report. However, anyone who is looking to reproduce material from the report should meet the following conditions.(1) The RCP should be acknowledged as follows: 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.(2) The material must not be modified/amended in any way.(3) The NEWS2 charts must be reproduced in colour.(4) Please use the high-resolution versions of the chart attached to this page. Do not use the low-quality version in the report itself.

Over the study period, there was a statistically significant and clinically meaningful reduction in mortality for patients at risk of sepsis in emergency admissions, contemporaneous with implementation, compared to historical data from the same region and comparative data from the rest of England. Their Figure 3, a statistical process chart, shows a change over time in crude mortality from ~6.2% to ~5.2%, compared to the rest of England which remained unchanged at ~6.7% (their Figure 2). e24fc04721