The impact of introducing the early warning scoring system and protocol on clinical outcomes in tertiary referral university hospital

Figures & data

Figure 1 The hospital protocol structure for response to the deterioration of patients.

Abbreviations: ICU, intensive care unit; NEWS, national early warning score.

Table 1 The National early warning scoring (NEWS)

Physiological parameters	3	2	1	0	1	2	3
Respiration rate (breaths per min)	≤8		9–11	12–20		21–24	≥25
SpO2 (%)	≤91	92–93	94–95	≥96
Any supplemental oxygen?		Yes		No
Temperature (°C)	≤35.0		35.1–36.0	36.1–38.0	38.1–39.0	≥39.1
Systolic BP (mmHg)	≤90	91–100	101–110	111–219			≥220
Heart or pulse rate (beats per minute)	≤40		41–50	51–90	91–110	111–130	≥131
Level of consciousness using the AVPU system				A			V, P or U

Notes: SpO₂, estimate of arterial oxygen saturation. BP, blood pressure. Reprinted from Resuscitation, 84(4), Smith GB, Prytherch DR, Meredith P, Schmidt PE, Featherstone PI, 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, 465–470, 2013, with permission from Elsevier.⁵

Abbreviations: A, alert; P, pain; U, unresponsive; V, verbal.

Table 2 Protocol for clinical response and intervention for NEWS trigger

Levels of severity	Scores 0–1	Scores 2–4	Scores 5–6, alert sign 1 time (regardless of other scores)	Scores ≥7 and 5–6 or alert sign 2 times
Nurse response	Routine	Routine	Move the bed near the nurse counter for close monitoring	Transfer to ICU
Doctor response	Routine	Routine	First-year resident within 30 min	Both first-year and senior residents within 15 min
Frequency of monitoring	Every 8 h	Every 4 h	Every 2 h	Continuous monitoring
Notify attending staff	Routine (daily)	Routine (daily)	Within 8 h	Immediate

Abbreviations: ICU, intensive care unit; NEWS, national early warning score.

Figure 2 The association between in-hospital mortality and percentage of ICU transfer with risk.

Note: Stratification by NEWS.
Abbreviations: ICU, intensive care unit; NEWS, national early warning score.

Table 3 Baseline characteristics and bedside observations for NEWS on admission

Parameters	Pre-protocol group (N=564)	Protocol group (N=581)	P-value
Age (years), mean (SD)	55.64 (17.54)	59.61 (16.86)	0.64
Male sex, n (%)	317 (56.2)	293 (50.4)	0.05
ICD diagnosis group, n (%)			0.00
Infectious diseases	28 (40)	42 (60)	0.11
Neoplasm	368 (58.2)	264 (42.8)	0.00
Cardiovascular diseases	33 (28.9)	81 (71.1)	0.00
Respiratory diseases	31 (32)	66 (38)	0.00
Gastrointestinal diseases	36 (51.4)	34 (48.6)	0.71
Neurologic diseases	13 (56.5)	10 (43.5)	0.48
Urologic diseases	16 (39)	25 (61)	0.18
Bone and connective tissue	7 (43.8)	9 (56.3)	0.66
Hematological disease	12 (63.2)	7 (36.8)	0.22
Endocrine disease	5 (33.3)	10 (66.7)	0.21
Skin and subcutaneous tissue disease	5 (55.6)	4 (44.4)	0.70
Other diagnoses	10 (25.6)	29 (74.4)	0.00
NEWS at admission, mean (SD)	1.77 (2.16)	2.4 (2.4)	0.00
Patients stratified by NEWS, n (%)
Low risk	509 (90.2)	470 (80.9)	0.00
Moderate risk	26 (4.6)	69 (11.9)
High risk	29 (5.1)	42 (7.2)

Abbreviation: NEWS, national early warning score.

Table 4 Outcomes of the national early warning scoring system and protocol

	Pre-protocol group	Protocol group	P-value
Rate of intensive care unit transfer, n (%)
Total	22 (3.9)	33 (5.7)	0.16
Low risk	9 (1.8)	10 (2.1)	0.68
Moderate risk	7 (26.9)	6 (8.7)	0.02
High risk	6 (20.7)	17 (40.5)	0.08
In-hospital mortality, n (%)
Total	11 (2)	15 (2.6)	0.47
Low risk	4 (0.8)	7 (1.5)	0.23
Moderate risk	4 (15.4)	2 (2.9)	0.03
High risk	3 (10.3)	6 (14.3)	0.62

SmithGBPrytherchDRMeredithPSchmidtPEFeatherstonePIThe ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and deathResuscitation201384446547023295778

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