I was in a patient’s home, let’s call her Sarah, during those chaotic early weeks of the pandemic in March. Naturally, I was not wearing a mask or gloves (at that time I still thought PPE was just a degree that future Tory politicians did at Oxford). In front of me was a young woman with asthma, her worried husband holding her hand. Sarah was breathless at rest, having to work to breathe, and febrile. Her hair was stuck to a damp, sweaty brow. But her chest was clear with a few wheezes. She was tachypnoeic, but her obs were not as bad as she looked. My gut feeling though was that she needed to go in, and to go in quickly. I called the local acute admissions unit and also the paramedics, and both asked me a question I hadn’t been asked before: ‘What is her NEWS score?’.
Now, being a bit of a dinosaur, back in my hospital days, there was no National Early Earning Score NEWS score. To be honest, there wasn’t much of anything systematic back then apart from a hand-written, occasionally glanced at chart on a clipboard hanging off the end of the bed. But in recent years through trainees, newer GPs, and discharge summaries I have come to understand what the NEWS score is: an observation-based, physiological scoring system used in secondary care to predict clinical deterioration, whether patients’ care needs escalation and the urgency needed of that escalation. The crucial phrase of course there is ‘secondary care’ because that is where it has been researched, validated, and used.
But, by mission creep, NEWS (or the updated NEWS2) has now started to filter into primary care. It’s easy to see why. It is tempting to have a simple, objective measure to make complex clinical decision making easier, to iron out variations in care, and to get us to speak a ‘common language’ which is understood by paramedics and secondary care. In 2018 NHS England made use of the score mandatory in ambulance trusts and said that paramedics should use the score for ‘pre-hospital patients who are ill and at risk of deteriorating’ i.e. in the community. Since then GPs have started being asked by ambulance trusts what the score is before transferring a patient to hospital, and anecdotally it has been in much wider use since the onset of the COVID-19 pandemic. The NICE COVID-19 guideline has a specific recommendation that ‘NEWS2 may be useful’, but that a face to face consultation should not be arranged solely to measure it given that it includes BP and O2 saturation measurement.
But where is the evidence that this is a validated and robust tool to use in primary care? Well, there is the rub. There hasn’t been. A recent evidence review by the Centre of Evidence-Based Medicine in Oxford conclude that ‘NEWS2 has not been validated in COVID-19 patients nor in primary care’ and that enthusiasm for use in primary care may be ‘premature’. In addition, there are other problems with the score. It takes no account of age and co-morbidities, and as every GP knows it is how things evolve over time that is more important than single snapshots. And as every amateur statistician knows, tests that have a good predictive value in a high prevalence environment (i.e. hospital) will have lower predictive values in low prevalence environments (i.e. the community).
So, should we be using this score in primary care? This sunny month of June, the BJGP has published an excellent editorial on the use of NEWS in primary care in response to new research done in primary care. This research suggests that the use of the score in pre-hospital care improves outcomes in patients with suspected sepsis and that a high NEWS score in the community predicts faster transfer and clinical review in secondary care. However, these are both small observational studies and the editorial warns against widespread adoption yet in primary care. The editorial stresses the complexity of clinical decision making, and states ‘before supporting NEWS it needs to be established that this tool will provide safer care than communicating a full set of clinical observations’. There are clearly risks of both over and under-diagnosis if we are over-reliant on a score, and as the editorial states ‘no score can communicate the gut feeling of an experienced clinician’.
So, what happened with Sarah? Her NEWS2 score was only 3, and yet 5 is the usual level that mandates an escalation of care. But my ‘gut feel’ was that she was sick and needed hospital care. To be fair, both the hospital and the ambulance were happy to take her (she was subsequently diagnosed with pneumonia and admitted) but if we become over-reliant on such scores will that always be the case?
NEWS2 is seductive as it seems to give us a pure and simple tool to guide clinical decision making. But, as Oscar Wilde famously said, ‘the truth is rarely pure and never simple’. We need more robust evidence before adopting this score widely in primary care. In the meantime, it can be used to help communication with ambulance crew and secondary care but should not replace clinical decision making.