‘Stably unstable’ – limitations with NEWS charting

Summary

In this blog, Claire discusses the use of NEWS2 in coronavirus patients and the importance of recognising, tracking and alerting the appropriate team that your patient has an increasing oxygen demand to ensure that the risk of more people being exposed to the virus is minimal.

Content

I have just finished a stint of four long days working as an outreach nurse. Many of our staff are self-isolating. As outreach nurses, we come into contact with many different types of patient on a daily basis. We could be seeing a surgical patient with sepsis to a pre-eclamptic lady on maternity, it just depends on who needs you. 

The varied case load is what I enjoy; the work can be stressful, but we have numerous algorithms, policies and procedures that we follow. These policies and procedures keep our patient safe and also gives us evidence-based approach to the treatment we give.

We are now seeing many COVID-19 patients. We now have two resuscitation bays in our emergency department: one side green (COVID free) and one side red (COVID-19). Anyone with a respiratory complaint is cohorted on the acute medical ward if they require admission. 

As an outreach nurse we spending a fair amount of time within the acute medical ward. This new cohort of patients seem to require higher concentration, they deteriorate quickly and need a close eye on.

We have electronic observations which has been a real game changer. We can now see all the patients in the hospital who are having a high NEWS score, we can track these patients and give the ward the support they need in caring for the deteriorating patient. Having this electronic system at this time has never been so crucial.

However, don’t be fooled by the number. One of the limitations of the NEWS2 charting is that the patient doesn’t score more for an increasing oxygen demand. The patient will score for being on oxygen whether that be one litre or 60%.

A patient (patient 1) can be scoring 4 on the NEWS chart and not be referred to outreach, as they do not ‘trigger’ until they get to 5. For example, in patient 1 – NEWS2 = 4

• Resps: 21
• Sats: 96%
• On 2 litres oxygen
• BP: 120/80
• HR: 60
• Aprexial

This patient is only on 2 litres of oxygen. This is relatively little oxygen, but they score for being on it as it is a sign of deterioration, but look at an example for patient 2:

• Resps: 21
• Sats: 96%
• On 15 litres oxygen
• BP: 120/80
• HR: 60
• Apyrexial

This NEWS2 score remains 4, despite patient 2 being on the maximum amount of oxygen staff can give on the wards.

During this crisis, I want to highlight that a patient with an increasing oxygen demand is escalated to either the ward doctors or the outreach team. Patients with COVID-19 deteriorate quickly on admission; they require increasing concentrations of oxygen over a short period of time.

Emergency intubation of COVID-19 positive patients on a ward is not safe. Staff need to wear full personal protective equipment (PPE) (not just a surgical mask and apron) to intubate as it is an aerosoled generating procedure. Our aim would be to get the patient to the intensive care ward first where the intubation is controlled with all the right PPE and only with a limited team to limit exposure.

Recognising and alerting the appropriate team that your patient has an increasing oxygen demand will reduce the risk of more people being exposed to this virus.

• What further work is needed to ensure that an increasing demand for oxygenation is added to the scoring of the NEWS chart?
• Is this a recognised issue for other healthcare professionals?
• What are other outreach teams doing to track patients with increasing oxygen demands? (tweet to @CCC_Outreach)