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Baseline measurements and clinical judgement are crucial to detecting deterioration in older patients
I have completed the 2,300 practice hours required by the Nursing and Midwifery Council to be able to join the nursing register.
Nursing Older People. 35, 5, 16-17. doi: 10.7748/nop.35.5.16.s6
Published: 03 October 2023
During my training, I lost count of just how many routine observations I have taken: checking vital signs and watching for any indications of deterioration.
My experience has taught me that while the Royal College of Physicians’ National Early Warning Score (NEWS2) is an essential tool, it is not the be-all and end-all, particularly in our detection of early clinical deterioration in patients.
As a nursing student in the north east of England, this has been particularly relevant. We have some of the highest annual rates of avoidable mortality and morbidity in the UK– more than double the average of those living in less deprived areas of the country.
These statistics include mortality and morbidity as a result of delayed treatment, which could include morbidity and mortality from late or undetected deterioration.
There is no doubt that NEWS2 is a valuable system. Its numerical score helps us determine the urgency of the required clinical response by quantifying the severity of a patient’s condition.
But it is one piece of a bigger puzzle – a snapshot of a moment quantifying physiological measurement that does not tell the full story of a patient’s health trajectory. As such, it is risky to over-rely on that single perspective, sometimes at the cost of a more comprehensive, holistic view of a patient’s well-being.
My understanding of the NEWS2 scoring system has grown during my placements and I have also become aware of its limitations and the importance of context when taking routine observations.
A wider perspective is vital, as numerical scores may not convey nuanced changes in a patient’s clinical state. Measuring vital signs can show improvement or decline, but both are more evident if we also monitor a patient’s baseline observations and track their observational trends over time.
Observations in isolation may be misleading as they miss trends and it is just as important that we use a patient’s baseline to gauge their ‘normal’. Any significant deviation from this baseline can be an early sign of clinical deterioration, even if the NEWS2 score is within acceptable range.
Similarly, trends in observations can alert us to a gradual shift in a patient’s condition. These subtle changes, while not yet raising alarms on a single NEWS2 scale, might signal the onset of a more serious issue when observed over time.
One example from my practice would be my experience of taking routine observations on a patient who was new to me. They had a systolic blood pressure of 112mmHg and a pulse rate of 95bpm. Their overall NEWS2 score was 1, for a slightly elevated heart rate, but they did not score for any other of the routine observations.
If we were to rely solely on this stand-alone score, it is likely there would be no need for immediate interventions as per NEWS2 guidelines.
However, the patient in question had a consistently recorded blood pressure of about 160mmHg and a heart rate of 70-75bpm, indicating a significant drop in blood pressure combined with a new fast heart rate.
‘Any significant deviation from a patient’s baseline can be an early sign of clinical deterioration, even if the NEWS2 score is within acceptable range’
‘Even as nursing students, our regular interaction with patients often enables us to perceive subtle changes that might be overlooked in a numerical scoring system’
If we ignore the single perspective and consider this patient’s baseline, we can detect definite clinical signs of a change in health.
This may not be of major concern or could be early deterioration, but it should be enough to instigate further checks – how does the patient look? Are they pale? Is their skin cold and clammy? Are they restless or agitated? And so on.
In this case the patient did deteriorate and was experiencing a post-surgical bleed, something that would have been missed had we relied on the NEWS2 score alone.
NEWS2 or similar evidence-based tools are valuable, but we should augment them with a heightened sensitivity towards our patients’ ‘normal’ and consider any subtle changes that might not be immediately reflected in a one-off set of physiological parameters.
No detail is too small or insignificant and any subtle change from a patient’s norm may hold the key to understanding their health status and act as an early warning sign before it is reflected in their NEWS2 score.
It is also important to trust our clinical judgement and intuition. Even as nursing students, our regular interaction with patients often enables us to perceive subtle changes that might be overlooked in a numerical scoring system.
These perceptions, when backed by baseline and trending data, can lead to early identification of clinical deterioration and timely interventions.
There is evidence that assessment of deterioration is not always optimal – there have been countless reports outlining the problem of poor assessment. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reports from 2005-15 all show the same trends of poor assessment.
The latest identified failings throughout the patient pathway are highlighted in the NCEPOD report Just Say Sepsis!: from carrying out a timely initial assessment and identifying the source of infection to adequate monitoring and timely initiation of treatment.
Therefore, I wonder if all nurses see NEWS2 as part of a suite of assessments, rather than a standalone answer?
National Confidential Enquiry into Patient Outcome and Death. www.ncepod.org.uk
National Confidential Enquiry into Patient Outcome and Death (2015) Just Say Sepsis! A Review of the Process of Care Received by Patients with Sepsis.
Royal College of Physicians (2023) National Early Warning Score (NEWS) 2.