Implementation of the National Early Warning Score in the Emergency Department

Abstract

Problem & Purpose: Delayed recognition of clinical deterioration is associated with increased risk for serious adverse events, including unplanned intensive care unit (ICU) admissions. The rate of transfer of general ward patients to the ICU within 24-hours of admission from the emergency department (ED) have increased, identifying process gaps in the recognition of clinical deterioration and disposition of admitted patients from the ED. The purpose of this quality improvement project was to implement the National Early Warning Score (NEWS) in the adult ED and monitor use to promote patient admission to the appropriate level of care. Methods: The ED nursing staff were educated about NEWS prior to project implementation. NEWS values were manually calculated at the time of ED rooming and time of admission. Patients with NEWS five and greater were considered for ICU admission based on inpatient ICU acceptance policies. A 10% sample of weekly census (10 patients/day) and all admissions were obtained for data collection. Weekly chart audits were conducted over a 14-week period to monitor adherence to the new practice, observe trends, and identify potential ICU admissions for patients with NEWS five and greater. Results: Over 75% of patients received NEWS screening with appropriate documentation (n=873). Overall accuracy of NEWS calculation was 99.4%. Of the 21 patients with ED NEWS greater than five, 14 (66.7%) were admitted directly to the ICU. Of the seven patients with ED NEWS greater than five not directly admitted to the ICU, four (57%) required an unplanned ICU or interfacility transfer within 24-hours of hospitalization. Conclusion: The ED staff reported NEWS improved patient monitoring, detection of deterioration, and communication of findings to providers. Integrating NEWS into electronic health systems may promote adherence and accuracy. Higher NEWS were associated with ICU admission but admitting decisions for higher NEWS varied between admitting services. The NEWS can establish a common language across disciplines and can facilitate admitting decisions with consideration for patient acuity and resource availability. Use of NEWS five and greater in other ED settings may predict ICU admission and potentially reduce unplanned transfers.