Validation of the National Early Warning Score in the prehospital setting



      Early intervention and response to deranged physiological parameters in the critically ill patient improves outcomes. A National Early Warning Score (NEWS) based on physiological observations has been developed for use throughout the National Health Service (NHS) in the UK. Although a good predictor of mortality and deterioration in inpatients, its performance in the prehospital setting is largely untested. This study aimed to assess the validity of the NEWS in unselected prehospital patients.


      All clinical observations taken by emergency ambulance crews transporting patients to a single hospital were collated along with information relating to hospital outcome over a two month period. The performance of the NEWS in identifying the endpoints of 48 h and 30 day mortality, intensive care unit (ICU) admission, and a combined endpoint of 48 h mortality or ICU admission was analysed.


      1684 patients were analysed. All three of the primary endpoints and the combined endpoint were associated with higher NEWS scores (p < 0.01 for each). The medium-risk NEWS group was associated with a statistically significant increase in ICU admission (RR = 2.466, 95% CI 1.0–6.09), but not in-hospital mortality relative to the low risk group. The high risk NEWS group had significant increases in 48 h mortality (RR 35.32 [10.08–123.7]), 30 day mortality (RR 6.7 [3.79–11.88]), and ICU admission (5.43 [2.29–12.89]). Similar results were noted when trauma and non-trauma patients were analysed separately.


      Elevated NEWS among unselected prehospital patients is associated with a higher incidence of adverse outcomes. Calculation of prehospital NEWS may facilitate earlier recognition of deteriorating patients, early involvement of senior Emergency Department staff and appropriate critical care.


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        • Rivers E.
        • Nguyen B.
        • Havstad S.
        • et al.
        Early goal-directed therapy in the treatment of severe sepsis and septic shock.
        N Engl J Med. 2001; 345: 1368-1377
        • Dellinger R.P.
        • Levy M.M.
        • Rhodes A.
        • et al.
        Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock.
        Intensive Care Med. 2012; 39: 165-228
        • Smith T.
        • Den Hartog
        • D.
        • Moerman
        • T.
        • et al.
        Accuracy of an expanded early warning score for patients in general and trauma surgery wards.
        Br J Surg. 2012; 99 (ISSN: 0007-1323): 192-197
        • Morgan R.J.M.
        • Williams F.
        • Wright M.M.
        An early warning score for the early detection of patients with impending illness.
        Clin Intensive Care. 1997; 8: 100
        • Goldhill D.R.
        • McNarry A.F.
        Physiological abnormalities in early warning scores are related to mortality in adult inpatients.
        Br J Anaesth. 2004; 92: 882-884
      1. Standardising the assessment of acute-illness severity in the NHS. Report of a working party.
        Royal College of Physicians, London2012
        • Smith G.B.
        • Prytherch D.R.
        • Meredith P.
        • et al.
        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.
        Resuscitation. 2013; 84: 465-470
        • Groarke J.D.
        • Gallagher J.
        • Stack J.
        • et al.
        Use of an admission early warning score to predict patient morbidity and mortality and treatment success.
        Emerg Med J. 2008; 25: 803-806
        • Griffiths J.R.
        • Kidney E.M.
        Current use of early warning scores in UK emergency departments.
        Emerg Med J. 2012; 29: 65-66
        • Rees J.E.
        • Mann C.
        Use of the patient at risk scores in the emergency department: a preliminary study.
        Emerg Med J. 2004; 21: 698-699
        • Timothy J.
        An early warning? Universal risk scoring in emergency medicine. Roland, Damian and Coats.
        Emerg Med J. 2011; 28: 263
        • Roland D.
        • Jahn H.
        Are early warning scores too early for paramedic practice?.
        J Paramed Pract. 2012; 4: 16
      2. Correspondence between National Ambulance Service Medical Directors Group and Royal College of Physicians.
        2013 ([unpublished])
        • Scottish Ambulance
        Service Clinical Strategy 2011–2015.
        • Prytherch D.R.
        • Smith G.B.
        • Schmidt P.E.
        • et al.
        ViEWS – towards a national early warning score for detecting adult inpatient deterioration.
        Resuscitation. 2010; 81: 932-937
      3. Manchester Triage. Group Emergency Triage.
        Blackwell, 2006
        • Cooke M.W.
        • Jinks S.
        Does the Manchester triage system detect the critically ill?.
        J Accid Emerg Med. 1999; 16: 179-181
        • McNeill G.
        • Bryden D.
        Do either early warning systems or emergency response teams improve hospital patient survival? A systematic review.
        Resuscitation. 2013; 84: 1652-1667
        • Wheeler I.
        • Price C.
        • Sitch A.
        • et al.
        Early warning scores generated in developed healthcare settings are not sufficient at predicting early mortality in Blantyre, Malawi: a prospective cohort study. 3.
        PLOS ONE. 2013; 8: e59830
        • Eccles S.R.
        • Subbe C.
        • Hancock D.
        • et al.
        CREWS: improving specificity whilst maintaining sensitivity of the National Early Warning Score in patients with chronic hypoxaemia.
        Resuscitation. 2013; 85: 109-111
        • O’Driscoll R.
        Emergency oxygen use.
        Br Med J. 2012; 345: e6856
        • Hands C.
        • Reid E.
        • Meredith P.
        • et al.
        Patterns in the recording of vital signs and early warning scores: compliance with a clinical escalation protocol.
        BMJ Qual Saf. 2013; 22: 719-726
        • McBride J.
        • Knight D.
        • Piper J.
        • et al.
        Long-term effect of introducing an early warning score on respiratory rate charting on general wards.
        Resuscitation. 2005; 65: 41-44
        • Hammond N.E.
        • Spooner A.J.
        • Barnett A.G.
        • et al.
        The effect of implementing a modified early warning scoring (MEWS) system on the adequacy of vital sign documentation.
        Aust Crit Care. 2013; 26: 18-22
        • Burch V.C.
        • Tarr G.
        • Morroni C.
        Modified early warning score predicts the need for hospital admission and inhospital mortality.
        Emerg Med J. 2008; 25: 674-678
        • Corfield A.R.
        • Lees F.
        • Zealley I.
        • et al.
        Utility of a single early warning score in patients with sepsis in the emergency department.
        Emerg Med J. 2013;
        • Mohammed M.A.
        • Rudge G.
        • Watson D.
        • et al.
        Index blood tests and national early warning scores within 24 hours of emergency admission can predict the risk of in-hospital mortality: a model development and validation study.
        PLOS ONE. 2013; 8: e64340
        • Jarvis S.
        • Kovacs C.
        • Badriyah T.
        • et al.
        Combining the National Early Warning Score with an early warning score based on common laboratory test results better discriminates patients at risk of hospital mortality. Rapid response systems and medical emergency teams. Projects: CHMI. Health informatics.
        • Fullerton J.N.
        • Price C.L.
        • Silvey N.E.
        • et al.
        Is the Modified Early Warning Score (MEWS) superior to clinician judgement in detecting critical illness in the pre-hospital environment?.
        Resuscitation. 2012; 83: 557-562
        • Booth S.M.
        • Bloch M.
        An evaluation of a new prehospital pre-alert guidance tool.
        Emerg Med J. 2013; 30: 820-823
        • Challen K.
        • Walter D.
        Physiological scoring: an aid to emergency medical services transport decisions?.
        Prehosp Disaster Med. 2010; 25: 320-323