Implementing the National Early Warning Score (NEWS)

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Introduction Why change? Form your team Agree your measures Agree your actions Known issues Appendixes
Introduction

Acknowledgement
License
This toolkit has been developed based on resources
produced by the Royal College of Physicians in collaboration
Training materials and supporting resources are © West of England Academic Health Science Network 2016, and
with the Royal College of Nursing and the National Outreach
provided under license for use by WEAHSN members under the following terms:
Forum, building on recommendations made by NICE (2007)
and the Department of Health and Modernisation Agency in
• Attribution – You must give appropriate credit, provide a link to the license, and indicate if changes were made.
2003. The College’s materials were used as a template for
You may do so in any reasonable manner, but not in a way that suggests that the licensor endorses you or your
the development of vital signs charts in acute trusts in the
use.
South West of England.
• Non-commercial – You may not use the material for commercial purposes.
• Share alike – If you remix, transform or build upon the material, you must distribute your contributions under the
Materials within this implementation pack have been
same license as the original.
developed by the West of England Academic Health Science
• No added restrictions – You may not apply legal terms or technological measures that legally restrict others
Network. Thanks are due to a number of individuals who
from doing anything the license permits.
have contributed directly and indirectly.

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Introduction Why change? Form your team Agree your measures Agree your actions Known issues Appendixes
Introduction

Aim
Contents
This toolkit supports the implementation of the National Early
Warning Score (NEWS) in a variety of health care settings
Introduction
and gives advice and guidance on achieving a successful
implementation in any health care setting. About the National Early Warning Score

1. Why change?
This toolkit also provides information and links to resources
2. Form your team
on change management methods. More support in
improvement techniques is available from the West of 3. Agree your measures
England Academic Health Science Network website at http:// 4. Agree your actions
www.weahsn.net/what-we-do/west-of-england-academy/
5. Known issues
improvement-resources-and-tools/the-improvement-
journey/steps-in-the-improvement-journey/ Appendixes

Supporting tools and templates are available online to support this toolkit at http://www.weahsn.net/what-we-do/
Who this document is for enhancing-patient-safety/the-deteriorating-patient/
This guide is for managers, commissioners, clinical staff and
trainers, from primary through secondary to tertiary care. It
should be useful for GPs, district and community nurses, staff
working in nursing homes or ambulance services, and staff
working in the full range of hospital settings.

NEWS has a use in any environment where vital signs are

taken and recorded.

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 About the West of England Academic Health Science Network

The West of England Academic Health Science Network

(AHSN) is delivering positive healthcare outcomes locally and
nationally by driving the development and adoption of new
innovations and making a meaningful contribution to the
economy.
E
We are one of 15 AHSNs across England, established by NHS
England in 2013 to spread innovation at pace and scale.
F
As the only bodies that connect NHS and academic
organisations, the third sector and industry, we are catalysts F
A
that create the right conditions to facilitate change across
whole health and social care economies, with a clear focus B
FC
on improving outcomes for patients.
D
G

Find out more at our website http://www.weahsn.net/

Follow us on Twitter at @WEAHSN

A South Gloucestershire
B Bristol E Gloucestershire
C North Somerset F Swindon
D Bath and North East Somerset G Wiltshire

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Introduction Why change? Form your team Agree your measures Agree your actions Known issues Appendixes
About the National Early Warning Score

NEWS has been produced as a way of making sure that

where a patient is at risk of acute deterioration, then vital
signs are recorded at a frequency suitable to the clinical
scenario, and that escalation of treatment is timely and
appropriate where it is needed. Since then it has become
promoted as a communication device providing a summary
of a patient’s condition and a prompt for intervention,
escalation of care or referral as required.

Calculating NEWS

Vital signs are recorded as a way of finding out if there has

been a positive response to treatment, or whether a patient
needs a change to an ongoing treatment plan. Whilst it
is recognised that serious complications may happen to
patients without any warning, in the majority of situations
there are warning signs that if acted on are likely to be
associated with better outcomes.

NEWS is an inherently simple device but its implementation

may involve considerable complexity depending on the
organisation in which it is being used. There are two areas
The Royal College of Physicians (RCP) has led the development of the National Early Warning Score which advocated
that require concentrated efforts; these are ensuring that
standardising the use of a NEWS system across the NHS in order to drive the ‘step change’ required in the assessment
NEWS is recorded accurately, and ensuring that NEW Scores
and response to acute illness.
are well linked to escalation of treatment where this is
required. There are significant training implications in any Find out more at https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news
NEWS implementation.

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About the National Early Warning Score

NEWS provides the basis for succinct and efficient What is SBAR?
communication about the physiological state of patients
SBAR is a tool for communication and stands for:
where there is transfer of information between different
SITUATION S professional groups or between different service providers. • Situation. Patient/ client’s details, identify reason
for this communication, describe your concern.
In combination with communication tools like SBAR • Background. Relating to the patient/ client/
(Situation Background Assessment Recommendation), it service user/ resident significant history; this may
is possible to communicate the right information about
BACKGROUND B patients in a succinct format that helps to assure a quality
include medications, investigations, treatments.

• Assessment. What is your assessment of the

communication.
patient/ client or situation. This can include clinical
impressions/ concerns, vital signs if relevant.
We have developed a toolkit to support organisations
ASSESSMENT A to implement SBAR for human factors in their team. This • Recommendation. Be specific, explain what
is available online at http://www.weahsn.net/what- you need, make recommendations, clarify
we-do/enhancing-patient-safety/collaborating-in-the- expectations and confirm actions to be taken.
community/human-factors/

RECOMMENDATION R

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Introduction Why change? Form your team Agree your measures Agree your actions Known issues Appendixes
About the National Early Warning Score

What NEWS is for

NEWS is a scoring grid for physiology where six be reason enough to seek a review; or small changes in Benefits of NEWS
physiological parameters that make up routine vital two or more vital signs accumulate in a score to trigger the
1. Improved patient safety by accurate recording
signs recording of an adult patient, are scored along need for review.
and auditing of vital signs measurements
with an additional score for when a patient is receiving
In different health care settings and in different acute 2. Saving of training time where staff work in many
supplemental oxygen. The NEWScore is calculated from
hospitals, the detail of the escalation responses will be different organisations: (essentially) one system
totals for the seven elements that are recorded. If a
influenced by local service configuration. to be learned than a previous large variety of
NEWScore is high then the greater a patient’s physiology
different EWS systems
varies from normal. The greater the variation from normal Implementing NEWS may provide an opportunity to assess
3. NEWS becomes part of the language used in
then the worse their physiological condition. the appropriateness of some services and may act as a
communication between different health care
lever for service change to enhance patient safety.
NEWS is for use with adults, but not if more than 20 weeks professionals about patients
pregnant. It is not suitable for children or neonates and is What NEWS does 4. Formalisation and clarity of escalation responses
not used within critical care or operating theatres. for patients who deteriorate in physiological
• It provides a baseline measure of an individual’s
condition.
NEWS has a prescriptive clinical response about who physiological functioning (from a gathered sequence
5. Surveillance of baseline physiology to detect
should be contacted if NEWS increases over different of vital signs recordings);
departure from normal physiology; collection of
thresholds, as well as prescription for the minimum
• It measures the effectiveness of some treatment trend information allows monitoring of variance
frequency at which physiological observations should be interventions when there is a change in NEWS; to assure appropriate changes in care where
recorded. The escalation response is based on a two-tier
required.
escalation depending on the magnitude of the NEW Score. • It provides a risk assessment of an individual based
6. Compliance with national recommendations
on recorded observations;
A very high score requires a senior review (or emergency for acute illness management; national
input); a less high score requires a more junior response. • It can assist in timely escalation of clinical response recommendations tend to be based on better
in the event of an acute physiological deterioration evidence than can be obtained locally.
NEWS has a single parameter element and an aggregate when there is an increase in NEWS.
scoring system. This means that a single vital sign may

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Introduction Why change? Form your team Agree your measures Agree your actions Known issues Appendixes
About the National Early Warning Score

What NEWS is not for

Sensitivity and Specificity
NEWS is not a panacea. It is a simple and fairly blunt In most instances NEWS (and its change over time)
device that provides decision support to clinical staff provides a useful statement of an individual’s vital signs Sensitivity and Specificity are two important aspects of
assessing patients. It is decision support tool and not the reliability of a test.
NEWS is a generic tool, and may require other
decision-replacement. Although it has been developed
assessments such as Glasgow Coma Score or Forced Vital • Sensitivity measures the proportion of actual
with specificity and sensitivity in mind, it cannot be a
Capacity or Peak Flow. These other measures supplement positives which are correctly identified as such.
replacement for clinical judgment. It does however
and enhance NEWS.
provide a level of information that is clinically useful in an • Specificity measures the proportion of actual
abbreviated and succinct format that allows appropriate It may require that NEWS is measured alongside a manual negatives that are correctly identified as negative.
discussion about patient management. handling or transfer risk assessment to provide more
A perfect measure would be 100% sensitive and 100%
appropriate information. This does not invalidate the
It is not a comprehensive description of a patient. For specific.
implementation of NEWS even in a tertiary care setting,
example NEWS does not include a measure for urine
but NEWS often needs to exist alongside other clinical NEWS related to need for escalation of treatment
output which is regarded as an easy to measure of organ
information and protocols. offers high sensitivity and low specificity.
perfusion in acute illness. It includes a component score
for a patient receiving supplemental oxygen, but does NEWS is a part of the story and not the whole story. A useful article to explain the difference between
not provide clinical detail about how that oxygen is being sensitivity and specificity can be found at: http://
delivered. Patients receiving a lot of oxygen are generally a As part of this toolkit you can download Frequently Asked
ceaccp.oxfordjournals.org/content/8/6/221.full.
lot sicker than patients receiving much less. The distinction Questions about NEWS and key messages to support
pdf+html
between receiving some extra oxygen or no supplemental implementation of NEWS.
oxygen is all that is scored in NEWS.

For a full physiological profile of a patient information is

required about vital signs (including NEWS); manner of
oxygen delivery and oxygen requirement to maintain safe
and appropriate oxygenation; and accurate fluid balance
-- knowledge of input and output to assure adequate
hydration and good organ perfusion.

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NEWS, Sepsis and Acute Kidney Injury

Any strategy to introduce NEWS should include AKI and Sepsis, bound together by consideration of human factors. SNOOP and SHOUT are useful acronyms.

Sepsis is a major cause of avoidable death in hospital and

any implementation of NEWS should be linked to improved SHOUT Signs of Sepsis
surveillance for it.
S Sepsis Does the patient look ill?
Sepsis is defined as life-threatening organ dysfunction
caused by a dysregulated host response to infection. H Hypovolaemia Are they triggering an early warning score.

The role of NEWS in sepsis is to prioritise where patients have O Obstruction Are there signs of infection?

become unwell with sepsis for urgent treatment. For a patient U Urine Analysis Chemotherapy in last 6 weeks?
to score highly in NEWS though, the patient may well already
have severe sepsis or even organ dysfunction or failure. All T Toxins This could be sepsis.
implementations of NEWS should include reference to and be
associated with treatment of Sepsis and Acute Kidney injury

A key message with NEWS is that a patient may require

intervention to treat sepsis even with a relatively low SNOOP Complete the Sepsis 6 within 1 hour
NEWScore, but any septic patient with a NEWScore over S SEPSIS Give O2 to keep sats above 94%
threshold requires prompt treatment and intervention. Take blood cultures
N NEWS
The UK Sepsis Trust have published very helpful clinical Give IV antibiotics
toolkits available at http://sepsistrust.org/ O OXYGENATION Give a fluid challenge
Measure lactate
Acute Kidney Injury O OUTPUT OF URINE Measure urine output

NEWS is not a fully comprehensive descriptor of an P PAIN

individual’s physiology. Along with a drive to improve
management of sepsis, there is a drive that should be
associated with avoiding acute kidney injury (AKI).

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 Form your team

Your NEWS steering group may be incorporated as part of a deteriorating patient steering group, or established as NEWS specific depending on the organisation.

It will be important to establish a steering group to NEWS adoption involves behaviour change. Change
Identify project team members oversee the implementation process. This group will from staff who record vital signs; change from staff who
need to be at least partly representative of all of the key respond to elevated NEW Scores.
• Executive / Board sponsor
groups influenced by the change. The group is largely
• A project leader, (with quality and change To achieve implementation, the context of the organisation
operational in focus with a key emphasis on leadership
management, and leadership skills). needs to be understood. Drawing up a commitment
and delivery of the project of NEWS implementation. Terms
• Risk manager plan is a useful approach as it allows a description of
of reference and group membership will be dependent of
• Representation of non-medical clinical groups the degree of movement that needs to be obtained from
the organisation that is being served.
involved, and likely to consist of nurse(s), drawn from different staff where there may be negativity, or even
clinical practice and management; physiotherapists Meeting frequency of the steering group will depend on obstruction to a change. A commitment plan can be
(AHPs); paramedic(s), GP practice lead, community the stage of the project, but will likely to be around two- focussed on individuals or groups of staff or departments.
(district) nurses; rehabilitation team; community monthly , with more or less frequency depending on the It allows a plan to describe the behaviour changes that
integrated care team staff stage of the project. are needed for a successful implementation. Not everyone
• Medical representation: senior clinician (consultant) has to be necessarily in favour of a change but opposition
from surgery, medicine, emergency care and critical The reporting function of the group will be dependent on
may need to be managed depending on where it is
care; junior doctor; GP(s); the clinical governance structure of the organisation. The
coming from.
steering group will require an executive sponsor, the role
• Education lead
of whom will change depending on the precise details of
• Sepsis and AKI leads
the project (e.g. if NEWS implementation forms part of a
• Audit expert
CQUIN).
• Secretary (note-taker)
The leader must be appropriately supported for a change
Others may be required depending on the stage of
to be successful.
implementation who can be drawn in as required.
This might include people with an IT background, Terms of reference will be dependent on the organisation
communications department staff (for publicity). being served, but clear accountability and reporting
arrangements must be agreed and established.

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Role descriptions

Each organisation will need to appoint individuals to specific roles within each project team. It is a strongly suggested that these roles are fulfilled by staff already in post working, not staff brought
in for the specific functions/roles outlined in this Toolkit. In order to release people to complete the roles specified in this Toolkits, a commitment must be given by the Trust to backfill the individuals
undertaken them.

Lead Nurse Lead Consultant Audit Coordination Nurse / Data Analyst

Providing day to day nursing leadership to the Project Providing day to day medical leadership to the Project Collecting and collating agreed metrics

Agree quality metrics for measurement (clinical and Agree quality metrics for measurement (clinical and Review retrospective data to enable comparison of current
operational) to assess impact of project with Lead Consultant operational) to assess impact of project with Lead Nurse results

Educating staff on the project aims, methodology and Provide education support in all aspects of the project, but Managing supporting staff involved in auditing
anticipated patient safety impact, by a full range of with specific emphasis on medical staff at all levels and
Liaise with trust data analysts to present data effectively and
communication methods and briefing sessions. consultant colleagues.
professionally
Delivering appropriate training and staff briefing sessions. Champions of the project on the shop floor
Contribute and present data results to project group and
Champions of the project on the shop floor Presenting project information and results in a variety of wider audience
formats
Ensuring regular feedback results to all staff groups
Target specific staff groups according to their involvement in
Presenting information in a variety of formats Other key stakeholders
the project (e.g. CSMs)
Coordinate regular meetings with Project Team to discuss Senior Medical & Nursing Team – need to entrust
Write and present reports as required
project progression and action plan/delegation of commitment to project and be a champion on shop floor
responsibilities
Data Analyst needs to be on board and prepared to assist
Target specific staff groups according to their involvement in project with data production and presentation
the project (admin staff, clinical site managers)
Receptionist/Patient Flow Coordinators needs to be on board
Liaise with trust data analysts to present data effectively and and understand their contribution as per local procedures
professionally

Write and present reports as required

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Identify barriers to change

The steering group will need to establish where barriers to

implementation exist and discuss these at steering group
meetings.
Project related Resource related
Commitment planning is a useful way of articulating where
Lack of leadership support Competing priorities
barriers exist, and prompting where actions may be required
to manipulate barriers. See example below. Weak sponsorship Time pressure

Some barriers can be avoided by the way that the steering Lack of accountability Work pressure / overloaded workforce
group is established and because of the skills of the
Lack of consensus Shortage of internal resources
membership. Others are external to the group.
Lack of control plan / measures Financial cost
The list provided is not exhaustive and depends on
the context of the organisation in which NEWS is being
implemented.

Staff related Organisation related

No perceived benefit from implementation Unanticipated events

No perceived relevance from change Cultural change

Staff fear of change Lack of communication

Resistance to change

Motivation and engagement

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 Carry out a gap analysis

Gap analysis is what it implies. It involves comparison between current state and future or desired state. The nature of the gap informs the process by which an implementation plan can be developed.

It is an essential part of the planning process, and requires Case study 2

Current state
a high level of thoroughness. If the gap is small the action
At another site where a critical care outreach team was
plan is unlikely to be that complicated. If the gap is large it
available data were collected on 100 patients and a direct GAP
may point to key factors that must be considered in detail
comparison between pragmatic EWS and NEWS. In that
for a successful implementation plan.
instance the two systems were very similar in the activity
Case study 1 they would initiate through escalation calls. Desired state

The need for thoroughness in gap analysis is illustrated

by the example of an implementation in an acute trust
involving replacement of an existing pragmatic EWS with
NEWS.
Action plan
Create an action plan based on your
Because NEWS was far more sensitive than the existing
analysis of the key factors for change
EWS, there was an early perceived increase in workload.
This had implications, particularly for training.

Gap analysis in that instance involved a simple data

collection exercise to measure the increased escalation
activity that came from the increased sensitivity of NEWS.

NEWS was identifying essentially the same patients,

but sooner. Early increases in activity were partly due to
decisions about patient management not being made on
routine ward rounds. Had that been done an estimated 20-
30% reduction in actual activity could have been achieved.

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Agree your measures

In order to implement NEWS in a sustainable way in your The IHI Model for Improvement What are we trying to
organisation, and to be able to measure the impact of accomplish?
this intervention, we recommend a structured Quality There are three questions to ask when developing
Improvement framework for implementation. implementation projects shown to the right.

Quality Improvement science is the application of a These are then followed by rapid cycle improvement
using PDSA.
How will we know if a change
systematic approach using specific methods and techniques is an improvement?
in order to deliver measurable improvements in quality, care
and safety. Plan, Do, Study, Act is an effective method that
helps teams plan the actions for their model, test it
The processes we describe can be adapted to meet the on a small scale, and review before deciding how to
needs of your staff, service users and organisational context. continue. What changes can we make that
Our approach uses the methodology developed by the will result in an improvement?
Institute of Health called the IHI Model of Improvement. Using PDSA cycles are a fantastic way of taking ideas,
trying them in practice, learning what works, and
You can find out more about the Model for improvement what doesn’t to help you achieve success.
through our Improvement Journey at http://www.weahsn.
You can then broaden the scale of the test, or adjust

PL
net/what-we-do/west-of-england-academy/improvement-

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resources-and-tools/the-improvement-journey/steps-in-the- your ideas through more than one PDSA cycle ­— it
improvement-journey/ make take a few before the idea starts to work
reliably.

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DO
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For an introduction to PDSA cycles
For a fun way to introduce a team to quality

Y
watch this video https://youtu.be/
xzAp6ZV5ml4 improvement, check out this blog post http://www.
weahsn.net/2016/01/anyone-for-tennis/

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 Agree your measures

Different types of measures Reasons for measuring:

• Measurement for judgement: where measures are
There are different types of measures: used to judge us against performance targets, other
• Process measures, e.g. the number of sessions Trusts, etc. Improvement is not about judgement,
delivered each month, number of staff trained in each however, you can use measures to judge and
session, number of public contributors involved in manage your own progress
training sessions. • Measurement for diagnosis: where data is
gathered to understand the process, to see if
• Outcome measures, e.g. staff attitude survey of there is a problem and how big it is. This is a
perception of communication within the team and safety useful technique, especially early in your work, for
attitudes, and confidence with using SBAR before and example, to really understand the demand and
after the intervention capacity at a bottleneck in the process
• Measurement for improvement: where a few
• Balancing measures, e.g. number of 999 call outs
specific measures, linked to the your objectives and
from residential homes before and after training
aims, demonstrate whether the changes are making Run charts
delivered, staff sickness and turnover rates. A run chart is a tool for improvement which shows how your
improvements
project is going.
What can you measure? • Measurement for sustainability: to ensure
the changes and the improved outcomes are To show that things have improved you need to show the
We can count something, e.g. the number of patients who maintained and are part of everyday practice. These things that have changed, and that the change is not a
have diabetes in a given population, or the number of are long term measures linked to organisational one off. You must consider whether the change has been
serious adverse events in a given time period. aims sustained. Run or control charts allow you to see if this has
• Measurement for spread: specific measures to happened.
We can use ratios which consider of two numbers, a For more information on run charts visit http://www.weahsn.net/
numerator and a denominator. Sometimes this number is demonstrate the extent to which learning and
what-we-do/west-of-england-academy/improvement-resources-and-tools/
expressed as a percentage. For example if there are 5 change principles for improvement have been
the-improvement-journey/steps-in-the-improvement-journey/step-4-test-
adverse events each year in a 250 population, that is 0.02 adopted.
and-measure-improvement/run-charts/
adverse events per person (ratio) or a 2% adverse event rate
(percentage).

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 Ways to measure

Measuring the accuracy of NEWS

Measuring Appropriate Escalation some useful information to support information about
There are a range of ways in which measurement of accuracy of escalation. This source is generally quite limited as reporting
This area of measurement presents an immense challenge
NEWS can be accomplished. Careful consideration needs to be given of NEWS related incidents plus actual are not likely to be
and is associated with the way in which an organisation
to who does the measuring. The options are self audit; audit by close numerically. Serious untoward incidents reporting
works.
“buddy”; audit by someone external to the department but within severe system failures may help with cultural change
the organisation or audit by someone external to the department NEWS is designed to provide a score which is associated and improvement over time, but would require consistent
and the organisation. There are advantages and disadvantages to with an escalation response; the higher the score, the reporting. Also incidents reported as relating to NEWS may
all. External audit is resource intensive and unlikely to be possible, more urgent the escalation. In a process where a transfer have different root cause.
although an audit from someone within the organisation but not is influenced by NEWS measurement is relatively easy and
Using a reduction in resuscitation team or emergency calls
the department is the more affordable option. The advantage of an data are likely to be easily available. Where it is possible
as a proxy measure for failed processes may be useful,
external person is that they can be trained to a consistent standard to demonstrate an “always” result with high NEWS always
but is confounded by the fact that team calls are more
and are unlikely to be responsive to bias compared to a self audit leading to an appropriate response, infrequent audit
influenced by appropriate placement of Do Not Attempt
approach. is required. Where this is not the case frequent audit is
Cardio-Pulmonary Resuscitation (DNACPR) orders than
required.
With any sort of measurement audit the idea of keeping it simple is a anything else. If resources allow, every resuscitation team
good one, and there may be opportunities to combine data collection In an acute trust measurement is likely to be harder, where or emergency team call should be subjected to a serious
with existing audits or have it as a part of traffic light or safety most bleep systems in use remain fairly unsophisticated. untoward incident reporting process, particularly given that
thermometer processes. If bleep referrals are (preferably automatically) associated premonitory signs of acute deterioration before cardiac
with data collection, as may be the case with some Out of arrest are common. Routing review of National Cardiac
In the South West there has been a very successful safety project
Hours / Hospital at Night processes, then measurement Arrest Data (NCAA) in the context of NEWS is recommended.
organised through the IHI. Where this has been the case a certain
may be easier.
maturity of data collection and processing to support NEWS may be Although it requires registration the Institute of Healthcare
relatively easy to develop, building on existing processes. Where data are lacking it may be possible to use a Global Improvement provides a global trigger tool that is useful,
Trigger Tool approach where selected notes are analysed particularly if used with patient records where high NEW
Data collection relating to news accuracy using run charts provides a
against a standard template of questions. If possible the Scores are known to have been recorded.
good reporting system.
notes selection process should filter to obtain patients who
It is worth noting that obtaining an acceptable level of accuracy may have had elevated NEW Scores during their stay.
not be achieved immediately, and patience and detailed audit by
Proxy measures such as incident reporting may provide
department is required.

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A case study: Royal United Hospitals Bath NHS Foundation Trust

The RUH Bath NHS Foundation Trust implemented NEWS

in 2014. The trust had an established critical care outreach
team (CCOT) which provided the cascade training to achieve
a critical mass of staff to support a safe implementation.

Achieving NEWS accuracy is challenging, because there are

some inherent complexities in its use and because of the
influence of human factors. In accuracy is more likely the
higher the NEWS – in other words at a time when its accuracy
is most important.

Measurement of NEWS accuracy used auditors external to

departments to ensure accurate results. Accuracy came in at
around 86%. As progress towards instillation of the system
in the trust continued, a robust approach towards improving
accuracy has been taken.

The key elements of this were:

• Formalised approach to cascade training with

objectives and measurement of training built in
• Continued audit by external auditors until high
accuracy achieved
• Shared and detailed analysis of training delivered
by cascade trainers in wards
• Targeted action dependent on that analysis

Contact Anne Plaskitt, Senior Nurse Quality Improvement,

Royal United Hospitals NHS Trust

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Introduction Why change? Form your team Agree your measures Agree your actions Known issues Appendixes
A case study: North Bristol NHS Trust

North Bristol NHS Trust implemented NEWS in collaboration

with University Hospitals Bristol NHS Foundation Trust in
December 2015.
NEWS of 5 or 3 in one parameter NEWS of 7 or more
Audit of NEWS accuracy was a relatively simple modification (or if you feel in your clinical judgement that
of existing well established audits of documentation. the patient requires urgent review
irrespective of NEWS) Check score
Measurement of compliance with referral was less easy as Airway Breathing Circulation
a number of different referral processes exist throughout the
trust.
Review by medical team (F1 and Review by ward registrar of SNP
One advantage is that for many referrals a process existed above or SNP) within 30 minutes immediately

where calls to a central number are logged with some

information about the referral collected. Referral processes 09:00 to 17:30 Handover using SBAR 09:00 to 17:30
• Inform nurse in charge • Inform nurse in charge
within the trust for this system were already very formalised
• Ring 6999 for ward doctor (tell • Ring 6999 for ward registrar for
with a requirement to attend patients with high EWS and Dial 2222 if cardiac arrest
switchboard the name of the immediate review (tell
team needed
now NEWS. This had an impact on referral rate as NEWS is registrar to bleep) switchboard the name of the
more sensitive than the system it replaced, but does provide registrar to bleep)
Handover using SBAR
the basis for good data collection relating to appropriate Continue observing patient
If no review with 30 minutes ring 17:30 to 20:30 or 08:30 to 09:00
escalation. 6999 for ward registrar or Record actions on • Ring 6999 for medical registrar on
consultant observation chart call
The information collected is not complete where ward based
staff are immediately available and some departments use Clarify management plan
17:30 to 20:00 ring 6999 and ask Continue observing patient
more traditional bleep referral processes. for SHO for your zone colour with doctor/ SNP
If deteriorates call 2222
Continue to monitor If no review with 15 minutes ring
The Trust has an advantage in measuring compliance with
20:30 to 08:30 ring 6999 for H@N observations 2222
escalation with a drive to develop a single referral process
throughout the trust. This should facilitate a more efficient 08:30 to 09:00 ring 6999 and ask 20:30 to 08:30 Ring 6999 for H@N
use of a Global Trigger Tool approach. for Medical Registrar on call for immediate review

Continue observing Continue observing

Contact: Seema Srivastava, Associate Medical Director for
If no review within 30 minutes ring If no review with 15 minutes call
Safe Care, North Bristol Trust 6999 for medical registrar on-call or 2222
consultant

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Introduction Why change? Form your team Agree your measures Agree your actions Known issues Appendixes
 Trials and testing

Related to the gap analysis and consideration of existing documentation, a working draft of a NEWS chart is useful to initiate testing. The RCP template of the front of the adult observation chart is a
good place to start for acute settings, but is unlikely be suitable on its own.

There may be environments where serial recording of caser scenario, the withdrawal of a new process may
Measures to test vital signs is less formalised in which case how NEWS be required. If a large “big-bang” implementation fails,
would be incorporated within existing documentation or without a contingency plan, then patient safety may be
In implementing NEWS it is important to have an idea
included within data fields of an IT system would need to compromised.
early on about how a successful implementation may
be measured. The detail of this may be sketchy at first be considered.
There is a short period of risk that needs to be assessed
as there are some issues relating to measurement At the same time as producing a template chart (or where parallel referral systems may exist. Good
that may only emerge as a project develops.
similar) due consideration needs to be given to the referral communication should minimise any risk.
Mike Davidge of the NHS institute presents a very processes associated with different NEW Scores.
A full implementation is then possible with a high degree
useful video entitled “Measurement for Improvement”.
A useful chart developers guide is available at: of confidence in success.
It can be accessed at: https://youtu.be/Za1o77jAnbw
http://www.safetyandquality.gov.au/wp-content/
Key elements of NEWS chart
Measures can relate to input, process or output and uploads/2012/02/ORC-Developers-Guide-4-Oct-2010.pdf
may involve: The key elements that make up NEWS are:
The PDSA approach lends itself to refining different
• Observation of practice elements of a NEWS chart / documentation or process in • A single parameter scoring system
• Interviewing key individuals different environments. The same approach can also be • A multi-parameter scoring system
• Questionnaires / focus groups / surveys • Stated range of weightings for different parameters
used for a larger trial of an implementation.
• Analysis of untoward incidents / incident reports • Prescribed minimum frequency of observations
• Preparation, delivery and measurement of result A larger trial is recommended, particularly in a large • Four groupings of patients depending on score
of educational materials organisation such as an acute trust, but anywhere where • Two-tier clinical response if escalation required.
• Tap opinion leaders many departments or locations will be implementing
• Audit and compliance with standards NEWS.

A trial in two or three areas, allows any unanticipated

problems that may arise to be managed. In the worst

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Trials and testing -- example of forms in use across the West of England

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Introduction Why change? Form your team Agree your measures Agree your actions Known issues Appendixes
 Initiation

With any communication strategy there is always the worry that staff may (legitimately) be able to turn round and say that they did not know anything about it. Good publicity using all available media
is likely to lead to saturation. NEWS is a delightful acronym for an implementation.

It is noted elsewhere in this toolkit that a trial of NEWS Publicity can be achieved in a large number of ways:
implementation should be undertaken where possible
• Informal and formal staff meetings
and appropriate. This has the advantage of both testing
• Publication of steering group minutes
the system, but also of providing a fair measure of
• Publication of results of tests and trials
publication. Where a trial is undertaken both formal and
• Drop in sessions for both awareness and education
informal information systems within organisations will
• Senior / middle manager meetings
give the message that NEWS is coming, making its full
• Sister / Charge nurse meetings
implementation aware to all staff.
• Medical Grand Rounds
A useful resource to plan your communication is the • Clinical Governance meetings
Health Foundation communication toolkit available at • Intranet or local information systems
http://www.health.org.uk/collection/communications- • Message of the day (or similar)
health-care-improvement-toolkit • Hijack front page of intranet
• Introduction within existing education
Resources are available to support training and
• Posters
communication including:
• Emails
• NEWS Frequently Asked Questions • Newsletters
• Key messages to support use of new adult • Twitter campaign
observation charts
• NEWS in 10 minutes
• NEWS on Steroids: Scenarios and Discussion
Questions
• NEWS for doctors, teaching plan, and slides
• Example slides for teaching nursing staff

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Implementing and embedding

There are three phases to establishing NEWS within an Initial implementation is a process of weeks and months,
The Life System Platform organisation: instillation is a process that may take many months or
even years, depending on the culture in which NEWS is
The West of England AHSN would be grateful if • Introduction
being used.
participating EDs submit their data on a monthly • Implementation
basis on the Life System platform. This platform will • Instillation
also have run chart and notice board capabilities to
facilitate the sharing of information between LITs and While the three is may overlap to some extent; they cannot “It is important to remember when
across the programme. be regarded as discrete phases. implementing NEWS that it is not just
about introducing a new observation
Introduction
The Life System is a web based platform designed chart.”
to assist front line staff running Quality and Safety Introduction involves all of the groundwork to allow the
improvement projects and has been developed as Anne Pullyblank, Consultant
system to be rolled out through the organisation. The
part of the Patient Safety Collaborative in partnership colorectal surgeon, North Bristol Trust
introduction involves all of the development work to get
with SeeData and South West Academic Health the tool right for applying.
Science Network.
Implementation
The Life System has been built to support team
working and collaboration whilst maintaining the Once this is done the implementation is the rolling out of
principle of an open and transparent culture. It is not NEWS through the organisation. In small services this can
designed to collect detailed information on users, be achieved quite quickly. In larger and more complex
organisations or patients, and is not a performance organisations, this process may take several months, and
management tool; instead the information collected is may require ongoing development and refinement.
only to be used to support improvement.
Instillation
Contact your Academic Health
Instillation (or embedding) is ensuring that the use of
Science Network to find out
NEWS is thoroughly embedded into the organisation. If the
if you have access to the Life
aim is to use NEWS as a communication device throughout
System. West of England
a service, then instillation has happened when the use of
members can sign up for
NEWS is fully embedded. The degree of integration within
free access here: https://life.
the processes of an organisation can be measured.
seedata.co.uk/login/

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Introduction Why change? Form your team Agree your measures Agree your actions Known issues Appendixes
Project completion

A project has a beginning, a middle and an end. The project steering group meeting regularly can appraise its various stages. One important role of the steering group is to evaluate what worked and
what didn’t during the course of the project. This will allow an adaptive response from the project team making implementation smoother.

Evaluation Reliance on cascade training to be successful requires

formal establishment, monitoring and reporting.
Celebration As well as considering the structuring and implementation
of appropriate audit, the effectiveness of all of the • Ongoing education can be easily factored into future
On project completion, even though there may be a approaches listed in the Introduction leading to training plans.
recognition that there is still much to do, it is important implementation section where used should be appraised.
to remember celebration. The timeline of the project should also be reviewed so that
Celebrate project completion with the team: any departure from planned timetable to actual delivery
can be examined to identify themes that may inform
• Ensure the sponsor and stakeholders are involved future projects.
(if possible).
Some key points are as follows:
• Acknowledge everybody’s efforts.
• There is no ideal time to implement a change.
• Share and reflect on the positive lessons learned. Implementation in any health care environment has
to fit on with other priorities.
• Use corporate recognition systems.
• Seasonal variation in workload is less variable than it
• Avoid “institutionalised recognition” – be sincere.
once was, but new clinical implementation in January
• Say “thank you” and mean it. are not recommended

• Where logistics are involved (such as printing)

avoiding holiday periods is recommended (unless
logistics shortfalls have contingency plans)

• If possible training should be appropriately resourced.

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Some known issues

What is the issue? What is the solution?

NEWS itself has a number of known issues associated with When it comes to problem solving through issues, you can use this framework:
it. Unanticipated problems may be avoided by considering
what is raised in this section. Some of the issues are niche • What is the problem?
specific and relate to specific areas, and may be more • Why is it a problem?
problematic in acute services, but the principles can be • When is it a problem?
generalised. • Where is it a problem?
• How is it a problem?
• Who is it a problem for?
Specific issues that are discussed are:
If you don’t truly understand the problem, you cannot solve it! The cornerstone of any effective root cause analysis is
• Trigger re-setting having an accurately defined problem.
• Training
Using robust problem solving techniques will ensure you address the ‘real’ issue – not just the symptoms. It’s not
• Cultural change
difficult - just have a questioning attitude. Never stop with the first reason given or the obvious.
• Oxygen saturation Target Range
• Neurological Assessment There may be multiple root causes for any given problem. Make sure you follow all of them through – they may all
need fixing!

The five whys is a tool that helps to identify the root cause of a problem by verbally questioning the reasons given.
It enables the peeling away of layers through a process of questions repeatedly asking “why” until you reach the
root cause.

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Known issue: trigger re-setting

What is the issue? What is the solution?

NEWS is designed to identify patients who are high risk NEWS needs to be regarded as both a physiological risk assessment and a prompt for escalation of treatment,
for deterioration or patients who are in the process of transfer or referral. It is important to consider any patient with abnormal physiology being regarded as high risk for
deteriorating. It does this by scoring physiology so that deterioration.
abnormal physiology is scored highly.
Where care is appropriate and a high NEWScore can be tolerated, the solution is for the trigger to be reset to a
Abnormal physiology is caused by acute illness or is a different level from the standard clinical response.
reflection of chronic ill health. A high score should be linked
This might require development of a local standard or an individualised management plan. In both instances the
to the formation of a detailed management plan. Once that
new trigger response for review or action must be clearly agreed documented and communicated.
is done, if the care and treatment plan is appropriate, no
further review is necessary unless the NEWScore increases Trigger re-setting is not risk free and needs to be crafted with skill. Some advice relating to an acute setting is
further. It may take time in an acute illness for a patient’s accessible.
physiology to improve.

It is important to develop processes that allow high

NEWScores in some circumstances to be acknowledged but
not require action.

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Introduction Why change? Form your team Agree your measures Agree your actions Known issues Appendixes
Known issue: training

What is the issue? What is the solution?

Training in NEWS is key and often underrated. An assumption In an acute situation where NEWS has increased from baseline there are three tiers of escalation response:
is often made that implementation is simple because there
1. An individual management plan which offers the physiological parameters that will require review. This is
is already a well-established understanding of recording vital
established as a patient’s treatment is initiated and optimised. It may be appropriate in and out of hospital.
signs. If an existing EWS is already in use then introducing
NEWS may be perceived as a simple swap process. A similar 2. The second tier of response is a local (or departmental) standard where (usually condition-specific) situations
assumption is often made that staff recording vital signs will are managed by a documented and agreed local protocol.
act when they are awry.
3. The third tier of response is a generic clinical response prescribed by a specific NEWScore.
Once the recording of vital signs is subjected to scrutiny a
number of issues tend to emerge that relate to the accuracy Training needs to focus on these three responses, which are often not well understood. Training needs to be
of vital signs recording, and interpretation of the results. focused on accuracy of scoring, what to do with high NEWScores and assuring appropriate escalation. There also
Where NEWS is replacing an existing EWS there is some needs to be a focus on training people to audit compliance with using NEWS appropriately.
nuance in how it is used. NEWS is more sensitive than most The default position for NEWS implementation is often a round of cascade training. The reality is that if timing allows
other EWS systems it replaces, which is often interpreted as a structured approach to cascade training is indicated to ensure that a critical mass of staff are trained.
producing “false positives”. This is inaccurate because as well
as being a device to prompt the escalation of care it is a risk It is also important to maintain ongoing training through core skills updates, induction, and mandatory training. For
assessment (see previous section). NEWS this is likely to require ongoing specific training.

A number ot training resources have been produced and are available online at http://www.weahsn.net/what-we-
do/enhancing-patient-safety/the-deteriorating-patient/

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Known issue: cultural change

What is the issue? What is the solution?

It is well know that implementing a change may take many It is recommended to “stay the course”, in the sense that a longer term view is more likely to produce a positive
years from the publication of the original idea. NEWS is no result. The full instillation of NEWS will outlive a project to implement it.
exception; it represents a culmination of over a decade of
Once a project is completed ongoing development will need to be considered.
proposal relating to “Track and Trigger” systems and other
EWSs. NEWS must not be perceived as a nurse only issue in an acute hospital.

If the process of fully adopting NEWS is to be truly successful, Full adoption of NEWS requires a change in medical behaviour, particularly on ward rounds.
a longer timescale is required. There are processes of
introduction, implementation and installation that are If NEWS is to be developed as a “language” of health care, its full use will have different trajectories in different
needed. The first two can be achieved quite promptly. A environments.
full installation of NEWS requires considerable change in In the short term, it is important to resist changing too much relating to NEWS documentation. There is a tendency
sometimes well-entrenched tradition. to “blame” shortfalls in service delivery on NEWS when in reality it may be something completely different and more
Full instillation of a system is where the effectiveness of fundamental that may need to be changed.
the use of NEWS has a tangible and measurable effect on
reducing avoidable system failures or failures in care.

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Introduction Why change? Form your team Agree your measures Agree your actions Known issues Appendixes
Known issue: oxygen saturation target range

What is the issue? What is the solution?

NEWS as implemented in many acute trusts has a Balancing measures are not risk free, but may be necessary. It is generally better to adopt a fix that does not score
balance added for the oxygen saturation target range. oxygen saturations that are within the target saturation range. If there are adjustments made to NEWS on this basis,
The idea of NEWS is that a high score is associated with this needs to be taught and communicated well. There is a trade off in the safety gain of getting the scoring system
high (physiological) risk or the need for escalation of right versus an added complexity which may influence the accuracy of NEWS calculation.
clinical response. For different target saturation ranges as
There is a criticism that can rightly be levelled that if the oxygen saturation score is manipulated that it is no longer
recommended in the prescription of oxygen via the British
NEWS. The “fix” is widely implemented and so long as it is communicated, it is not a problem. If NEWS is a language
Thoracic Society, NEWS is too sensitive if the target range is
then the oxygen saturation “fix” is merely a dialect. It is hoped that the fundamental problem of oxygen saturation
set at 88-92%. Additionally there is a potential safety risk in
target range scoring is improved when NEWS is revised.
having a NEWScore which increases as a patient receives
the correct treatment (i.e. appropriately targeted oxygen The British Thoracic Society guidelines for emergency oxygen use are recommended and available at https://www.
therapy). brit-thoracic.org.uk/guidelines-and-quality-standards/emergency-oxygen-use-in-adult-patients-guideline/.

It is less of an issue where oxygen therapy is of short The guidelines (as is NEWS) are planned for review in 2016.
duration, but it should be noted that any system that
increases the risk of over-oxygenation can have serious
consequences (including ventilatory failure and death).

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Introduction Why change? Form your team Agree your measures Agree your actions Known issues Appendixes
Known issue: Neurological assessment

What is the issue? What is the solution?

Neurological assessment forms part of the overall NEWScore. There is a clear need to address this area of assessment thoroughly in any training that is provided. Although
It is unfortunately the one aspect of vital signs assessment training is another known issue, this one is important enough to require special attention.
that is least well done. It uses AVPU which is essentially a
The teaching message is that the key emphasis in using AVPU is that the system should record the best response
simple system compared to a fuller neurological assessment
that the patient can muster, so if a patient awakes and then drifts off to sleep again, that should be scored as A and
as in the Glasgow Coma Score. Because of its weighting,
not V. Neurological assessment should record the best neurological response that can be elicited.
anything other than Alert (A) scored in AVPU is a single
parameter score of 3 means that a patient should receive In addition there are circumstances where NEWS may be
and escalation review or referral. used during procedural sedation, where neurology will
always score, or in some situations where a patient may AVPU
remain V (Responding to Voice and not Alert) perhaps for
a few hours after an anaesthetic. In these (and similar A Alert
instances) a documented and agreed local standard may
V Responds to voice
be an appropriate way of avoiding unnecessary requests
for review, but still maintain patient safety. P Responds to Pain
U Unresponsive

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Introduction Why change? Form your team Agree your measures Agree your actions Known issues Appendixes
Recommended resources

West of England Academic Health Science Network practice-barriers-to-change.pdf of settings including OOH, community, pre-hospital, general
Improvement journey http://www.weahsn.net/what-we-do/ practice, ED and AMU, inpatients and labs http://sepsistrust.
Gap analysis diagram: http://systemicpov.com/old-school-
west-of-england-academy/improvement-resources-and- org/clinical-toolkit/
strategy-new-school-success/gapanalysis
tools/the-improvement-journey/steps-in-the-improvement-
Health Education England have created a video https://
journey/ Driver diagram help: http://www.weahsn.net/what-we-do/
www.youtube.com/watch?v=vxmUVCu6CDI and e-learning
skills-knowledge-development/quality-improvement-tools/
The Royal College of Physicians key document: https://www. materials http://www.e-lfh.org.uk/programmes/sepsis for
quality-improvement-toolkit/qi-toolkit-driver-diagrams/
rcplondon.ac.uk/projects/outputs/national-early-warning- GPs. More details at https://www.hee.nhs.uk/news-events/
score-news Mike Davidge (NHS institute) “Measurement for news/film-puts-spotlight-recognising-signs-sepsis-children
Improvement”: https://youtu.be/Za1o77jAnbw
Article explaining sensitivity and specificity: http://ceaccp. NHS Improvement published a number of patient safety
oxfordjournals.org/content/8/6/221.full.pdf+html Developers guide for observation charts: http://www. alerts for the deteriorating patient: https://improvement.nhs.
safetyandquality.gov.au/wp-content/uploads/2012/02/ORC- uk/uploads/documents/Patient_Safety_Alert_Stage_2_-_
National Confidential Enquiry into Patient Outcome and
Developers-Guide-4-Oct-2010.pdf Deterioration_resources_July_2016_v2.pdf
Death (NCEPOD) sepsis report: http://www.ncepod.org.
uk/2015report2/downloads/JustSaySepsis_FullReport.pdf Communication in healthcare: http://www.health.org.uk/ The adult patient who is deteriorating: sharing learning
collection/communications-health-care-improvement-toolkit from literature, incident reports and root cause analysis
NICE guidelines on acute kidney injury: https://www.nice.org.
National Cardiac Arrest Audit: NCAA https://www.resus.org. investigations report https://improvement.nhs.uk/uploads/
uk/guidance/cg169
uk/research/national-cardiac-arrest-audit/ documents/Deterioration_in_adults_report_7july.pdf
Care bundles to supplement NEWS for sepsis and AKI
IHI Global trigger tool: http://www.ihi.org/resources/pages/ Resources for the deteriorating patient https://improvement.
[SHOUT]: http://qir.bmj.com/content/4/1/u207938.w3198.full.
tools/ihiglobaltriggertoolformeasuringaes.aspx nhs.uk/resources/detection-and-management-deterioration-
pdf+html
adult-patients/ including a reference to this toolkit.
NPSA 2007: http://www.nrls.npsa.nhs.uk/EasySiteWeb/ The British Thoracic Society guidelines for emergency oxygen
use: https://www.brit-thoracic.org.uk/guidelines-and- A safe system framework for recognising and responding
getresource.axd?AssetID=60151
quality-standards/emergency-oxygen-use-in-adult-patients- to children at risk of deterioration: http://www.rcpch.ac.uk/
NPSA checklist: http://www.nrls.npsa.nhs.uk/ safer-system-children-risk-deterioration and resource http://
guideline/
resources/?EntryId45=59834 www.rcpch.ac.uk/sites/default/files/user158/A-safe-system-
NICE guidance Sepsis: recognition, diagnosis and early
NICE CG50: at: https://www.nice.org.uk/guidance/cg50 for-children-at-risk-of-deterioration-2016-07.pdf
management https://www.nice.org.uk/guidance/ng51 and
NICE “How to change practice” (2007): https://www.nice. resources https://www.nice.org.uk/guidance/ng51/resources
org.uk/Media/Default/About/what-we-do/Into-practice/
UK Sepsis Trust have published clinical toolkits in a variety
Support-for-service-improvement-and-audit/How-to-change-

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Notes

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Upodated August
2016

@WEAHSN

www.weahsn.net