Module 2 of 2 · 50 minutes
Recognising and escalating deterioration, with NEWS2 and SBAR
By the end of this module you will be able to
- State the NEWS2 parameters and the response thresholds
- Say where local policy governs and what a clinician may decide
- Escalate using SBAR
- Document a concern and an escalation to the standard the Code requires
- Continue to escalate when the response does not match the concern
Work through it
1 interactive for this module, built on the WAJD Teach engine. Nothing moves until you ask it to, and every one has a written version if you would rather read it.
Watch: Emma and George talk it through
4 minutes. Captions are on, and the same conversation is written out in full below. The voices are computer generated.
Emma George, I take observations all day. But if I'm honest, I'm never fully sure what to do with the number once I've got it. Walk me through NEWS2.
George Six parameters. Respiration rate, oxygen saturation, systolic blood pressure, pulse, level of consciousness or new confusion, and temperature. Each is scored, and you add two points for anyone who needs oxygen to keep their saturation at the recommended level.
Emma New confusion is the one I always wonder about.
George It's the one that's missed most. Someone orientated yesterday who's muddled today has changed, whatever their other numbers say. Score it and say it out loud.
Emma And the totals?
George Four bands. Zero to four is low risk, usually continued monitoring and a registered nurse decides how often. A single parameter scoring three, the most extreme for that measurement, is low to medium and needs an urgent ward-based response even if the total is low.
Emma Even with a low total?
George Yes, because the total can hide one very abnormal number. Five or six is medium, the key threshold for an urgent response by a clinician competent in acute illness. Seven or more is high, and that's an urgent or emergency response from a team with critical care skills.
Emma Is that the same in every hospital?
George Follow your trust's chart and escalation policy. It can differ in detail. There's also a second saturation scale a clinician may decide to use for someone with confirmed hypercapnic respiratory failure. That's a clinician's decision. Not a healthcare assistant's, not a student's.
Emma What about when the score's fine and something still feels wrong?
George That's exactly Martha's Rule's territory. The score tells you what the numbers say now. It doesn't tell you they've gone quiet, or look grey, or that their daughter's frightened.
Emma What are the soft signs?
George A change in behaviour. New drowsiness or agitation. Not eating or drinking. Not passing urine. A change in colour. And a feeling that something's wrong, which counts. Say that feeling out loud when you escalate.
Emma I get tongue tied when I phone a doctor. Is there a structure?
George SBAR. Situation, who you are, where, who the patient is, what's wrong now. Background, why they're here and what matters. Assessment, your observations, the score, what you think is happening and how worried you are. Recommendation, what you want and by when.
Emma The last bit's the one I skip.
George Everybody does, and it's the most important. I would like you to review him within fifteen minutes is a request. Can you have a look at some point is not. Be specific.
Emma And if they say they're coming and they don't?
George Escalate again, to the next level, and say why. If the response doesn't match your concern, that's the point of the Martha's Rule line. Nobody should be criticised for using it in good faith.
Emma What do I write down?
George What you found, the score, who you escalated to, when, what they said, what happened. A family member's concern, in their words, and what you did about it. Clause 13.2 asks for timely referral. Clause 10.1 for records at the time or as soon as possible.
Emma And the one that scares me. Going over someone's head.
George Clause 17.1. Take all reasonable steps to protect people at risk of harm. Escalating again is a reasonable step. Stopping at the first no may not be. You'd rather explain why you called than why you didn't.
The written material
What NEWS2 measures
The National Early Warning Score 2, from the Royal College of Physicians, is built on six physiological parameters: respiration rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new confusion, and temperature. Each measurement is given a score, and two further points are added for a person who needs supplemental oxygen to keep their saturation at the recommended level.
New confusion is scored like any other change in consciousness, and it is easily missed. A patient who was orientated yesterday and is muddled today has changed, whatever their other numbers say.
Thresholds and responses
The aggregate score places a patient in one of four bands of clinical risk. A score of 0 to 4 is low risk and usually means continued monitoring in the ward, with a registered nurse deciding whether to change how often. A single parameter scoring 3, the most extreme for that measurement, is low to medium risk and calls for an urgent ward-based response even when the total is low. An aggregate of 5 or 6 is medium risk and is the key threshold for an urgent response by a clinician with the competence to assess acute illness. An aggregate of 7 or more is high risk and calls for an urgent or emergency response by a team that includes staff with critical care skills, usually with continuous monitoring.
Where the score ends and the worry begins
The score tells you what the numbers say now. It does not tell you that this patient is not themselves, that they look grey, that they have gone quiet, or that their daughter is frightened. All of those are reasons to escalate whatever the total. Martha's Rule exists because they are so often the first and only sign.
Learn the soft signs and treat them as signs: a change in behaviour, new drowsiness or agitation, not eating or drinking, not passing urine, a change in colour, and a feeling that something is wrong. Say that feeling out loud when you escalate.
Escalating with SBAR
SBAR is a structured way to say a lot in a short time to someone who does not know the patient. Situation: who you are, where you are, who the patient is and what is wrong now. Background: why they are here and what is relevant. Assessment: your observations and score, what you think is happening and how worried you are. Recommendation: what you want, and by when.
Be specific about the last part. I would like you to come and review him within the next 15 minutes is a request. Can you have a look at some point is not. If the person says they will come and does not, or the response does not match your concern, escalate again, to the next level, and say why.
- Situation: who and where you are, who the patient is, what is wrong
- Background: why they are here, what matters
- Assessment: observations, score, what you think, how worried you are
- Recommendation: what you want and by when
Document it, and keep going
Clause 13.2 of the Code asks you to make a timely referral to another practitioner when action or treatment is required, and clause 10.1 asks you to complete records at the time or as soon as possible afterwards. Record what you found, the score, who you escalated to and when, what they said and what happened. Include a family member's concern in their own words and what you did about it.
If you are not satisfied, say so and go up the chain. The Martha's Rule line is for exactly this. A request for a review that does not come, a decision that does not match what you see, or a tired team that has already said no are all reasons to use it, and nobody should be criticised for doing so in good faith.
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