NICE1 recommends ‘track and trigger’ systems for all adult acute hospital admissions and the RCP2 advocates the use of the National Early Warning Score (NEWS) to promptly highlight high risk patients. In non-selected medical patients a higher admission NEWS correlates with higher mortality, with a step-wise increase as the score increases. Anecdotally patients with COPD have high rates of NEWS alerting. No studies have looked at the validity of the NEWS in COPD patients though the issue was raised in a previous abstract.
We retrospectively interrogated an electronic observation database in our Trust (two acute sites) over a year (February 2012–January 2013). We compared acute medical unit (AMU) admissions aged over 50 years (n = 13,291) with patients admitted with a primary diagnosis of COPD (n = 1119). Despite a similar age profile (median 74 & 77) and inpatient mortality (5.3% & 6.2%), the COPD cohorts admission NEWS was double that of the AMU patients (median 4 vs 2). This difference persisted throughout admission to discharge.
Admission NEWS showed a step-wise increase in mortality amongst the AMU patients. In contrast, the COPD cohort with NEWS of 5 or 6 had lower in-patient mortality compared to COPD patients scoring 2–4. NEWS of ≥7 is used to trigger urgent medical attention and 20% of patients with COPD fulfilled this criteria (compared to 6.6% of non-COPD patients). When NEWS score was ≥10, mortality in both groups was high (31.6% in COPD patients, 40% in AMU patients)(graph 1).
In conclusion, we have shown that acute COPD patients have similar mortality to other emergency medical admissions yet persistently higher NEWS. This requires addressing possibly by adjusting the NEWS to take into account lower oxygen saturation targets in selected COPD patients (median 93% compared to 96% in AMU patients) and thus reduce over-alerting of those not necessarily at high risk of death.
Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital. http://www.nice.org.uk/nicemedia/pdf/CG50FullGuidance.pdf
National Early Warning Score (NEWS) Standardising the assessment of acute-illness severity in the NHS - Report of a working party July 2012 http://www.rcplondon.ac.uk/sites/default/files/documents/national-early-warning-score-standardising-assessment-acute-illness-severity-nhs.pdf