DISCUSSION
Systems for the triaging of patients are well established in emer-
gency medicine. The concept of triage dates back to the Napoleonic
wars, and at its core is the assessment of a patient by an experienced
person to determine the priority and timescale of treatment and
intervention based on the severity of their condi-tion. Over the years
the concept of triage has become more scien-tific and a variety of
tools utilising physiological data and algorithms have been
developed to assist with effective triage.
It is well recognised from large national audits that existing
systems failed to recognise or respond appropriately to early signs
of critical illness. 21 22 This in turn may lead to significant morbidity
or mortality for the patient. Many such patients exhibit physio-
logical derangement hours before their deterioration was detected
by clinical staff and hospital systems. 9 Evidence suggests that a
large proportion of ward based patients receive substandard care
prior to ICU admission and that 20–40% of such admissions are
potentially avoidable.23 This number has decreased over the last 15
years, but remains significant.24
In response to such findings, EWS have become increasingly
prevalent across medicine globally over the past two decades to
identify the deteriorating patient and to activate an appropriate
response, the so called‘track and trigger’ systems. Within the UK,
there are many such systems in place across the NHS but most lack
rigorous evaluation and validation.25 A recent postal survey also
highlighted that there is great variability in how such EWS are
utilised in EDs across the NHS.26
The Royal College of Physicians of London, in its 2007 report
‘Acute medicine: the right person, in the right setting—first time’,
Corfield AR, et al. Emerg Med J 2014;31:482–487. doi:10.1136/emermed-2012-202186
recognised that a standardised EWS, used across the NHS could
provide a step change in improving clinical outcomes in people
with acute illness.27 A standardised NHS-wide NEWS would have
advantages with regard to reliability of completion and promoting
continuity throughout the patient’s journey. However given the size
of the NHS and diversity of work which is undertaken, any such
tool is unlikely to perform well across all patient groups. This may
give rise to false positives, or patients being falsely reassured by
false negatives. There is some evidence that the use of EWS can
predict need for hospital admission and mortality in ED patients. 28
29
However, Roland and Coates suggested, in a recent commentary,
that any such system proposed for the ED should be validated in ED
patients.17 Other scoring systems such as the mor-tality in
emergency departments sepsis (MEDS) score have been suggested
as useful predictors of outcome in the ED. 28 Although these scoring
systems have a higher sensitivity, they rely on some laboratory
investigations which necessitate a delay in obtaining the results.
The NEWS also has the advantage that it is proposed to be used
universally; therefore a diagnosis for the patient is not required in
order to use the tool.
This study has several potential limitations. Among the group of
patients selected for this analysis (N=2489), only 2003 could be
assessed due to missing observations on attendance. This missing
information was generally only one or two of the six required
physiological data points, but prevented an accurate calculation of a
NEWS value. No information is available for patients who attended
and were discharged within 2 days of attendance. This group should
by virtue of the fact that they are discharged within 2 days have a
much lower incidence of signifi-cant illness. Our data only included
ICU admission within 2 days, so we are unable to comment on
patients who may have been admitted to the ICU later in their
hospital admission. However, for our target group of ED patients at
presentation it could be argued that ICU admission more than 2
days after ED attendance is less linked to features of illness present
at initial ED presentation.
We only collected information on in-hospital mortality. No
attempt was made to follow-up patients after discharge from
485
 Downloaded from http://emj.bmj.com/ on September 14, 2015 - Published by group.bmj.com

Original article

Table 5 NEWS receiver operating curve (ROC)

characteristics for combined endpoint (ICU and/or mortality)
Positive Negative
NEWS predictive predictive Youden’s
≥ Sensitivity Specificity value value index

0 1.000 0.000 0.188 – 0.000

1 0.995 0.007 0.188 0.857 0.002
2 0.979 0.054 0.193 0.917 0.033
3 0.960 0.110 0.200 0.923 0.070
4 0.936 0.199 0.213 0.931 0.135
5 0.888 0.299 0.227 0.921 0.188
6 0.816 0.427 0.248 0.910 0.244
7 0.723 0.543 0.268 0.895 0.267
8 0.617 0.666 0.299 0.883 0.283
9 0.524 0.774 0.349 0.876 0.298
10 0.431 0.848 0.395 0.866 0.278
11 0.322 0.904 0.437 0.852 0.226
12 0.250 0.950 0.537 0.846 0.200
13 0.184 0.971 0.595 0.837 0.155
14 0.106 0.986 0.635 0.827 0.092
15 0.061 0.995 0.742 0.821 0.056
16 0.029 0.998 0.733 0.816 0.027
17 0.016 0.998 0.667 0.814 0.014
18 0.008 0.999 0.600 0.813 0.007
19 0.005 1.000 1.000 0.813 0.005
20 0.003 1.000 1.000 0.813 0.003
ICU, intensive care unit; NEWS, national early warning score.

hospital, so any patients who were discharged and died at home

within 30 days are not included in our data. Our study did not
record any information on patients’ co-morbidity.
The data presented in this study show there is some promise for
the use of a single EWS in the ED, when applied to a large cohort
of patients with a potentially serious condition. Among patients
who have sepsis, a single EWS of≥7 in the ED indi-cates a 27%
chance of requiring admission to the ICU within 48 h and/or death
within 30 days. At this level, an argument can be made for
mandating senior ED clinical review for all these patients. In
addition, there could also be an argument for man-datory review by
a critical care outreach team, regardless of ultimate destination. Our
study only looked at patients with sepsis, so the generalisability to
other serious conditions is unknown. However, given that sepsis is a
common condition with potential significant morbidity and
mortality but that also has a heterogeneous presentation, suggests
that this approach may be more widely applicable and this potential
warrants further research.

This concept also lends itself to extension to prehospital care and

Figure 2 National early warning score (NEWS) and age
adjusted NEWS receiver operating curve (ROC) for: (A)
admission to intensive care unit (ICU) within 2 days; (B) 30-
day mortality; (C) combined endpoint (ICU and/or mortality).
ambulance services. Most ambulance services routinely collect the
physiological data required to calculate an EWS score, and indeed
some ambulance services have incorporated this into electronic
patient record forms. An agreed EWS score of greater than a
specific level could be used as a trigger for ambulance service pre-
alert of a receiving ED.
Point of care lactate testing has also been shown to be feasible in
the ED.30 Serum lactate is recognised as an independent predictor
of mortality in sepsis31 and there may be potential for combining
EWS systems and point of care to further improve diagnostic accur-
acy for patients at risk of adverse outcomes in sepsis. 32
Collaborators Scottish Trauma Audit Group Steering Committee.

486 Corfield AR, et al. Emerg Med J 2014;31:482–487. doi:10.1136/emermed-2012-202186

Downloaded from http://emj.bmj.com/ on September 14, 2015 - Published by group.bmj.com

Original article
Contributors All authors have made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis
and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be submitted.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES
1 Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 1992;101:1644–55.
2 Levy MM, Fink MP, Marshall JC, et al. 2001, SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003;31:1250–6.
3 Rivers E, Nyguen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368–77.
4 Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and
associated costs of care. Crit Care Med 2001;29:1303–10.
5 Bakker J, De Munck P, Rommes H, et al. Cost of severe sepsis in a multidisciplinary intensive care unit. Crit Care Med 1998;26:A131.
6 Dellinger PR, Levy MM, Carlet JM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and
septic shock. Crit Care Med 2008;36:296–327.
7 Kumar A, Roberts D, Wood KE. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of
survival in human septic shock. Crit Care Med 2006;34:1589–96.
8 Franklin C, Mathew J. Developing strategies to prevent in-hospital cardiac arrest: analysing responses of physicians and nurses in
the hours before the event. Crit Care Med 1994;22:464–75.
9 Schein MH, Hazday N, Pena M, et al. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 1990;98:1388–92.
10 Hourihan F, Bishop G, Hillman KM, et al. The Medical Emergency Team: a new strategy to identify and intervene in high-risk
patients. Clin Intensive Care 1995;6:269–72.
11 Goldhill DR, Worthington L, Mulcahy A, et al. The patient-at-risk team: identifying and managing seriously ill ward patients. Anaesthesia 1999;54:853–60.
12 Hillman K, Parr M, Flabouris A, et al. Redefining in-hospital resuscitation: the concept of the medical emergency team. Resuscitation 2001;48:105–10.
13 Bristow PJ, Hillman KM, Chey T, et al. Rates of in-hospital arrests, deaths and intensive care admissions: the effect of a medical
emergency team. Med J Aust 2000;173:236–40.
14 Buist DM, Moore GE, Bernard SA, et al. Effects of a Medical Emergency Team on reduction of incidence, and mortality from, unexpected
cardiac arrest in hospital: a preliminary study. BMJ 2002;324:387–90.
15 Rees J, Mann C. Use of the patient at risk scores in the emergency department: a preliminary study. Emerg Med J 2004;21:698–9.
16 Groake JD, 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;25:803–6.
17 Ronald D, Coats TJ. An early warning? Universal risk scoring emergency medicine. Emerg Med J 2011;28:263.
18 National Early Warning Scores (NEWS). Standardising the assessment of acute-illness severity across the NHS. R Coll Physicians 2012. http://www.rcplondon.
ac.uk/sites/default/files/documents/national-early-warning-score-standardising-assessment-acute-illness-severity-nhs.pdf (accessed 1 Mar 2013).

19 Sepsis Management in Scotland. A report by the Scottish Trauma Audit Group. Information Services Division, NHS National Services Scotland, Edinburgh. November
2010. http://www.stag.scot.nhs.uk/SEPSIS/Main.html(accessed 8 Jan 2013).
20 Subbe CP, Kruger M, Rutherford P, et al. Validation of a modified early warning score in medical admissions. Q J Med 2001;94:521–6.
21 National Confidential Enquiry into perioperative deaths 1996–97. HMSO. November 1997. http://www.ncepod.org.uk/pdf/1996_7/Full%20Report%201996%20-%
201997.pdf (accessed 8 Jan 2013).
22 National Confidential Enquiry into Peri-operative deaths “An acute problem?”
2005. http://www.ncepod.org.uk/2005report/index.html (accessed 8 Jan 2013).
23 McQuillan P, Pilkington S, Allan A, et al. Confidential enquiry into the quality of care before admission to intensive care. BMJ 1998;316:1853–8.

24 Findlay GP, Shotton H, Kelly K, et al. Time to Intervene? A review of patients who underwent cardiopulmonary resuscitation as a result of an in-hospital
cardiorespiratory arrest. 2012. http://www.ncepod.org.uk/2012report1/downloads/ CAP_fullreport.pdf (accessed 8 Jan 2013).
25 Gao H, McDonnell A, Harrison DA, et al. Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk
patients on the ward. Intensive Care Med 2007;33:667–79.
26 Griffiths JR, Kidney EM. Current use of early warning scores in UK emergency departments. Emerg Med J 2012;29:65–6.
27 Acute medical care “The right person in the right setting—first time” Report of the Acute Medicine Task Force. http://bookshop.rcplondon.ac.uk/details.aspx?
e=235 (accessed Jan 8 2013).
28 Vorwerk C, Loryman B, Coats TJ, et al. Prediction of mortality in adult emergency department patients with sepsis. Emerg Med J 2009;26:254–8.
29 Burch VC, Tarr G, Morroni C. Modified early warning score predicts the need for hospital admission and in hospital mortality.
Emerg Med J 2008;25:674–8.
30 Shapiro NI, Fisher C, Donnino M, et al. The feasibility and accuracy of point-of-care lactate measurement in emergency department patients with suspected infection.
J Emerg Med 2010;39:89–94.
31 Mikkelsen ME, Miltiades AN, Gaieski DF, et al. Serum lactate is associated with mortality in severe sepsis independent of organ
failure and shock. Crit Care Med 2009;37:1670–7.
32 Jo S, Lee JB, Jin YH, et al. Modified early warning score with rapid early lactate level in critically ill medical patients: the ViEWS-L
score. Emerg Med J 2013;30:123–29.