Early Warning Scores for Neonates – a pilot study

Zsuzsoka Kecskes

Seren Ovington

Nicole Slater

Department of Neonatology, Centenary Hospital for Women and Children

ANU Medical School

Early Recognition of the Deteriorating Patient Program

Background

• Patient deterioration preceded by abnormalities in physiological signs.

• Early warning systems (EWS) developed to facilitate early recognition of deteriorating patients

• EWS valuable in in predicting admission to hospital, patients at risk of deterioration, transfer to higher care and in-hospital mortality.

• EWS for adult, paediatric and obstetric populations

• Little research on the use of an early warning system in neonates

• No standardized early warning system specific to neonates has been developed and accepted to date

Background

• Fetus – dependent on mother/placenta for oxygen

• Birth - transition

• Most newly born babies are vigorous

• 10% of newborns require some assistance

• 1% need major resuscitative measures (intubation, chest compressions, and/or medications)

Background

In the fetus

• Pulmonary arterioles constricted

• Pulmonary blood flow diminished

• Blood flow diverted across ductus arteriosus

Background

1-6

Signs of a Compromised Newborn

• Poor muscle tone

• Depressed respiratory drive

• Bradycardia

• Low blood pressure

• Tachypnoea

• Cyanosis

Good tone with cyanosis

Bad tone with cyanosis

1-7

A

B

C

D

Assessment

Resuscitation

Flow-diagram

Risk Factors

Prepartum

Maternal

Eclampsia

Isoimmunisation

Infection

Drug addiction

Cardiovascular disease

Obstetric

Abruption

Cord prolapse

Placenta praevia

Oligohydramnios

Intrapartum Abnormal presentation Precipitous delivery Prolonged labour Difficult forceps delivery Intrauterine growth restriction Prolonged pregnancy Prolonged rupture of membranes Postnatal Prematurity Respiratory distress Cardiopulmonary anomalies Sepsis Haemolytic disease

Are newborn patients?

• Most babies cared for in a ward with mother

• Not considered a ‘patient’

• Some feeding support

• Extra care requires extra staffing ($)

• Treatment provided on ward: feeding, sometimes phototherapy, rarely antibiotics

• Universal SaO2 screening introduced 2013

• Recognition of unwell neonate dependant on midwifery expertise

• Wellness model (limited observations)

Term babies – a problem?

Total babies born in TCH 01/01/13-31/12/13 : 3308

2954 (89.3%) >37weeks • 37-40 weeks 2382 (72.01%) • 41-42 weeks 571 (17.26%) • 8.6% admitted (8-25%)

2013 Total Admissions NICU/SCN 570 Term babies 284 (49.8%)

Most common reasons: risk of infection, respiratory distress, feeding, jaundice

Background

• Australian Commission on Safety and Quality in Health Care requires organizations to implement mechanisms for recording observations,

• Needs to incorporate triggers to escalate care when deterioration occurs.

• No system available for well neonates at Canberra Hospital and Health Services (CHHS) to fulfill these requirements

EWS for neonates

Roland et al (2010) • Correctly identified at risk neonates, increased observations and guided

management decisions

Nowlan et al (2011) • Value in identifying infants with confirmed or suspected sepsis, utilising a

traffic light alert system

Holme et al (2013) • Retrospective chart analysis, predicted admission to the NICU, need for

intravenous fluids and continuous positive airway pressure

Roland D, Madar J, Connolly G. The Newborn Early Warning (NEW) system: development of an at-risk infant intervention system. Infant. 2010;6(4):116. Nowlan K, Soliman M, Mathur R, Jaiswal S. A Pilot Study Validating the Use of a Neonatal Early Warning Score. Pediatric Research. 2011;70:701 Holme H, Bhatt R, Koumettou M, Griffin MA, Winckworth LC. Retrospective evaluation of a new neonatal trigger score. Pediatrics. 2013;131(3):e837-e42.

Aims

• To develop a newborn risk assessment tool

• To develop and trial a neonatal early warning score (NEWS)

• To assess whether the NEWS was calculated correctly in well neonates in a postnatal ward environment

• To examine whether the risk assessment lead to appropriate observations

• To determine whether the NEWS correctly identified sick neonates and lead to timely review

Methods

• Risk factors (NSW NICUS group) • Maternal opiate treatment within 4 hours of birth

• Meconium stained liquor

• Vaginal swab positive for GBS

• Maternal fever >38°C

• Prolonged rupture of membranes >18 hours

• Born before 37 weeks

• Vacuum assisted delivery

• Determined frequency of observations

Normal ranges

Old observation chart

Observation chart

• Age-specific ward observation chart (0-3 months) previously developed

• Vital sign variables had a discrete area on the y-axis (except HR and BP) with same scale, and charted graphically

• Vital sign variables were colour coded for the Neonatal Early Warning Score (NEWS) earned

• Scores and adapted with permission from the scoring system used at Great Ormond Street Hospital, London, United Kingdom

McKay H, Mitchell IA, Sinn K, et al. Effect of a multifaceted intervention on documentation of vital signs and staff communication regarding deteriorating paediatrics patients Journal of Paediatrics and Child Health (2012)

Methods Neonatal Early

Warning Score

4 3 2 1 0 1 2 3 4

Respiration Rate

(Breaths/minute)

≤ 20 20-24 25-29 30-59 60-64 65-69 70-80 >80

Respiratory Effort Normal Mild Moderate Severe

Oxygen Delivery Room Air Micro/Low

flow

Cot >30%

Oxygen Saturation <85 85-90 91-94 ≥95

Temperature (°C) <36.5 36.5-37.5 37.6-38 >38

Heart Rate

(Beats/minute)

<60 60-69 70-79 80-89 90-160 161-170 171-180 181-190 >190

Systolic Blood

Pressure (mmHg1)

<60 60-79 80-89 90-99 100-150 >150

Methods

• Trial July-December 2013

• Pre-NEWS: January-March 2013

• Post-NEWS September-November 2013 • Babies born in birth centre excluded

• Intense education period, COMPASS© training

• Data collected prospectively from ACTPAS and BOS

• NEWS charts randomly reviewed in regards to completion of risk assessment, appropriateness of observations and correctness of NEWS

• 50 random babies in each group assessed for correct calculated of NEWS after risk assessment

• All babies admitted to NICU or SCN reviewed for deterioration, timeliness of medical review and outcome

• SPSS 21, Chi square, Mann-Whitney U-test and t-test for statistical analysis

Results – audit

• 62 babies audited

• Risk assessment done in 75-80%, accuracy 65 to100%.

• The median time to record the first observations 72.5-210 minutes

Results – random babies

n Pre NEWS (n=50) Post NEWS (n=50) P-value

Risk factor present (%)

50 50 NS

Admission to NICU/SCN

11 7 NS

Any vital signs recorded

46 50 NS

Full set of vital signs recorded

0 35 <0.001

No risk factors present, and vitals recorded every 12 hrs

9 22 <0.01

Risk factors present, and vitals recorded every 12 hrs

3 12 <0.01

Total 668 (pre NEWS) and 677 (post NEWS) babies No differences in GA (38.7 vs 38.9 wks), birth weight (3279 vs 3274 gms), Apgar 1 (8 vs 9), Apgar 5 (9 vs 9)

Results – babies requiring higher care

n Pre NEWS (n=88) Post NEWS (n=84) P-value

Risk factor present (%) 47 58 NS

Reason for review (n,%) • maternal opiates • meconium liquor • Prematurity • GBS positive • PROM > 18 hrs • Vacuum extraction • multiple risk factors

2 (4.9) 5 (12.2) 5 (12.2) 10 (24.4) 2 (4.9) 4 (9.8) 13 (31.8)

5 (10.2) 9 (18.4) 3 (6.1) 14 (28.6) 4 (8.2) 5 (10.2) 9 (18.4)

NS

NEWS 4 or more or RR high

6 6 NS

NEWS 4 or more or RR high and admitted to NICU/SCN

6 2 <0.05

Total 668 (pre NEWS) and 677 (post NEWS) babies No differences in GA (38.9 vs 38.8 wks), birth weight (3306 vs 3348 gms), Apgar 1 (9 vs 9), Apgar 5 (9 vs 9)

Babies with high NEWS or respiratory distress

NEWS implemented GA risk factor highest NEWS

review within 30 min tf to NICU dx

Patient 1 no 38.2 multiple 1 yes yes normal

Patient 2 no 38.4 mec liquor Increased RR yes yes TTN

Patient 3 no 38.5 none Increased RR yes yes TTN, Trisomy 18

Patient 4 no 37.2 multiple Increased RR, NEWS 5 no yes Normal, ROS

Patient 5 no 39.1 mec liquor Bradycardia, NEWS 1 no yes normal

Patient 6 no 39.2 none Increased RR, fever no yes Normal, ROS

Patient 7 yes 37 none 5 yes no dehydration

Patient 8 yes 38 none 6 yes no TTN

Patient 9 yes 39 multiple 6 yes yes TTN

Patient 10 yes 41 multiple 6 yes no TTN

Patient 11 yes 41 GBS positive 8 yes yes Pulmonary hypertension

Patient 12 yes 41 GBS positive 5 yes no TTN

Conclusion

• Newborn risk assessment tool targets at risk babies for the use of neonatal early warning score (NEWS)

• The risk assessment did not lead to appropriate observations in all babies, especially in high risk babies

• The NEWS was calculated correctly in well neonates in a postnatal ward environment

• The NEWS correctly identified sick neonates and lead to timely review