In any hospital, the risk of a patient’s condition suddenly deteriorating is a constant clinical reality. Studies show that patients who eventually require admission to an Intensive Treatment Unit (ITU) often display significant derangements in their vital signs—such as oxygen saturation, heart rate, respiratory rate, and blood pressure—for hours beforehand. Historically, responses to these signs were sometimes delayed or unsatisfactory.
As one clinical text vividly puts it, “Sick patients are sliding metaphorically along an icy slope to the edge of the cliff and can be saved if caught earlier. Cardiac arrest patients have fallen. Their chance of survival is then so much worse. Far better to treat earlier.”
To solve this problem, the Royal College of Physicians (RCP) developed the National Early Warning Score (NEWS) and updated it to NEWS2 in 2017. It is an evidence-based “track-and-trigger” system designed to provide a standardized, objective language for assessing and responding to acute illness, mandated for use across the NHS in England for all adult patients.
How NEWS2 Works: The Scoring System
NEWS2 is an aid to, but not a substitute for, competent and experienced clinical assessment. It works by assigning points to seven key physiological measurements. The points are aggregated to create a single score, which indicates the patient’s level of illness and triggers a specific clinical response.
The score is based on seven components:
- Respiratory Rate
- Oxygen Saturation (using one of two scales)
- Systolic Blood Pressure
- Pulse Rate
- Level of Consciousness (or new confusion)
- Temperature
- Supplemental Oxygen Use (This is a key component)
A score of ‘0’ is given for parameters in the “normal” range, with points (1, 2, or 3) added as the measurement strays further from the norm.
For example, a normal respiratory rate (12-20 breaths/min) scores 0, but a rate of 21-24 scores 1 point, and a rate of ≥ 25 scores 2 points. A very low rate ≤ 8 scores 3 points.
Similarly, a normal pulse (51-90 bpm) scores 0. A high pulse of 91-110 bpm scores 1 point, 111-130 scores 2, and ≥ 131 scores 3.
Systolic blood pressure scores 0 for a normal reading of 111-219 mmHg. It scores points for being low (e.g., 91-100 scores 2 points, ≤ 90 scores 3) or very high ≥ 220 scores 3).
Temperature is scored 0 for 36.1-38.0 °C. A slight fever (38.1-39.0 °C) scores 1, while a higher fever ( ≥ 39 °C) scores 2. A low temperature ( ≤ 35.0°C) scores 3.
For consciousness, a patient who is Alert (A) scores 0. Any new Confusion (C) or a reduced level of consciousness—responding only to Voice (V), Pain (P), or being Unresponsive (U)—scores 3 points.
The Two Most Important Nuances of NEWS2
1. Supplemental Oxygen
A crucial update in NEWS2 is the automatic scoring for supplemental oxygen.
- If a patient is on room air, their score for this component is 0.
- If a patient requires any supplemental oxygen (from nasal cannula to a ventilator) to maintain their saturation, they automatically receive 2 points.
This change flags that any patient needing oxygen support is, by definition, sicker than one who does not, even if their saturation reading appears normal.
2. The Two Oxygen Saturation Scales
This is the most significant clinical update in NEWS2, designed to protect patients with chronic respiratory conditions.
- Scale 1 (SpO2 Scale 1): This is the default scale for the vast majority of patients. It scores points for any saturation ≤ 95%.
- ≤ 91%: 3 points
- 92-93%: 2 points
- 94-95%: 1 point
- ≥ 96%: 0 points
- Scale 2 (SpO2 Scale 2): This scale is only used for patients confirmed to have hypercapnic respiratory failure (e.g., severe COPD) for whom a lower oxygen target of 88-92% is appropriate. This decision must be made by a senior clinician.
- ≤ 83%: 3 points
- 84-85%: 2 points
- 86-87%: 1 point
- 88-92%: 0 points
- 93-94% (on O2): 1 point
- ≥ 95% (on O2): 2 points
This second scale prevents clinical staff from mistakenly giving too much oxygen (which can be harmful) to these specific patients in an attempt to “correct” their saturation to a normal level.
Here is a simplified breakdown of the scoring:
| Parameter | Score 3 | Score 2 | Score 1 | Score 0 | Score 1 | Score 2 | Score 3 |
| Resp Rate (per min) | ≤ 8 | – | 9-11 | 12-20 | 21-24 | ≥ 25 | – |
| Pulse Rate (per min) | ≤ 40 | – | 41-50 | 51-90 | 91-110 | 111-130 | ≥ 131 |
| Systolic BP (mmHg) | ≤ 90 | 91-100 | 101-110 | 111-219 | – | – | ≥ 220 |
| Temperature (°C) | ≤ 35.0 | – | 35.1-36.0 | 36.1-38.0 | 38.1-39.0 | ≥ 39.1 | – |
| Consciousness | C, V, P, or U | – | – | Alert (A) | – | – | – |
The ‘Track-and-Trigger’ Response
The total NEWS2 score dictates the urgency and seniority of the clinical response. This response must always be considered alongside a patient’s “ceilings of care” or treatment escalation plans.
- Score 1–4 (Low Risk):
- Response: Assessment by a competent registered nurse. The nurse decides whether to increase the frequency of monitoring or escalate care.
- Score 3 in a single parameter (Low-Medium Risk):
- Response: This is considered unusual and a potential warning sign. It requires an urgent review by a clinician competent in assessing acute illness (e.g., a ward-based doctor) to find the cause.
- Score 5–6 (Medium Risk):
- Response: Requires an urgent review by a ward-based doctor or an acute team nurse. They must urgently decide if escalation to a Critical Care Outreach Team is needed.
- Score ≥ 7 (High Risk):
- Response: This triggers an immediate Medical Emergency Team (MET) assessment. This team, which has critical care competencies, will manage the patient and may move them to a High Dependency Unit (HDU) or ITU.
Communication and Clinical Judgment
A score is just a number; how it is communicated is vital. The RCP recommends using the SBARR (Situation, Background, Assessment, Recommendation, Response) protocol to improve the clarity and effectiveness of escalation communication.
Crucially, NEWS2 does not replace clinical judgment. A nurse or doctor’s “worry” or concern about a patient, even with a low NEWS2 score, is a valid and powerful reason to escalate care. Conversely, the system provides an objective, standardized language that empowers all staff members to call for help when a patient’s score is high, removing ambiguity and standardizing the response.
By providing a single, shared language, NEWS2 helps clinical teams work together to catch the deteriorating patient, pulling them back from the “icy slope” long before they reach the edge of the cliff.
References and Further Reading
Primary Sources (Royal College of Physicians)
Dr. Kunal Varma Bheecarry, MD is a GMC registered substantive Consultant Physician in the UK, specializing in Internal Medicine. With more than 15 years of experience on the clinical frontlines in both General Internal Medicine and Acute Medicine, he is passionate about translating complex medical topics, common problems and clinical guidelines into clear, actionable knowledge for healthcare professionals and patients alike. Every article is written and rigorously reviewed by him and other registered medical professionals to ensure clinical accuracy, guideline compliance, evidence-based reliability, authoritativeness and trustworthiness.
Disclaimer: All content is purely educational and does not constitute personal medical advice. It is not a substitute for professional clinical advice and readers must consult their own primary team. All views and interpretations are mine and not related to the work place.