A score that should be lower

Review and sources

Not clinically reviewed. No clinician has signed this scenario.

• Royal College of Physicians. National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. Updated report of a working party. London: RCP, 2017. Chart 1 publishes both SpO2 scales: Scale 1 scores 91% or below as 3, 92-93% as 2, 94-95% as 1, and 96% or above as 0; Scale 2 scores 88-92%, or 93% or above on air, as 0. Recommendation 25 confines Scale 2 to patients with hypercapnic respiratory failure confirmed on blood gas who require supplemental oxygen, with a prescribed target of 88-92%. The requirement is a property of the admission rather than of the current minute, which is why Scale 2 carries a band for 93% or above on air. Recommendation 26 requires the decision to be made by a competent clinical decision maker and recorded in the notes. The chart directs that the section not being used is crossed out.
• O’Driscoll BR, Howard LS, Earis J, Mak V; British Thoracic Society Emergency Oxygen Guideline Group. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017;72(Suppl 1):ii1-ii90. doi:10.1136/thoraxjnl-2016-209729. States the 88-92% target for patients at risk of hypercapnic respiratory failure (Grade A for chronic obstructive pulmonary disease, evidence level 1+), that it is not known whether 88-92% is the ideal range, and that patients within 88-92% score points on the earlier early-warning score and that this may prompt nursing staff to increase the inspired oxygen and put the patient at risk.
• Austin MA, Wills KE, Blizzard L, Walters EH, Wood-Baker R. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. BMJ. 2010;341:c5462. doi:10.1136/bmj.c5462. Cluster-randomised by paramedic rather than by patient; intention-to-treat mortality 21/226 (9%) with high-flow oxygen versus 7/179 (4%) with titrated oxygen, relative risk 0.42 (95% CI 0.20-0.89), P=0.02. Thirty-seven percent of the confirmed cases received non-protocol treatment, and in the per-protocol analysis the difference did not reach significance.
• Tirkkonen J, Karlsson S, Skrifvars MB. National early warning score (NEWS) and the new alternative SpO2 scale during rapid response team reviews: a prospective observational study. Scand J Trauma Resusc Emerg Med. 2019;27:111. doi:10.1186/s13049-019-0691-6. In 886 rapid-response reviews, applying Scale 2 to the 11.7% with confirmed hypercapnic respiratory failure did not improve discrimination for either immediate or in-hospital outcome.