IMPROVING RECOGNITION AND TIMELY ESCALATION OF CLINICAL DETERIORATION IN GENERAL MEDICAL INPATIENTS USING NEWS 2 A CLINICAL AUDIT AND PDSA-BASED QUALITY IMPROVEMENT PROJECT

Abstract

Background: Clinical deterioration in hospitalised medical patients may initially present with changes in routine physiological observations. Timely recognition of these changes and appropriate escalation are therefore important components of safe inpatient care. The National Early Warning Score 2 (NEWS2) provides a standardised method for assessing physiological deterioration and can support communication and escalation within general medical wards. However, its effectiveness in practice depends on complete observation recording, accurate scoring, and recognition of abnormal scores, escalation and a reliable response pathway.

Aim: To improve the recognition and timely escalation of clinical deterioration among adult general medical inpatients at Ayub Teaching Hospital, Abbottabad, through the structured use of NEWS2.

Methods: A prospective before-and-after quality-improvement clinical audit using Plan–Do–Study–Act (PDSA) methodology was conducted in the Medical B Unit of Ayub Teaching Hospital, Abbottabad, Khyber Pakhtunkhwa, Pakistan. The baseline audit was performed from 1 March to 10 May 2025, followed by an intervention phase from 10 May to 31 May 2025 and a post-intervention audit from 10 June to 20 August 2025. The intervention consisted of focused staff and house officers education, standardized NEWS2 documentation, accessible NEWS2 scoring guidance, reinforcement of the escalation pathway, and feedback during implementation. Eligible adult general medical inpatients were assessed using the same predefined audit criteria before and after the intervention. The primary process measure was complete and correctly calculated NEWS2 assessment. Secondary measures included completeness of physiological observations, NEWS2 documentation, and recognition of triggering scores, documented clinical escalation, clinical review, and repeat monitoring. Descriptive statistics and categorical comparisons were used to assess changes between the baseline and post-intervention periods.

Results: A total of 121 patients were included in the baseline audit and 128 in the post-intervention audit. Complete documentation of the physiological observations required for NEWS2 increased from 58.5% to 88.9%, while documentation of a NEWS2 score increased from 45.8% to 83.3% (both p<0.001). Complete and correctly calculated NEWS2 assessment improved from 39.0% at baseline to 77.8% after the intervention (p<0.001). Among NEWS2 trigger episodes, appropriate recognition increased from 61.8% to 87.2% (p=0.012), while documented appropriate clinical escalation increased from 47.1% to 79.5% (p=0.004). Documentation of clinical review following a trigger improved from 41.2% to 74.4% (p=0.004), and documentation of an appropriate repeat-observation or monitoring plan increased from 35.3% to 71.8% (p=0.002). The predefined target of at least 80% compliance was achieved for complete physiological observations and NEWS2 score documentation, but not for complete NEWS2 assessment or appropriate escalation.

Conclusion: A structured NEWS2-based quality-improvement intervention was associated with substantial improvement in the assessment, documentation, recognition, and escalation of clinical deterioration among general medical inpatients. The findings indicate that combining staff education with standardised documentation, accessible scoring guidance, and a defined escalation pathway can improve key deterioration-recognition processes within a tertiary-care medical ward. However, compliance with complete NEWS2 assessment and appropriate escalation remained below the predefined target, highlighting the need for continued reinforcement, re-audit, and further PDSA cycles to sustain and extend the improvement.