Chan Man Yi, NC (Neonatal Care) Dept. of Paed. & A.M., PMH 16 May 2017

The implementation of an integrated observation chart with Newborn Early Warning Signs (NEWS)

to facilitate observation of infants at risk of clinical deterioration

Background

Different observation charts using in Special Care Baby Unit (SCBU)

BP, Temperature & Pulse Chart Newborn Observation Chart Neonatal Skin Assessment

Record Pain Assessment Record

Background

No reference range of significant clinical signs in traditional observation chart Affect early recognition of infants at risk of clinical

deterioration Hinder effective team communication and take

appropriate interventions promptly

Early identify signs of deterioration

Prompt intervention and step up further

care

Reduce morbidity

(Duncan, 2007)

Objectives

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Combine into one chart: Integrated Observation Chart with Newborn Early Warning Signs (NEWS)

To develop an integrated observation chart with NEWS to facilitate nurses for identifying infants at risk of clinical deterioration for taking appropriate interventions in SCBU

To evaluate the discrimination ability of NEWS in screening the infant for Neonatal Intensive Care Unit (NICU) admission

Methodology

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Study Design Retrospective chart review diagnostic study

Settings Special Care Baby Unit (SCBU) in PMH

Period 1 Feb 2015 - 31 Jan 2016

Subjects All eligible cases and 1:2 matched controls in the 1 year study period

Subjects

Inclusion Criteria Case Aged ≤ 28 days or 44 weeks

post-conception Transferred from SCBU to

NICU for clinical deterioration and step-up care

Matched control Admitted to SCBU within ± 3

days of the case’s SCBU transferal date

Length of stay in SCBU ≥ length of stay of the case

Without NICU admission

Exclusion Criteria Had previous NICU admission Electively transferred to NICU for procedure, monitoring or

management without clinical signs of deterioration

Data Collection

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Subjects were identified from the admission records of NICU and SCBU, as well as Electronic Patient Record (ePR).

Demographics and clinical information were collected from medical records.

Example for data collection

Data Analysis & Development of NEWS

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Step 1: Draft of NEWS Developed by a clinical expert

panel including neonatologist and neonatal nurses

Included five physiological items, temperature, cardiovascular status, respiratory status, neurological status and severity of abdominal distension

Three colour zone (white, yellow and red) to indicate the urgency in intervention

Red zone to indicate the need of immediate intervention for clinical deterioration

Data Analysis & Development of NEWS

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Step 2: Data analysis for NEWS modification

Demographics and clinical information of the subjects were reported as mean ± SD, range or count (%).

Chi-square test, Fisher's exact test, Mann-Whitney U test, independent samples t-test were used for comparing variables among groups.

The subjects were divided into training set (~70%) for developing modified versions of NEWS and testing set (~30%) for testing the modified charts.

Sensitivity, specificity, accuracy, positive and negative predictive values of red zone in NEWS for screening infants with NICU admission were calculated.

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Step 3: Finalizing NEWS

The modified versions of NEWS were discussed by the expert panel to develop the finalized version of NEWS.

Sensitivity, specificity, accuracy, positive and negative predictive values of red zone in NEWS for screening infants with NICU admission were calculated using all recruited subjects.

Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS version 22.0; SPSS, Chicago, IL, USA) and Open Source Epidemiologic Statistics for Public Health (OpenEpi version 3.01). P value <0.05 was considered as statistical significant.

Data Analysis & Development of NEWS

Sample Size Estimation

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First study to evaluate NEWS

No prior information about its screening ability

Assume: Sensitivity = 90%; Specificity = 90% Precision = 10% Ratio of case to matched control = 1:2 Prevalence = 33% (=1/3) Confidence level = 95%

→ At least 104 samples would be needed

Results – Recruitment

56 cases transferred to NICU

36 cases recruited

20 cases not eligible - 1 with age > 28 days or 44 weeks post-conception - 19 electively transferred for procedure, monitoring or management +

Recruitment flow chart

72 matched controls

108 patients recruited

Training set (n=75) 25 cases

50 matched controls

Testing set (n=33) 11 cases

22 matched controls

Results – Baseline Characteristics

Results – Baseline Characteristics

Results – Baseline Characteristics

Results – Baseline Characteristics

Results – NEWS Modification

Training Set Version 1 (Draft) Version 2 Version 3 Version 4

Accuracy (%;95%CI) 85.3 (75.6 - 91.6) 93.3 (85.3 - 97.1) 94.7 (87.1 - 97.9) 100 (75.1 - 100)

Sensitivity (%;95%CI) 72.0 (52.4 - 85.7) 96.0 (80.5 - 99.3) 100 (86.7 - 100) 100 (86.7 - 100)

Specificity (%;95%CI) 92.0 (81.2 - 96.8) 92.0 (81.2 - 96.8) 92.0 (81.2 - 96.8) 100 (92.9 - 100)

PPV (%;95%CI) 81.8 (61.5 - 92.7) 85.7 (68.5 - 94.3) 86.2 (69.4 - 94.5) 100 (86.7 - 100)

NPV (%;95%CI) 86.8 (75.2 - 93.5) 97.9 (88.9 - 99.6) 100 (92.3 - 100) 100 (92.9 - 100)

Items / Color Zone Version 1 Version 2 Version 3 Version 4 Mild & Moderate Retraction Mild & Moderate Abdominal Distension Temperature (°C)

35-35.9 <35

Results – NEWS Modification

Testing Set Version 1 (Draft) Version 2 Version 3 Version 4

Accuracy (%) 75.8 84.8 90.9 100

Sensitivity (%) 54.5 81.8 100 100

Specificity (%) 86.4 86.4 86.4 100

PPV (%) 66.7 75.0 78.6 100

NPV (%) 79.2 90.5 100 100

Training Set Version 1 (Draft) Version 2 Version 3 Version 4

Accuracy (%;95%CI) 85.3 (75.6 - 91.6) 93.3 (85.3 - 97.1) 94.7 (87.1 - 97.9) 100 (75.1 - 100)

Sensitivity (%;95%CI) 72.0 (52.4 - 85.7) 96.0 (80.5 - 99.3) 100 (86.7 - 100) 100 (86.7 - 100)

Specificity (%;95%CI) 92.0 (81.2 - 96.8) 92.0 (81.2 - 96.8) 92.0 (81.2 - 96.8) 100 (92.9 - 100)

PPV (%;95%CI) 81.8 (61.5 - 92.7) 85.7 (68.5 - 94.3) 86.2 (69.4 - 94.5) 100 (86.7 - 100)

NPV (%;95%CI) 86.8 (75.2 - 93.5) 97.9 (88.9 - 99.6) 100 (92.3 - 100) 100 (92.9 - 100)

Results – Finalized NEWS

All Subjects Version 1 (Draft) Finalized Version of NEWS

Accuracy (%;95%CI) 82.4 (74.2 - 88.4) 87.0 (79.4 - 92.1) Sensitivity (%;95%CI) 66.7 (50.3 - 79.8) 80.6 (65.0 - 90.3) Specificity (%;95%CI) 90.3 (81.3 - 95.2) 90.3 (81.3 - 95.2) PPV (%;95%CI) 77.4 (60.2 - 88.6) 80.6 (65.0 - 90.3) NPV (%;95%CI) 84.4 (74.7 - 90.9) 90.3 (81.3 - 95.2)

Items / Color Zone Draft NEWS Finalized version of NEWS Retraction Mild

Moderate Abdominal Distension

Mild Moderate

Temperature (°C) 35-35.9 <35

Discussion

The NEWS chart with action pathway and reference range of significant clinical signs

Facilitate early identification of infants at risk of clinical deterioration and take appropriate interventions promptly

Enhance effective team communication especially inexperienced nurses on the recognition of the unwell infant in SCBU

Discussion

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The NEWS chart is only a set of observations, but the subsequent full clinical evaluation of the infant is needed.

The other elements of assessment is also significant.

For respiratory assessment, chest retraction is one of clinical signs for respiratory distress. The observation of respiratory pattern, SpO2 and O2 requirement are also very important for infants.

The chest retraction scale is simply defined as mild or severe in new version instead of mild and moderate or marked.

Discussion

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For abdominal distension assessment, it is associated with feeding tolerance, nature and frequency of stool in daily intake and output chart, and soft or tense in abdominal palpation.

The abdominal distension scale is simply defined as mild or severe in new version instead of mild and moderate or marked.

Discussion

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Hypothermia is common in newborn infants despite measures to prevent hypothermia <36°C immediate after birth, resuscitation, and warm transportation.

Neonatal hypothermia is associated with increased morbidity and mortality especially among sick newborn infants who need medical attention in SCBU.

Nurses have to step up appropriate supportive intervention, and notify concerned parties.

The temperature scale is kept status quo in new version.

Clinical Practice

A new version of the NEWS chart is developed and will be implemented in 2017 when available.

The NEWS chart is only one component of our assessment for early identifying newborn infants at risk of clinical deterioration in SCBU.

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NEWS can facilitate early identification of infant’s clinical deterioration in SCBU and provide guidance for nurses to initiate appropriate intervention for improving patient outcome.

Conclusion