Does anyone know about NEWS2 scores and ICU?

[Fuuuuuckit]

I'm looking for advice please.

Does anyone know what the criteria for admission to ICU is, with NEWS2 scores?

My mum passed away in hospital earlier this year and (after already admitting a catalogue of errors) the hospital said something that I'm questioning.

If someone was admitted query sepsis (but misdiagnosed) with NEWS2 scores of 3/4 obs 3-4 hours. This jumped to 9 at which point all hell broke loose.

She was admitted to ICU 6 hours AFTER a score of 12 was recorded, (having only had 2 assessments carried out since the 9) and having had scores of 8 to 11 in those 6 intervening hours.

Just wondering if ITU would have made any difference at all? She died without any family close by (still using covid protocols) and someone mentioned that they didn't think ICU was the right pathway, and she could have been cared for palliativly with us close by.

Any thoughts?

Firstly I’m sorry for your loss.

im a midwife rather than a nurse so we use MEWS! Not NEWS but the principle is the same though the scoring is slightly different. I’ve cared for women before with a MEWS score of 9 on the Labour ward as no space in ICU, this was sepsis. Not ideal but well supported by the ICU outreach time both in person and over the phone.

also when my dad was sick with a high NEWS score ICU refused to admit him, the outreach team came to talk to me and said ICU was for when there was an organ failure which needed support and that wasn’t the case with my dad, he didn’t need dialysis, he didn’t need ventilation.

can you ask for some sort of debrief where you can ask someone (while looking at your mums notes) these sort of questions. I think the answer might depend on what was wrong with her and what treatment she needed. But be aware there isn’t always a bed in ICU for someone who needs it, or not immediately. So ICU might be hastily trying to discharge the least sick person to a ward to admit someone like your mum. But they might have to wait for the ward to be able to discharge someone. ICU generally will only admit someone if they think their care will make a difference.

Icu is a place rather than a treatment.

If no additional support that would require moving her to icu was felt appropriate, moving her there to receive ward level care would make no difference.

Sorry for your loss. The NICE guidelines are www.nice.org.uk/advice/mib205/chapter/The-technology which may be a starting point. Have you raised a complaint?

And I believe the CC team can be involved with patients in settings other than ITU and HDU.

Thanks both.

She WAS moved to ICU. But I'm not sure if there's normally a cut-off point for viability - excuse my clumsy language but I'd like to find out if the (incredibly expensive) 12 hours she spent all alone in ICU was really a viable option after several hours of NEWS2 scores ranging from 8 to 12. I have a horrible horrible feeling that by the time she was seen by a consultant (17 hours after admission straight to oncology, yes she missed the pm ward round due to documented and admitted errors, and a misdiagnosis and Conservative treatment for dehydration) things were already so badly badly wrong that it was a last ditch attempt at pulling things back rather than a realistic viable option.

I've had an initial briefing from the hospital and now I've looked through everything I'm wondering if paliative care would have been kinder

I'm so sorry that you're going through this. Some hospitals have high dependency wards and Intensive Care as separate units, whilst others have a combined HDU/ITU. Some hospitals have 'acute' wards in addition to the HDU/ITU.

HDU/ITU is generally needed when somebody needs blood pressure support that is given via their veins, optiflow (high flow oxygen delivered to the nose), CPAP (a continuous flow of air/oxygen under pressure, through a mask), BiPAP (similar to CPAP, but delivered slightly differently), ventilation, dialysis, or some other organ support that can't be safely delivered at ward level.

You really need someone to explain what it was that gave your DM the score that she got. For example, being confused on its own would score 3. Being on oxygen would score 2. I would go back and ask them to talk you through the charts and what was done as a result.

Some patients are 'too sick' for ITU - in other words, the intervention that would be used would cause them suffering without any benefit. Sadly, ITU care can't always help people.

@LIZS the hospital initiated a review and investigation. But there are so so many holes, questions, gaps, omissions that I am now thinking track-covering rather than viability

You're not going to be able to truly contextualise what NEWS scores would've meant for your mother because you a) don't have her full noted b) weren't there and c) don't have a medical degree plus the years of postgraduate education that the senior doctors caring for her would've had.

It isn't anywhere near as simple as NEWS x = sepsis = ITU.

There are so many factors.

I know you're looking for answers and someone to blame, but you're trying to interpret a serious medical situation when you aren't an expert in or even familiar with medicine.

There isn’t a cut off score, a NEWS score is a blunt tool. Doctors will look at each person on a case by case basis and what’s actually wrong with them and their medical history is probably more important. My gut feeling is they must have thought that moving her to ICU was worth a shot/could make a difference otherwise they wouldn’t done it. That’s certainly the experience with my dad and beds are under such pressure they wouldn’t put someone there who could either be cared for on a ward or was felt to have no chance.

Also especially in the age of google, everyone who isn't a doctor seems to forget how much uncertainty there is in medicine.

There is always a different path that could've been taken.

If it was easy, we wouldn't have a doctor shortage. We'd just let people with no training apply protocols based on NEWS scores and everyone would get the same outcome.

Real life isn't like that. Hindsight is 20/20.

Patients and families who've seen outcome B always want to know why they didn't get outcome A. And those that got A want it the other way round.

Excepting serious negligence, sickness and death is shit for everyone involved and like birth plans, rarely goes smoothly.

If they have done an investigation have been asked to a post investigation review meeting?

you should be as part of duty of Candour.

I’m an NHS clinician and do a lot of incident investigation for my/other departments.

in our place we send out the incident report and invite you in to speak with incident investigator to explain the investigation /answer any queries.

If people have questions after that meeting (and sometimes as you mail stuff over they crop up).

most clinicians would rather try to explain decision making than have families / patients feel they have been mistreated.

the vast majority of the time staff try to do the right things. Sometimes this is the wrong thing. This can be due to their error, operational factors (very common at the moment - you can’t work at 110% with no issues or the patients evolving condition.

my advice would be - reach out to the hospital and ask to talk the report and decision making over.

as someone who has previously made ICU admission decisions I can say do tors wouldn’t admit someone if they thought it was pointless. ICU clinicians are frequently criticised for being too pessimistic /reluctant to admit by their peers

I have her notes. I have the numbers (respiratory rate, BP, HR, temp etc) documented which determined the NEWS scores.

I'm fully aware of my limitations as a lay person using Dr Google but I know the difference between Dr Pimple Popper and NICE guidelines.

I've had 2 junior doctors look at the notes from the investigation, and they are horrified. It was them that independently told me that based on her notes (and a bit of background info) they wouldn't have expected a move to ICU.

I will be asking for another briefing with the hospital. I have a hundred questions to answer. Including an explanation for the huge gaps between observations, nobody looking at blood results (taken at admission, showing flashy red lights in CRP? terms) for 15 hours and why as part of the investigation they didn't speak to the admitting doctor.

Just to clarify your concern - it's that you think ICU admission was inappropriate for your mum, and that ward-based, less intensive care would have been more appropriate?

So you're angry she was admitted to ITU as you would've want her palliated, but you also feel there was medical negligence because a high CRP and NEWS were in your opinion not acted on quickly enough?

Honestly I think your grief is making you see fault where there is probably none.

Worrying over scores and bloods won't change what happened.

I get the impression that the OP is worried that the decision to move to ICU was taken too late. That if the decision had been made earlier, there may have been a chance of a different outcome. At the same time, I think the OP is worried that by the time the decision was made, it wasn't actually in her Mum's best interests to move to ICU and that palliation would have been kinder.

The two views aren't incompatible and do align with the reality of many medical decisions. There are always different treatment paths that can be taken and there will always be pros and cons with each.

The 'success stories' of ICU sometimes come at huge cost and recovery can take months, if not years. Sometimes it's only afterwards that a judgement can be made on whether the right decision was made.

I get the impression that the OP is worried that the decision to move to ICU was taken too late. That if the decision had been made earlier, there may have been a chance of a different outcome. At the same time, I think the OP is worried that by the time the decision was made, it wasn't actually in her Mum's best interests to move to ICU and that palliation would have been kinder.

Thankyou for putting it so eloquently, my brain is fried with it all at the moment.
Yes, many opportunities were missed to treat her sooner, and I am wondering if her move to ICU should have been made sooner.

On the other hand if her death was inevitable, (due to the many missed opportunities) then surely a palliative path would have been a better (?? Still awful, obviously) for her, for us, for her to have us with her, for us to have the opportunity to be there with her, rather than kicked out of a closed ICU (I tested several times that weekend) and not able to drive fast enough to be with her when they finally called me to go to her.

She had underlying health problems - she was on her very first round - in a 2 year plan of - chemo treatment (yes, number one sepsis query red flag for admission direct to an oncology ward from home, yet ignored), but her death was utterly unexpected which is where the shock/anger/frustration is coming from.

@Fuuuuuckit I am just so sorry. Even with her history, she went too soon and you weren't ready. I think that you could drive yourself mad with the numbers. Mistakes may well have been made. I do know that once she was in intensive care, she will have got the best care possible in the circumstances. I used to be an ICU nurse and caring for dying patients was something we took very, very, seriously.

It sounds like a very typical case of someone with lots of comorbidities arriving generally unwell, the picture only gradually becoming clearer over time, and sadly deteriorating so fast that a decision was made to give her one last shot and then she was palliated.

Unfortunately patients are often made palliative very suddenly. Active treatment can be withdrawn immediately and there is often no time to get family in before the person passes.

Nothing you've said screams negligence to me. It sounds like a very common, sad story. I'm sorry you lost your mum. But chasing after overworked junior doctors in an attempt for some control, for someone to blame, won't help you and is unfair on them.

@Karmapolice89 she was generally unwell and had spoken to the ward that afternoon explaining how she was feeling unwell. They were supposed to be expecting her when she came. Yet the big immunocompromised flag was dismissed and she was misdiagnosed. The picture was very clear yet not one person identified it. She then inexplicably was missed by the consultant at evening rounds, blood tests weren't picked up yet more were taken overnight with no 'apparent' reason why, no handover was done (yes, this is all documented). By the time the consultant came in the morning all hell broke loose and she was treated very aggressively. 8 hours later she went to ICU but died 15 hours later on her own.

The hospital have admitted several mistakes were made. It is in black and white. Documented. Yet even this report barely explains what went wrong, and certainly not why.

I have the greatest respect for the NHS. I have doctors in my family and friendship groups. My family literally would not be here today if not for the nhs.

But their admissions leave a very bitter taste. I was asking if there was some sort of standard for admission to ICU, and if it would have been futile then it truly is devastating to think that she died alone.

Her ICU nurse and team were phenomenal. But, septically, even this leaves me thinking were they so super nice because they knew the system had gone so wrong?

She won't have died alone, she'd have had her 1:1 nurse at least. All ITU patients have 1:1 nursing care. I think your grief has conjured up a devastating image that probably isn't the truth.

From my experience patients presenting extremely poorly with higher news scores will be seen by an outreach team that consists of highly skilled specialist nurses/doctors who decide the best route for the patient. Was this the case with your mum? I’m wondering if they decided that due to her condition she stood a chance of ITU care in the hope that they would be able to support her body while she fought the infection/sepsis. There will always be differing opinions but ultimately a decision was made in the best interest of your mum at the time.
It will take you a long time to grieve and come to terms with the sadness of your mums death. I hope you can find some answers. 💐

For every family in your situation who are upset that mum was moved to ITU, there will be another family equally upset that she Wasn't. An eg 10% chance of survival will be seen by some as worth trying anything for, and by others as worth just care and comfort.

The clinical decision itself probably isn't the issue here, it's the lack of communication.

The ward should have told you the likely outcomes, discussed your expectations of care, and involved you in the decision. I'm not sure why this didn't happen, but if you are going to complain, this is where your focus should be, rather than worrying about the actual clinical decision (which was likely sound, just perhaps not in her best interests in retrospect).

• when I say involved you in the decision, that's on the assumption that your mum wasn't able to make the decision herself