The deteriorating patient — NEWS2, escalation and the bleep

Why this matters on day one

On a night shift you hold twenty problems and can be in one place. The skill being tested is not diagnosis but triage — deciding, from a phone call, who is seen now, who is seen in twenty minutes, and who needs someone more senior than you.

The sequence

1. 1Score it. NEWS2 aggregates respiratory rate, saturations (with a separate scale 2 for confirmed CO₂ retainers on a target of 88–92%), air or oxygen, systolic BP, pulse, consciousness (new confusion scores 3) and temperature.
2. 2Act on the trigger. Score 5–6, or any single parameter scoring 3 → urgent review by a clinician competent in acute illness, and consider whether critical care outreach is needed. Score 7 or more → emergency assessment by a team with critical care competencies.
3. 3Triage the bleep list. Ask three questions of every call: what are the observations, what has changed, and is anyone with them. Sort into: see now (airway, saturations, hypotension, new chest pain, reduced consciousness, seizure), see soon (pain, vomiting, low urine output, new AF), and can wait (routine rewrites, non-urgent fluids, warfarin doses that are not due for hours).
4. 4Delegate and instruct. You can act by phone: ask for a repeat set of observations, an ECG, a capillary glucose, a fluid bolus already prescribed, or high-flow oxygen — and give a time to call you back. Say explicitly what would make them call you sooner.
5. 5Close the loop. Document the call, your instruction and your plan even if you have not attended. An undocumented telephone decision is indefensible and invisible to the next shift.

What goes wrong

• Trusting a single reassuring blood pressure. Young patients compensate then crash; NEWS2 catches the trend, not the snapshot.
• Being talked out of attending. If the nurse is worried and you cannot explain why they should not be, go.
• Using scale 2 on NEWS2 for anyone who "probably" retains CO₂. It applies only to a documented target of 88–92%.
• Task-switching without writing anything down — the second call erases the first.
• Escalating without SBAR, so the registrar has to interview you before they can help.