What is NEWS2?
The National Early Warning Score 2 (NEWS2) was published by the Royal College of Physicians in 2017 to give the NHS one standard way of recording observations and triggering a timely response. NHS England has endorsed it for acute hospitals and ambulance services, and it is widely used in community and mental health settings too. Because everyone uses the same system, a score of 7 means the same thing on every ward and in every handover.
Most patients who have a cardiac arrest or unplanned intensive care admission in hospital show physiological deterioration in the hours beforehand. National reviews in the UK have repeatedly found that these signs were recorded but not recognised, not acted on or not escalated in time. NEWS2 exists to close that gap.
NEWS2 is for adults aged 16 and over. It is not validated for children, who need a paediatric early warning score, or in pregnancy, where an obstetric early warning score is used. Follow your local policy.
What are the seven NEWS2 parameters?
Each parameter scores 0 to 3. The table summarises the RCP scoring bands for SpO2 Scale 1. Always use the official colour-coded chart or electronic system in your organisation.
| Parameter | Score 3 | Score 2 | Score 1 | Score 0 | Score 1 | Score 2 | Score 3 |
|---|---|---|---|---|---|---|---|
| Respiration rate (per minute) | 8 or less | 9 to 11 | 12 to 20 | 21 to 24 | 25 or more | ||
| SpO2 Scale 1 (%) | 91 or less | 92 to 93 | 94 to 95 | 96 or more | |||
| Air or oxygen | Oxygen | Air | |||||
| Systolic BP (mmHg) | 90 or less | 91 to 100 | 101 to 110 | 111 to 219 | 220 or more | ||
| Pulse (per minute) | 40 or less | 41 to 50 | 51 to 90 | 91 to 110 | 111 to 130 | 131 or more | |
| Consciousness | Alert | New confusion, Voice, Pain or Unresponsive | |||||
| Temperature (°C) | 35.0 or less | 35.1 to 36.0 | 36.1 to 38.0 | 38.1 to 39.0 | 39.1 or more |
Respiration rate: count it, do not guess it
A rising respiration rate is often the earliest sign of deterioration, in sepsis, heart failure, pulmonary embolism and acidosis. It is also the observation most often estimated. Count for a full 60 seconds by watching the chest, ideally without the patient noticing. A chart showing 16 or 18 every time suggests it is not being counted.
New confusion scores 3
NEWS2 uses ACVPU: Alert, new Confusion, Voice, Pain, Unresponsive. New confusion, disorientation or agitation scores 3. RCP additional guidance says to treat confusion as new unless it is confirmed to be normal for that patient, so ask family or carers. If the patient is more confused than usual, a delirium assessment such as the 4AT and a clinical review are needed.
When should you use SpO2 Scale 2?
Scale 1 is used for almost everyone. Scale 2 is only for patients with confirmed hypercapnic respiratory failure, usually on blood gas analysis, who have a prescribed target saturation of 88 to 92 percent. The decision must be made and documented by a competent clinician.
- On Scale 2, saturations of 88 to 92 percent score 0, and so do saturations of 93 percent or more on air.
- Saturations below 88 percent score 1 to 3 as they fall.
- On oxygen, saturations of 93 percent or more score 1 to 3 as they rise, because over-oxygenation is harmful in hypercapnic respiratory failure.
How do you calculate a NEWS2 score? Worked examples
Score each parameter, add them together, and check whether any single parameter scores 3.
Example 1: a post-operative patient
A 70-year-old woman, two days after hip surgery, has respiration rate 22, SpO2 95 percent (Scale 1) on air, systolic BP 105, pulse 104, alert, temperature 38.4.
| Parameter | Value | Score |
|---|---|---|
| Respiration rate | 22 | 2 |
| SpO2 Scale 1 | 95% | 1 |
| Air or oxygen | Air | 0 |
| Systolic BP | 105 | 1 |
| Pulse | 104 | 1 |
| Consciousness | Alert | 0 |
| Temperature | 38.4 | 1 |
| Total | 6 |
A NEWS2 of 6 is in the medium range and needs an urgent response, with at least hourly observations. She has a raised score and a possible source of infection, so sepsis must be considered.
Example 2: a single red score
An 82-year-old man has respiration rate 18, SpO2 97 percent on air, systolic BP 128, pulse 86, temperature 37.2. His daughter says he does not know where he is today, which is new. Everything scores 0 except new confusion, which scores 3. His total is only 3, but a single parameter scoring 3 is a red score that needs an urgent ward-based response. Possible causes include infection, hypoxia, hypoglycaemia, medicines, electrolyte problems and stroke.
When should you escalate a NEWS2 score?
The RCP links each score to a minimum monitoring frequency and a clinical response. Your organisation's escalation policy sets who you call and how, and may set stricter standards.
| NEWS2 | Clinical risk | Minimum monitoring | Response |
|---|---|---|---|
| 0 | Low | At least 12-hourly | Continue routine monitoring |
| 1 to 4 | Low | At least 4 to 6-hourly | Inform the registered nurse, who assesses and decides whether to increase monitoring or escalate |
| 3 in any single parameter | Low to medium | At least hourly | Registered nurse informs the medical team, who decide whether escalation is needed |
| 5 or more | Medium (urgent response threshold) | At least hourly | Registered nurse informs the medical team immediately and requests urgent assessment by a clinician or team competent in acute illness; consider a monitored setting |
| 7 or more | High (emergency response threshold) | Continuous | Emergency assessment by a team with critical care competencies, usually including airway skills; consider transfer to level 2 or 3 care |
Look at trends as well as the latest number. A patient whose score climbs from 0 to 2 to 4 over a shift is deteriorating, even though each reading is 'low'. Beta-blockers, pain relief and other medicines can mask a raised heart rate, so think about what the numbers might be hiding.
Patients with a treatment escalation plan or ReSPECT form that limits some treatments still need NEWS2 monitoring and assessment. The plan shapes the response; it does not cancel it.
How should you escalate? ABCDE and SBAR
Assess a patient with a raised score using the ABCDE approach taught by Resuscitation Council UK, treating problems as you find them within your competence and calling for help early. Then communicate clearly using SBAR: Situation, Background, Assessment, Recommendation.
'Hi, it's the nurse on Ward 6. Joan in bed 3 is a bit unwell, her NEWS is up. Could someone see her at some point?'
'This is Kemi, staff nurse on Ward 6. I'm calling about Joan in bed 3. Her NEWS2 is 15, up from 2 four hours ago. She is 78, two days after a bowel resection. Respiratory rate 26, saturations 92 percent on 2 litres, pulse 124, BP 96 over 60, newly confused, temperature 38.9. I'm worried she has sepsis. I need you to review her now. Shall I take blood cultures and a lactate, and should I call critical care outreach?'
The stronger call gives the score and trend, the key numbers, a clear concern and a specific request with a timescale. Document the time you escalated, who you spoke to and what was agreed. If the response is not adequate, escalate further, to the registrar, consultant, nurse in charge, outreach or emergency team, using plain words: 'I am very concerned and I need you to see this patient now.' Many hospitals in England also offer patients and families a route to request an urgent independent review under Martha's Rule; know how it works where you are.
Why is deterioration still missed?
- Observations not done at the right frequency, especially overnight.
- Respiration rate estimated rather than counted.
- Wrong SpO2 scale or wrong arithmetic.
- A high score not escalated, or escalated to someone who does not come.
- New confusion not recognised as a sign of illness.
- Trends ignored because each reading seemed acceptable on its own.
- Concerns from patients and families not taken seriously.
Tom, a physiotherapist, sees an 80-year-old man with pneumonia at 10 am. The last observations, at 6 am, gave a NEWS2 of 3. Tom notices the patient is breathing fast and drowsier than the day before, with saturations of 91 percent on 2 litres. He treats him and writes 'tired, SOB, sats 91%', mentioning it only to a healthcare assistant. At 1 pm a nurse records a NEWS2 of 9 and the patient is moved to a higher level of care. In his reflection, Tom accepts that every registered professional can and should take a full set of observations, calculate the score and escalate. He now does this whenever a patient looks different from the last recorded set, and hands concerns directly to the nurse in charge.
Building confidence with NEWS2
Practise scoring from real charts with a colleague, check your respiratory rate counting against someone else's, and audit a few of your own escalations against your local policy. This is useful evidence for revalidation and appraisal, and it builds confidence for newly qualified and internationally educated staff who may be used to different systems.
Our course Recognising the Deteriorating Patient (NEWS2) covers accurate observations, scoring including Scale 2 and new confusion, the clinical response, ABCDE assessment, SBAR and graded assertiveness, with a case study and guided reflection. It is suitable for nurses, nursing associates, doctors, physiotherapists, paramedics and other professionals caring for adults. It does not replace your organisation's mandatory training or accredited life support courses.
Frequently asked questions
What does a NEWS2 score of 5 mean?
A total NEWS2 of 5 or more is the urgent response threshold and indicates medium clinical risk. The registered nurse should inform the medical team immediately and request urgent assessment by a clinician or team competent in caring for acutely ill patients, observations should be at least hourly, and a monitored setting should be considered. Sepsis should be considered if infection is possible.
What is a red score in NEWS2?
A red score is when any single parameter scores 3, for example a respiration rate of 25 or more, systolic BP of 90 or less, or new confusion. Even if the total is low, it needs at least hourly observations and the registered nurse should inform the medical team, who decide whether further escalation is needed. Local policies may set a more urgent response.
When should NEWS2 Scale 2 be used?
Only for patients with confirmed hypercapnic respiratory failure, usually shown on blood gas analysis, who have a prescribed target saturation of 88 to 92 percent. The decision must be made and documented by a competent clinician. A diagnosis of COPD alone does not justify Scale 2, and using it wrongly can hide dangerous hypoxaemia.
Does new confusion always score 3 on NEWS2?
Yes. New confusion, disorientation or agitation scores 3, the same as responding only to voice or pain. RCP guidance says to treat confusion as new unless it is confirmed to be the patient's normal state, so check with family, carers or the notes. If the patient is more confused than usual, arrange a delirium assessment and clinical review.
Can NEWS2 be used in children or pregnant women?
No. NEWS2 is validated for adults aged 16 and over. Children should be monitored with a paediatric early warning score, and pregnant women with an obstetric early warning score, as set out in local policy. These tools use different normal ranges that reflect children's and pregnant women's physiology.
How many points does supplemental oxygen add?
A patient receiving any supplemental oxygen scores 2 for the 'air or oxygen' parameter, in addition to the score for their saturation level. Forgetting these 2 points is one of the most common NEWS2 scoring errors, and it can make a patient who needs urgent review look lower risk than they are.
What should I do if I am worried but the NEWS2 score is low?
Escalate anyway. NEWS2 supports clinical judgement and does not replace it. Medicines such as beta-blockers can mask changes, and some serious conditions show few early abnormalities. Explain your concern clearly using SBAR, document what you saw and who you told, and escalate further if the response is not adequate.
Related courses
Recognising the Deteriorating Patient (NEWS2)
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Sources and further reading
- National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. Royal College of Physicians.
- NEWS2 additional implementation guidance. Royal College of Physicians.
- Acutely ill adults in hospital: recognising and responding to deterioration (CG50). National Institute for Health and Care Excellence.
- Suspected sepsis in people aged 16 or over: recognition, assessment and early management (NG253). National Institute for Health and Care Excellence.
- Resuscitation Guidelines: the ABCDE approach. Resuscitation Council UK.
- The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Nursing and Midwifery Council.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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