NEWS2 is the Royal College of Physicians' track-and-trigger score, endorsed by NHS England and NICE CG50 for every adult in an acute hospital. It scores six parameters: respiration rate, oxygen saturation, systolic blood pressure, pulse, level of consciousness or new confusion, and temperature, plus a point for supplemental oxygen. The triggers are fixed. A score of 5 or more is the urgent-response threshold and 7 or more is the emergency-response threshold. Knowing those two numbers and what each obliges you to do is the core of this station.

How do I assess this patient?

Start with immediate management by ABCDE at the bedside, because a score is a summary of physiology you should be looking at directly. Then do the full assessment: look at the trend on the chart rather than the last value, because a patient climbing from 2 to 5 over four hours is a different problem from a patient who has been 5 for two days. Read the fluid balance and the drug chart. Then decide and plan, including who you are calling.

  • New confusion scores 3 on its own and is the parameter most often missed on a busy surgical ward
  • Use SpO2 Scale 2 only for patients with confirmed hypercapnic respiratory failure whose target is 88 to 92%; scoring them on Scale 1 inflates the score
  • A score of 3 in any single parameter is a red score and needs the medical team informed and a review, even if the aggregate is low

What are the key investigations and findings?

The investigations follow the abnormal parameter. Tachypnoea and desaturation call for a blood gas and a chest radiograph. Hypotension and tachycardia call for a lactate, a haemoglobin, a fluid balance review and a look at the wound and drains. New confusion calls for glucose, a gas, a septic screen and a medication review. In every case a full blood count, urea and electrolytes, CRP and cultures if infection is plausible, and an ECG.

What is the management?

The RCP chart sets the minimum response for each band and you should be able to say it.

  • Score 0: continue routine monitoring, minimum 12-hourly, which is also the CG50 floor for every inpatient
  • Aggregate 1 to 4: minimum 4 to 6 hourly observations; the registered nurse assesses and decides whether to escalate
  • 3 in a single parameter: minimum hourly observations; the nurse informs the medical team who review and decide
  • Aggregate 5 or 6: urgent response threshold. Hourly observations, the medical team informed immediately, urgent assessment by a clinician or team with core competencies in acute illness, and care in an environment with monitoring
  • Aggregate 7 or more: emergency response threshold. Continuous monitoring, the medical team informed at registrar level or above, emergency assessment by a team with critical care competencies including advanced airway skills, and consideration of transfer to level 2 or 3 care

Alongside the response, treat what you have found: oxygen to a BTS target, fluid if hypovolaemic, antibiotics within the hour if this is high-risk sepsis under NG253, and the specific treatment for the cause.

When do I escalate and to whom?

At 5 or more you call your registrar now and say the score, the trend, what you have done and what you want. At 7 or more you also call the critical care outreach team, or the intensive care registrar directly, and you inform the consultant. NG253 adds that if a high-risk patient has not responded within 1 hour of any intervention, the senior decision maker must attend in person and critical care must be involved. Escalate below these thresholds if the patient looks worse than the numbers, if you are worried, or if the score is rising fast. Document each call with the time.

What is the interviewer listening for?

  • The 5 and 7 triggers stated as numbers, with the response each requires
  • Recognition that NEWS2 is a trigger, not a diagnosis, and that a low score in a sick-looking patient is still a reason to act
  • Escalation that is early, specific and persistent: what you say, to whom, and what you do if they do not come
  • Awareness of the ceiling of care and whether an escalation plan already exists in the notes
  • A one-minute SBAR handover with numbers in it

What might they ask next?

  • Your registrar tells you to keep an eye on it. The score is now 7. What next?
  • The patient has a DNACPR form. Does that change the escalation?
  • Which single parameter would worry you most, and why?
  • How do you decide whether this patient needs a high-dependency bed?

The Core Surgery Interview question bank has a scored scenario on a rising NEWS2 on the surgical ward: /Question-Bank/Sample-Questions.