What is NEWTT2?
The Newborn Early Warning Track and Trigger 2 (NEWTT2) Deterioration of the Newborn framework, published by the British Association of Perinatal Medicine (BAPM) in 2023, is a novel set of safety tools designed to standardise the enhanced assessment of newborns at higher risk of ill health. NEWTT2 is an evolution of previous early warning systems (EWS), principally NEW (Plymouth, UK, 2010) and NEWTT (BAPM, 2015), developed by a UK multidisciplinary collaborative team, expanding into a set of interlinking tools for consistent identification, observation, escalation and clinical review of the at-risk newborn (www.bapm.org/pages/newtt-2).
The framework brings together national guidance and standards for early care of the newborn whilst acknowledging that there are certain conditions where such national steer does not exist, and local and regional decision making is required.
Who is NEWTT2 for?
NEWTT2 is recommended for use in at-risk newborns, as defined in the framework, in postnatal settings such as postnatal areas, transitional care and delivery suite, for both term and late preterm newborns.
How should NEWTT2 be implemented?
NEWTT2 and its allied tools were designed and tested during 2021-23. Testing, consensus and feedback was taken into consideration when choosing the charts’ colour schemes. Colour is especially important for the teams using paper versions of the charts including those implemented by the early adopter organisations and high-quality printing is required.
Since launching the framework clinical stakeholders have contributed to the development of the digitalisation of these tools. A blueprint for digital specification has been led byNHS England and is expected to launch in June 2025. All digital tools must be available to the entire perinatal team to ensure complete access to data and patient safety.
In your organisation the perinatal safety team would be an ideal collaborator to implement the NEWTT2 tools and wider framework. One of the many strengths is the emphasis on joint working and support between maternity, neonatology and parents to enhance patient safety.
Why should we implement NEWTT2?
A BAPM survey of UK centers in 2021 noted that 79% of respondents used a version of NEWTT. Encouraged by this uniformity, the NEWTT2 working group sought to further minimise unwarranted variation in newborn observation by developing updated and novel universally adoptable tools that are becoming familiar to all, including rotating trainees and temporary perinatal staff. NEWTT2 has become an essential requirement for perinatal teams to deliver (https://www.england.nhs.uk/publication/three-year-delivery-plan-for-maternity-and-neonatal-services/).
Which tools are available?
In addition to describing those newborns categorised as at-risk requiring enhanced observation there are three tools:
- NEWTT2 Observation Chart: Generates a total NEWTT2 Score
- Standardised Escalation Tool: Determines when and who should respond
- Joint Review Tool: Ensures a combined standardised response
To access all of the tools click here deterioration-of-the-newborn-newtt-2-a-framework-for-practice
All observations should be conducted every time (except for glucose which should only be measured where and when indicated). The frequency of observations is determined by national guidance or if none exist by local clinical discretion.
BAPM has a dedicated NEWTT2 webpage permitting free immediate access to the entire framework, all the tools, learning packages, FAQs and an enquiry system.
What’s new in NEWTT2?
- Involving Parents as Partners in Escalation of Care
One of the key features of NEWTT2 is the inclusion of “parental concern” as a factor in the care process. The framework emphasises the importance of including parents as partners in care, recognising their concerns as a vital part of the process. This acknowledges that there may be various reasons for escalating care beyond clinical observation findings alone and both parents and carers can seek help through escalation whenever necessary.
- Preventing harm: the big 3!!!
- The hypothermia blue line
We need to minimise the risk of newborns cooling down after birth as hypothermia is an avoidable harm for all babies not just those categorised as high-risk (https://www.england.nhs.uk/mat-transformation/reducing-admission-of-full-term-babies-to-neonatal-units/). So mild hypothermia, 36.0C-36.4C is a pale blue colour on the chart and prompts actions to warm baby with the goal that the temperature does not fall lower to more serious values. Hypothermia is associated with an increase in morbidity and mortality.
- Colour assessment and detection of hypoxia
In line with the national publication Review of neonatal assessment and practice in Black, Asian, and minority ethnic newborns report (July 2023, NHS Race and Health Observatory https://www.nhsrho.org/wp-content/uploads/2023/08/RHO-Neonatal-Assessment-Report.pdf) NEWTT2 provides guidance on the assessment of colour in all skin tones and supports the use of pulse oximetry with documentation of the % oxygenation value within the appropriate section of the chart. Hypoxia is an avoidable harm.
- Glucose measurement where indicated
Only a few newborns require glucose monitoring and NEWTT2 does not recommend unnecessary interventions such as blood tests during what is a transition period for metabolism and an essential time to support the establishment of feeding. Hypoglycaemia however is one of our Big 3 as it can cause life-long brain injury and it is our responsibility to support the feeding and glucose monitoring of newborns where required.
- Observation Scoring
Guidance is provided on how to complete the observation chart. Each observation is plotted within specific colour-coded boxes: white (score zero), yellow/amber/pale blue (score 1), pink/red (score 2), and purple for critical observations that require immediate escalation. A total score, the NEWTT2 score, is calculated for each set of observations.
- Escalation Tool
The total NEWTT2 score triggers one of five escalation levels or advises the continuation of routine care. The levels define the speed and seniority of response expected and have an in-built safety back-up response as required. Please note that healthcare professionals can override the NEWTT2 score to request a higher escalation at any time, but they must not dismiss a total NEWTT2 score and not act.
The Future
The NEWTT2 team are supporting implementation within perinatal centres in both paper and digital formats.
Initial feedback from early adopters has been very promising with reports of improvements in avoidable admissions to neonatal units and improved perinatal team working. We are currently developing a simple quality improvement tool for centres to utilise to assess local impact with an option to input into a UK collaborative sharing of data which will subsequently inform a wider evaluation of workload, acceptance and effectiveness.