Conclusions: NEWS can capture acutely ill patients to some degree. Using inpatient admission as a proxy for acutely ill, residents with NEWS of 5 and above were more likely to require inpatient admission. However, as a tool on its own, it is limited in its scope to avert ED attendance. There were conditions with a NEWS score of 0-1 which still required ED visits for treatment and services such as suturing and radiological investigations which were not available in the nursing homes. NEWS alone is also a poor tool in recognizing conditions such as mild acute bleeding (NEWS score 0), stroke (NEWS score 0) and myocardial infarction (NEWS score 3). Out of the 13 residents who were discharged from the ED, 4 residents could have potentially been managed in the community; they were diagnosed with LRTI, functional decline, dehydration and simple laceration. Matching these conditions with relevant care paths would allow appropriate utilization of community resources and may avert ED attendance. Teleconsultation facilitated the aversion of 3 cases but was not employed in 15 cases despite clear instructions. Further study is needed to explore the nurses' clinical decisionmaking process in overriding the NEWSteleconsultation guidelines and transferring residents to the ED immediately, as well as a wider research into expanding the assessment tools used. Access to medical advice is vital for aversion of ED attendance whether by teleconsultation or GP attendance. Despite the limitations, NEWS is still useful as an initial assessment tool in a nursing home setting where nurses rely on clinical assessment and medical support is low. Supplemented with teleconsultation, NEWS can recognize acutely ill patients and avert ED attendance.

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