101
|
Lind ML, Phipps AI, Mooney S, Liu C, Fohner A, Patel K, Ueda M, Pergam SA. Predictive Value of 3 Clinical Criteria for Sepsis (Quick Sequential Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and National Early Warning Score) With Respect to Short-term Mortality in Allogeneic Hematopoietic Cell Transplant Recipients With Suspected Infections. Clin Infect Dis 2021; 72:1220-1229. [PMID: 32133490 PMCID: PMC8028104 DOI: 10.1093/cid/ciaa214] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 03/02/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Sepsis disproportionately affects allogeneic hematopoietic cell transplant (HCT) recipients and is challenging to define. Clinical criteria that predict mortality and intensive care unit end-points in patients with suspected infections (SIs) are used in sepsis definitions, but their predictive value among immunocompromised populations is largely unknown. Here, we evaluate 3 criteria among allogeneic HCT recipients with SIs. METHODS We evaluated Systemic Inflammatory Response Syndrome (SIRS), quick Sequential Organ Failure Assessment (qSOFA), and National Early Warning Score (NEWS) in relation to short-term mortality among recipients transplanted between September 2010 and July 2017. We used cut-points of ≥ 2 for qSOFA/SIRS and ≥ 7 for NEWS and restricted to first SI per hospital encounter during patients' first 100 days posttransplant. RESULTS Of the 880 recipients who experienced ≥ 1 SI, 58 (6.6%) died within 28 days and 22 (2.5%) within 10 days of an SI. In relation to 10-day mortality, SIRS was the most sensitive (91.3% [95% confidence interval {CI}, 72.0%-98.9%]) but least specific (35.0% [95% CI, 32.6%-37.5%]), whereas qSOFA was the most specific (90.5% [95% CI, 88.9%-91.9%]) but least sensitive (47.8% [95% CI, 26.8%-69.4%]). NEWS was moderately sensitive (78.3% [95% CI, 56.3%-92.5%]) and specific (70.2% [95% CI, 67.8%-72.4%]). CONCLUSIONS NEWS outperformed qSOFA and SIRS, but each criterion had low to moderate predictive accuracy, and the magnitude of the known limitations of qSOFA and SIRS was at least as large as in the general population. Our data suggest that population-specific criteria are needed for immunocompromised patients.
Collapse
Affiliation(s)
- Margaret L Lind
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Amanda I Phipps
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Stephen Mooney
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
- Harborview Injury Prevention and Research Center, Seattle, Washington, USA
| | - Catherine Liu
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Alison Fohner
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Kevin Patel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Masumi Ueda
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Steven A Pergam
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| |
Collapse
|
102
|
Alhmoud B, Bonnici T, Patel R, Melley D, Williams B, Banerjee A. Performance of universal early warning scores in different patient subgroups and clinical settings: a systematic review. BMJ Open 2021; 11:e045849. [PMID: 36044371 PMCID: PMC8039269 DOI: 10.1136/bmjopen-2020-045849] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/01/2021] [Accepted: 03/04/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To assess predictive performance of universal early warning scores (EWS) in disease subgroups and clinical settings. DESIGN Systematic review. DATA SOURCES Medline, CINAHL, Embase and Cochrane database of systematic reviews from 1997 to 2019. INCLUSION CRITERIA Randomised trials and observational studies of internal or external validation of EWS to predict deterioration (mortality, intensive care unit (ICU) transfer and cardiac arrest) in disease subgroups or clinical settings. RESULTS We identified 770 studies, of which 103 were included. Study designs and methods were inconsistent, with significant risk of bias (high: n=16 and unclear: n=64 and low risk: n=28). There were only two randomised trials. There was a high degree of heterogeneity in all subgroups and in national early warning score (I2=72%-99%). Predictive accuracy (mean area under the curve; 95% CI) was highest in medical (0.74; 0.74 to 0.75) and surgical (0.77; 0.75 to 0.80) settings and respiratory diseases (0.77; 0.75 to 0.80). Few studies evaluated EWS in specific diseases, for example, cardiology (n=1) and respiratory (n=7). Mortality and ICU transfer were most frequently studied outcomes, and cardiac arrest was least examined (n=8). Integration with electronic health records was uncommon (n=9). CONCLUSION Methodology and quality of validation studies of EWS are insufficient to recommend their use in all diseases and all clinical settings despite good performance of EWS in some subgroups. There is urgent need for consistency in methods and study design, following consensus guidelines for predictive risk scores. Further research should consider specific diseases and settings, using electronic health record data, prior to large-scale implementation. PROSPERO REGISTRATION NUMBER PROSPERO CRD42019143141.
Collapse
Affiliation(s)
- Baneen Alhmoud
- Institute of Health Informatics, University College London, London, UK
| | - Timothy Bonnici
- Institute of Health Informatics, University College London, London, UK
- University College London Hospitals NHS Trust, London, UK
| | - Riyaz Patel
- University College London Hospitals NHS Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
- Barts Health NHS Trust, London, UK
| | | | - Bryan Williams
- University College London Hospitals NHS Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK
- University College London Hospitals NHS Trust, London, UK
- Barts Health NHS Trust, London, UK
| |
Collapse
|
103
|
Çalhan A, Cicioğlu M, Ceylan A. EHealth monitoring testbed with fuzzy based early warning score system. Comput Methods Programs Biomed 2021; 202:106008. [PMID: 33640651 DOI: 10.1016/j.cmpb.2021.106008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 02/14/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND AND OBJECTIVE EHealth monitoring systems are able to save the persons' lives and track some vital physiological signs of patients, sportsmen, and soldiers for some purposes. Instant data tracking enables appropriate clinical interventions. The early warning score concept defines that specific vital human body signs that are considered together and gives the persons' health score. The patient's vital signs are periodically recorded with the Early Warning Score (EWS) system and the illness severity score of the patient is decided manually. The aim of the study is to monitor a person's health data continuously and calculate the EWS score thanks to the fuzzy logic. Therefore, the simulation as a testbed is constructed for real-time applications with ISO/IEEE 11073 Health informatics - Medical/health device communication standard. METHODS In our paper, a fuzzy-based early warning score system in the EHealth monitoring testbed is proposed. Real-time data are obtained from Riverbed Modeler simulation software with socket programming and stored in the InfluxDB using Node-Red and monitored on the remote desktop with Grafana. RESULTS Heart rate, body temperature, systolic blood pressure, respiratory rate, and SPO2 are taken into consideration in the fuzzy-based evaluation system for EWS. The data produced in the Riverbed has been provided in a realistic manner because the real human vital sign values are considered during generating vital signs. CONCLUSIONS Using real-time Riverbed Modeler health data with fuzzy-based EWS, a more realistic testbed platform is constructed in this study.
Collapse
Affiliation(s)
- Ali Çalhan
- Computer Engineering Department, Düzce University, Düzce, Turkey.
| | - Murtaza Cicioğlu
- Computer Engineering Department, Bursa Uludağ University, Bursa, Turkey.
| | - Arif Ceylan
- School of Electrical-Electronic and Computer Engineering, Düzce University, Düzce, Turkey
| |
Collapse
|
104
|
López-Izquierdo R, Martín-Rodríguez F, Santos Pastor JC, García Criado J, Fadrique Millán LN, Carbajosa Rodríguez V, Del Brío Ibáñez P, Del Pozo Vegas C. Can capillary lactate improve early warning scores in emergency department? An observational, prospective, multicentre study. Int J Clin Pract 2021; 75:e13779. [PMID: 33095958 DOI: 10.1111/ijcp.13779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 10/16/2020] [Indexed: 12/23/2022] Open
Abstract
AIMS To determine the prognostic usefulness of the National Early Warning Score-2 (NEWS2) and quick Sepsis-related Organ Failure Assessment (qSOFA) scores, in isolation and combined with capillary lactate (CL), using the new NEWS2-L and qSOFA-L scores to predict the 30-day mortality risk. METHODS Prospective, multicentre and observational study in patients across four EDs. We collected sets of vital signs and CL and subsequently calculated NEWS2, qSOFA, NEWS2-L and qSOFA-L scores when patients arrived at the ED. The main outcome measure was all-cause mortality 30 days from the index event. RESULTS A total of 941 patients were included. Thirty-six patients (3.8%) died within 30 days of the index event. A high CL level has not been linked to a higher mortality. The NEWS2 presented AUROC of 0.72 (95% CI: 0.62-0.81), qSOFA of 0.66 (95% CI: 0.56-0.77) (P < .001 in both cases) and CL 0.55 (95% CI: 0.42-0.65; P = .229) to predict 30-day mortality. The addition of CL to the scores analysed does not improve the results of the scores used in isolation. CONCLUSION NEWS2 and qSOFA scores are a very useful tool for assessing the status of patients who come to the ED in general for all types of patients in triage categories II and III and for detecting the 30-day mortality risk. CL determined systematically in the ED does not seem to provide information on the prognosis of the patients.
Collapse
Affiliation(s)
| | - Francisco Martín-Rodríguez
- Faculty of Medicine, Advanced Life Support, Emergency Medical Services, Valladolid University, Valladolid, Spain
| | | | - Jorge García Criado
- Emergency Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | | | | | | | - Carlos Del Pozo Vegas
- Emergency Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| |
Collapse
|
105
|
Arjan K, Forni LG, Venn RM, Hunt D, Hodgson LE. Clinical decision-making in older adults following emergency admission to hospital. Derivation and validation of a risk stratification score: OPERA. PLoS One 2021; 16:e0248477. [PMID: 33735316 PMCID: PMC7971558 DOI: 10.1371/journal.pone.0248477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 02/26/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES OF THE STUDY Demographic changes alongside medical advances have resulted in older adults accounting for an increasing proportion of emergency hospital admissions. Current measures of illness severity, limited to physiological parameters, have shortcomings in this cohort, partly due to patient complexity. This study aimed to derive and validate a risk score for acutely unwell older adults which may enhance risk stratification and support clinical decision-making. METHODS Data was collected from emergency admissions in patients ≥65 years from two UK general hospitals (April 2017- April 2018). Variables underwent regression analysis for in-hospital mortality and independent predictors were used to create a risk score. Performance was assessed on external validation. Secondary outcomes included seven-day mortality and extended hospital stay. RESULTS Derivation (n = 8,974) and validation (n = 8,391) cohorts were analysed. The model included the National Early Warning Score 2 (NEWS2), clinical frailty scale (CFS), acute kidney injury, age, sex, and Malnutrition Universal Screening Tool. For mortality, area under the curve for the model was 0.79 (95% CI 0.78-0.80), superior to NEWS2 0.65 (0.62-0.67) and CFS 0.76 (0.74-0.77) (P<0.0001). Risk groups predicted prolonged hospital stay: the highest risk group had an odds ratio of 9.7 (5.8-16.1) to stay >30 days. CONCLUSIONS Our simple validated model (Older Persons' Emergency Risk Assessment [OPERA] score) predicts in-hospital mortality and prolonged length of stay and could be easily integrated into electronic hospital systems, enabling automatic digital generation of risk stratification within hours of admission. Future studies may validate the OPERA score in external populations and consider an impact analysis.
Collapse
Affiliation(s)
- Khushal Arjan
- Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Lui G. Forni
- Department of Clinical & Experimental Medicine, Faculty of Health Sciences, University of Surrey, Guildford, United Kingdom
- Intensive Care Unit, Royal Surrey Hospital, Guildford, Surrey, United Kingdom
| | - Richard M. Venn
- Department of Medicine for the Elderly and Intensive Care, Worthing Hospital, Western Sussex Hospitals NHS Foundation Trust, Worthing, United Kingdom
| | - David Hunt
- Department of Medicine for the Elderly and Intensive Care, Worthing Hospital, Western Sussex Hospitals NHS Foundation Trust, Worthing, United Kingdom
| | - Luke Eliot Hodgson
- Department of Clinical & Experimental Medicine, Faculty of Health Sciences, University of Surrey, Guildford, United Kingdom
- Intensive Care, Worthing Hospital, Western Sussex Hospitals NHS Foundation Trust, Worthing, United Kingdom
- * E-mail:
| |
Collapse
|
106
|
Yu Z, Xu F, Chen D. Predictive value of Modified Early Warning Score (MEWS) and Revised Trauma Score (RTS) for the short-term prognosis of emergency trauma patients: a retrospective study. BMJ Open 2021; 11:e041882. [PMID: 33722865 PMCID: PMC7959230 DOI: 10.1136/bmjopen-2020-041882] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES This study aimed to assess the predictive value of the Modified Early Warning Score (MEWS) and Revised Trauma Score (RTS) for emergency trauma patients who died within 24 hours. DESIGN A retrospective, single-centred study. SETTING This study was conducted at a tertiary hospital in Southern China. PARTICIPANTS A total of 1739 patients with acute trauma, aged 16 years or older who presented to the emergency department from 1 November 2016 to 30 November 2019, were included. INTERVENTIONS NONE None. OUTCOME 24-hour mortality was the primary outcome of trauma. RESULTS 1739 patients were divided into the survival group (1709 patients,98.27%), and the non-survival group (30 patients,1.73%). Crude OR and adjusted OR of MEWS were 1.99, 95% CI (1.73 to 2.29), and 2.00, 95% CI (1.74 to 2.31), p<0.001, respectively. Crude OR and adjusted OR of RTS were 0.62, 95% CI (0.55 to 0.69) and 0.61, 95% CI (0.55 to 0.68), p<0.001, respectively. The area under the curve of MEWS was significantly higher than that of RTS (p=0.005): 0.927, 95% CI (0.914 to 0.939) vs 0.799, 95% CI (0.779 to 0.817). CONCLUSIONS Both MEWS and RTS were independent predictors of the short-term prognosis in emergency trauma patients, MEWS had better predictive efficacy.
Collapse
Affiliation(s)
- Zhejun Yu
- Division of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Feng Xu
- Division of Emergency Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Du Chen
- Division of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| |
Collapse
|
107
|
Demir MC, Ilhan B. Performance of the Pandemic Medical Early Warning Score (PMEWS), Simple Triage Scoring System (STSS) and Confusion, Uremia, Respiratory rate, Blood pressure and age ≥ 65 (CURB-65) score among patients with COVID-19 pneumonia in an emergency department triage setting: a retrospective study. SAO PAULO MED J 2021; 139:170-177. [PMID: 33681885 PMCID: PMC9632522 DOI: 10.1590/1516-3180.2020.0649.r1.10122020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 12/10/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Healthcare institutions are confronted with large numbers of patient admissions during large-scale or long-term public health emergencies like pandemics. Appropriate and effective triage is needed for effective resource use. OBJECTIVES To evaluate the effectiveness of the Pandemic Medical Early Warning Score (PMEWS), Simple Triage Scoring System (STSS) and Confusion, Uremia, Respiratory rate, Blood pressure and age ≥ 65 years (CURB-65) score in an emergency department (ED) triage setting. DESIGN AND SETTING Retrospective study in the ED of a tertiary-care university hospital in Düzce, Turkey. METHODS PMEWS, STSS and CURB-65 scores of patients diagnosed with COVID-19 pneumonia were calculated. Thirty-day mortality, intensive care unit (ICU) admission, mechanical ventilation (MV) need and outcomes were recorded. The predictive accuracy of the scores was assessed using receiver operating characteristic curve analysis. RESULTS One hundred patients with COVID-19 pneumonia were included. The 30-day mortality was 6%. PMEWS, STSS and CURB-65 showed high performance for predicting 30-day mortality (area under the curve: 0.968, 0.962 and 0.942, respectively). Age > 65 years, respiratory rate > 20/minute, oxygen saturation (SpO2) < 90% and ED length of stay > 4 hours showed associations with 30-day mortality (P < 0.05). CONCLUSIONS CURB-65, STSS and PMEWS scores are useful for predicting mortality, ICU admission and MV need among patients diagnosed with COVID-19 pneumonia. Advanced age, increased respiratory rate, low SpO2 and prolonged ED length of stay may increase mortality. Further studies are needed for developing the triage scoring systems, to ensure effective long-term use of healthcare service capacity during pandemics.
Collapse
Affiliation(s)
- Mehmet Cihat Demir
- MD. Assistant Professor, Department of Emergency Medicine, Düzce University School of Medicine, Düzce, Turkey.
| | - Buğra Ilhan
- MD. Attending Emergency Physician, Department of Emergency Medicine, University of Health Sciences, Bakırköy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey.
| |
Collapse
|
108
|
Branes H, Solevåg AL, Solberg MT. Pediatric early warning score versus a paediatric triage tool in the emergency department: A reliability study. Nurs Open 2021; 8:702-708. [PMID: 33570310 PMCID: PMC7877131 DOI: 10.1002/nop2.675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/08/2020] [Accepted: 10/20/2020] [Indexed: 11/24/2022] Open
Abstract
AIM In the paediatric emergency department (PED), it is important to correctly prioritize children for physician assessment. The pediatric early warning score (PEWS), although not a triage tool, is often used for PED triage. The scandinavian Rapid Emergency Triage and Treatment System-pediatric (RETTS-p) is a reliability tested triage tool. We aimed to compare PEWS and RETTS-p in a Norwegian PED. DESIGN A reliability study. METHODS The PED nurse routinely did PEWS observations, while the principal investigator concomitantly made RETTS-p observations. Inter-tool agreement was calculated for the complete PEWS and RETTS-p and for vital signs scores, disregarding the RETTS-p emergency symptoms and signs (ESS). RESULTS Rapid Emergency Triage and Treatment System-pediatric assigned a higher urgency than PEWS. The inter-tool agreement between PEWS and RETTS-p was low (weighted kappa [95% confidence interval [CI] = 0.32 [0.24-0.40]]). Weighted kappa (95% CI) was 0.50 (0.41-0.59) for PEWS and RETTS-p without ESS, indicating that PEWS is not equivalent to five-level triage tools.
Collapse
Affiliation(s)
- Hanne Branes
- Lovisenberg Deaconal University CollegeOsloNorway
| | - Anne Lee Solevåg
- Lovisenberg Deaconal University CollegeOsloNorway
- The Department of Paediatric and Adolescent MedicineAkershus University HospitalLørenskogNorway
| | | |
Collapse
|
109
|
Owen RK, Conroy SP, Taub N, Jones W, Bryden D, Pareek M, Faull C, Abrams KR, Davis D, Banerjee J. Comparing associations between frailty and mortality in hospitalised older adults with or without COVID-19 infection: a retrospective observational study using electronic health records. Age Ageing 2021; 50:307-316. [PMID: 32678866 PMCID: PMC7454252 DOI: 10.1093/ageing/afaa167] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The aim of this study was to describe outcomes in hospitalised older people with different levels of frailty and COVID-19 infection. METHODS We undertook a single-centre, retrospective cohort study examining COVID-19-related mortality using electronic health records, for older people (65 and over) with frailty, hospitalised with or without COVID-19 infection. Baseline covariates included demographics, early warning scores, Charlson Comorbidity Indices and frailty (Clinical Frailty Scale, CFS), linked to COVID-19 status. FINDINGS We analysed outcomes on 1,071 patients with COVID-19 test results (285 (27%) were positive for COVID-19). The mean age at ED arrival was 79.7 and 49.4% were female. All-cause mortality (by 30 days) rose from 9 (not frail) to 33% (severely frail) in the COVID-negative cohort but was around 60% for all frailty categories in the COVID-positive cohort. In adjusted analyses, the hazard ratio for death in those with COVID-19 compared to those without COVID-19 was 7.3 (95% CI: 3.00, 18.0) with age, comorbidities and illness severity making small additional contributions. INTERPRETATION In this study, frailty measured using the CFS appeared to make little incremental contribution to the hazard of dying in older people hospitalised with COVID-19 infection; illness severity and comorbidity had a modest association with the overall adjusted hazard of death, whereas confirmed COVID-19 infection dominated, with a sevenfold hazard for death.
Collapse
Affiliation(s)
- Rhiannon K Owen
- Health Sciences, University of Leicester, Leicester, Leicestershire, UK
| | - Simon P Conroy
- Department of Health Sciences, Centre for Medicine University of Leicester, University of Leicester School of Medicine, Leicester LE1 7HA, UK
| | - Nicholas Taub
- Department of Health Sciences, University of Leicester, Leicester LE1 6TP, UK
| | - Will Jones
- Emergency Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Daniele Bryden
- Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Manish Pareek
- Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Christina Faull
- Health Sciences, University of Leicester, Leicester, Leicestershire, UK
| | - Keith R Abrams
- Health Sciences, University of Leicester, Leicester, Leicestershire, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, University College London, London WC1B 5JU, UK
| | - Jay Banerjee
- University Hospitals of Leicester NHS Trust, Leicester, UK
| |
Collapse
|
110
|
Messerer DAC, Fauler M, Horneffer A, Schneider A, Keis O, Mauder LM, Radermacher P. Do medical students recognise the deteriorating patient by analysing their vital signs? A monocentric observational study based on the National Early Warning Score 2. BMJ Open 2021; 11:e044354. [PMID: 33622952 PMCID: PMC7907869 DOI: 10.1136/bmjopen-2020-044354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Assessment of the expertise of medical students in evaluating vital signs and their implications for the current risk of a patient, an appropriate monitoring frequency, and a proper clinical response. METHODS 251 second-year and 267 fifth-year medical students in a curriculum consisting of 6 years of medical school at Ulm University, Germany, were interviewed in a paper-based questionnaire. The students were asked to rate their proficiency in interpreting vital signs and to give pathological thresholds of vital signs. Based on the National Early Warning Score 2 (NEWS2), nine vital signs of fictional patients were created and students were asked to comment on their clinical risk, to set an appropriate monitoring frequency as well as a clinical response. RESULTS Interviewing medical students regarding each vital sign individually, the students indicated a pathological threshold in accordance with the NEWS2 for respiratory rate, temperature, and heart rate. By contrast, inappropriate pathological limits were given regarding oxygen saturation and systolic blood pressure. Translating the vital signs into nine fictional patients, fifth-year medical students overall chose an appropriate response in 78% (67%-78%, median±IQR). In detail, fifth-year students successfully identified patients at very high or low risk and allocated them accordingly. However, cases on the edge were often stratified inappropriately. For example, a fictional case with vital signs indicating a surging sepsis was frequently underappreciated (48.5%) and allocated to an insufficient clinical response by fifth-year students. CONCLUSIONS Recognising the healthy as well as the deteriorating patient is a key ability for future physicians. NEWS2-based education might be a valuable tool to assess and give feedback on student's knowledge in this vital professional activity.
Collapse
Affiliation(s)
- David Alexander Christian Messerer
- Institute of Anaesthesiologic Pathophysiology and Method Development, University Hospital Ulm, Ulm, Baden-Württemberg, Germany
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm, Baden-Württemberg, Germany
| | - Michael Fauler
- Institute of General Physiology, Ulm University, Ulm, Baden-Württemberg, Germany
| | - Astrid Horneffer
- Medical Faculty, Office of the Dean of Studies, Ulm University, Ulm, Baden-Württemberg, Germany
| | - Achim Schneider
- Medical Faculty, Office of the Dean of Studies, Ulm University, Ulm, Baden-Württemberg, Germany
| | - Oliver Keis
- Medical Faculty, Office of the Dean of Studies, Ulm University, Ulm, Baden-Württemberg, Germany
| | - Lea-Marie Mauder
- Medical Faculty, Ulm University, Ulm, Baden-Württemberg, Germany
| | - Peter Radermacher
- Institute of Anaesthesiologic Pathophysiology and Method Development, University Hospital Ulm, Ulm, Baden-Württemberg, Germany
| |
Collapse
|
111
|
Richardson D, Faisal M, Fiori M, Beatson K, Mohammed M. Use of the first National Early Warning Score recorded within 24 hours of admission to estimate the risk of in-hospital mortality in unplanned COVID-19 patients: a retrospective cohort study. BMJ Open 2021; 11:e043721. [PMID: 33619194 PMCID: PMC7902318 DOI: 10.1136/bmjopen-2020-043721] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Although the National Early Warning Score (NEWS) and its latest version NEWS2 are recommended for monitoring deterioration in patients admitted to hospital, little is known about their performance in COVID-19 patients. We aimed to compare the performance of the NEWS and NEWS2 in patients with COVID-19 versus those without during the first phase of the pandemic. DESIGN A retrospective cross-sectional study. SETTING Two acute hospitals (Scarborough and York) are combined into a single dataset and analysed collectively. PARTICIPANTS Adult (≥18 years) non-elective admissions discharged between 11 March 2020 and 13 June 2020 with an index or on-admission NEWS2 electronically recorded within ±24 hours of admission to predict mortality at four time points (in-hospital, 24 hours, 48 hours and 72 hours) in COVID-19 versus non-COVID-19 admissions. RESULTS Out of 6480 non-elective admissions, 620 (9.6%) had a diagnosis of COVID-19. They were older (73.3 vs 67.7 years), more often male (54.7% vs 50.1%), had higher index NEWS (4 vs 2.5) and NEWS2 (4.6 vs 2.8) scores and higher in-hospital mortality (32.1% vs 5.8%). The c-statistics for predicting in-hospital mortality in COVID-19 admissions was significantly lower using NEWS (0.64 vs 0.74) or NEWS2 (0.64 vs 0.74), however, these differences reduced at 72hours (NEWS: 0.75 vs 0.81; NEWS2: 0.71 vs 0.81), 48 hours (NEWS: 0.78 vs 0.81; NEWS2: 0.76 vs 0.82) and 24hours (NEWS: 0.84 vs 0.84; NEWS2: 0.86 vs 0.84). Increasing NEWS2 values reflected increased mortality, but for any given value the absolute risk was on average 24% higher (eg, NEWS2=5: 36% vs 9%). CONCLUSIONS The index or on-admission NEWS and NEWS2 offers lower discrimination for COVID-19 admissions versus non-COVID-19 admissions. The index NEWS2 was not proven to be better than the index NEWS. For each value of the index NEWS/NEWS2, COVID-19 admissions had a substantially higher risk of mortality than non-COVID-19 admissions which reflects the increased baseline mortality risk of COVID-19.
Collapse
Affiliation(s)
- Donald Richardson
- Renal Medicine, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Muhammad Faisal
- Faculty of Health Studies, University of Bradford, Bradford, UK
- Bradford Institute for Health Research, Bradford, UK
- NIHR Yorkshire and Humber Patient Safety Translational Research Centre (YHPSTRC), Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
| | - Massimo Fiori
- York Teaching Hospital NHS Foundation Trust, York, UK
| | - Kevin Beatson
- York Teaching Hospital NHS Foundation Trust, York, UK
| | - Mohammed Mohammed
- Faculty of Health Studies, University of Bradford, Bradford, UK
- The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| |
Collapse
|
112
|
Schwab P, Mehrjou A, Parbhoo S, Celi LA, Hetzel J, Hofer M, Schölkopf B, Bauer S. Real-time prediction of COVID-19 related mortality using electronic health records. Nat Commun 2021; 12:1058. [PMID: 33594046 PMCID: PMC7886884 DOI: 10.1038/s41467-020-20816-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/15/2020] [Indexed: 12/15/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a respiratory disease with rapid human-to-human transmission caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Due to the exponential growth of infections, identifying patients with the highest mortality risk early is critical to enable effective intervention and prioritisation of care. Here, we present the COVID-19 early warning system (CovEWS), a risk scoring system for assessing COVID-19 related mortality risk that we developed using data amounting to a total of over 2863 years of observation time from a cohort of 66 430 patients seen at over 69 healthcare institutions. On an external cohort of 5005 patients, CovEWS predicts mortality from 78.8% (95% confidence interval [CI]: 76.0, 84.7%) to 69.4% (95% CI: 57.6, 75.2%) specificity at sensitivities greater than 95% between, respectively, 1 and 192 h prior to mortality events. CovEWS could enable earlier intervention, and may therefore help in preventing or mitigating COVID-19 related mortality.
Collapse
Affiliation(s)
| | - Arash Mehrjou
- Max Planck Institute for Intelligent Systems, Tübingen, Germany
- ETH Zurich, Zurich, Switzerland
| | - Sonali Parbhoo
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, USA
| | - Leo Anthony Celi
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
- MIT Critical Data, Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Harvard-MIT Health Sciences and Technology, Cambridge, USA
| | - Jürgen Hetzel
- Department of Medical Oncology and Pneumology, University Hospital of Tübingen, Tübingen, Germany
- Department of Pneumology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Markus Hofer
- Department of Pneumology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Bernhard Schölkopf
- Max Planck Institute for Intelligent Systems, Tübingen, Germany
- ETH Zurich, Zurich, Switzerland
| | - Stefan Bauer
- Max Planck Institute for Intelligent Systems, Tübingen, Germany
- CIFAR Azrieli Global Scholar, Toronto, Canada
| |
Collapse
|
113
|
Bolourani S, Brenner M, Wang P, McGinn T, Hirsch JS, Barnaby D, Zanos TP. A Machine Learning Prediction Model of Respiratory Failure Within 48 Hours of Patient Admission for COVID-19: Model Development and Validation. J Med Internet Res 2021; 23:e24246. [PMID: 33476281 PMCID: PMC7879728 DOI: 10.2196/24246] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 12/18/2020] [Accepted: 01/18/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Predicting early respiratory failure due to COVID-19 can help triage patients to higher levels of care, allocate scarce resources, and reduce morbidity and mortality by appropriately monitoring and treating the patients at greatest risk for deterioration. Given the complexity of COVID-19, machine learning approaches may support clinical decision making for patients with this disease. OBJECTIVE Our objective is to derive a machine learning model that predicts respiratory failure within 48 hours of admission based on data from the emergency department. METHODS Data were collected from patients with COVID-19 who were admitted to Northwell Health acute care hospitals and were discharged, died, or spent a minimum of 48 hours in the hospital between March 1 and May 11, 2020. Of 11,525 patients, 933 (8.1%) were placed on invasive mechanical ventilation within 48 hours of admission. Variables used by the models included clinical and laboratory data commonly collected in the emergency department. We trained and validated three predictive models (two based on XGBoost and one that used logistic regression) using cross-hospital validation. We compared model performance among all three models as well as an established early warning score (Modified Early Warning Score) using receiver operating characteristic curves, precision-recall curves, and other metrics. RESULTS The XGBoost model had the highest mean accuracy (0.919; area under the curve=0.77), outperforming the other two models as well as the Modified Early Warning Score. Important predictor variables included the type of oxygen delivery used in the emergency department, patient age, Emergency Severity Index level, respiratory rate, serum lactate, and demographic characteristics. CONCLUSIONS The XGBoost model had high predictive accuracy, outperforming other early warning scores. The clinical plausibility and predictive ability of XGBoost suggest that the model could be used to predict 48-hour respiratory failure in admitted patients with COVID-19.
Collapse
Affiliation(s)
- Siavash Bolourani
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Max Brenner
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Ping Wang
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Thomas McGinn
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Jamie S Hirsch
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Douglas Barnaby
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Theodoros P Zanos
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| |
Collapse
|
114
|
Abstract
It is recognised that infective endocarditis is frequently a challenging diagnosis to make, as it may present with a range of non-specific symptoms. A middle-aged man was admitted with an 8-day history of profuse non-bloody diarrhoea and vomiting. He had no medical history and no identifiable risk factors for infective endocarditis, and so this in combination with the patient's atypical symptoms presented a diagnostic challenge. The patient was eventually diagnosed with a Staphylococcus aureus right-sided infective endocarditis. This case report explores the events which led to this diagnosis and demonstrates a number of unique learning points. It also highlights the importance of maintaining an open mind and being prepared to revise an initial diagnosis in the face of medical uncertainty.
Collapse
Affiliation(s)
| | | | - Waheed Akhtar
- Lincolnshire Heart Centre, United Lincolnshire Hospitals NHS Trust, Lincoln, Lincolnshire, UK
| |
Collapse
|
115
|
Carr E, Bendayan R, Bean D, Stammers M, Wang W, Zhang H, Searle T, Kraljevic Z, Shek A, Phan HTT, Muruet W, Gupta RK, Shinton AJ, Wyatt M, Shi T, Zhang X, Pickles A, Stahl D, Zakeri R, Noursadeghi M, O'Gallagher K, Rogers M, Folarin A, Karwath A, Wickstrøm KE, Köhn-Luque A, Slater L, Cardoso VR, Bourdeaux C, Holten AR, Ball S, McWilliams C, Roguski L, Borca F, Batchelor J, Amundsen EK, Wu X, Gkoutos GV, Sun J, Pinto A, Guthrie B, Breen C, Douiri A, Wu H, Curcin V, Teo JT, Shah AM, Dobson RJB. Evaluation and improvement of the National Early Warning Score (NEWS2) for COVID-19: a multi-hospital study. BMC Med 2021; 19:23. [PMID: 33472631 PMCID: PMC7817348 DOI: 10.1186/s12916-020-01893-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/16/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The National Early Warning Score (NEWS2) is currently recommended in the UK for the risk stratification of COVID-19 patients, but little is known about its ability to detect severe cases. We aimed to evaluate NEWS2 for the prediction of severe COVID-19 outcome and identify and validate a set of blood and physiological parameters routinely collected at hospital admission to improve upon the use of NEWS2 alone for medium-term risk stratification. METHODS Training cohorts comprised 1276 patients admitted to King's College Hospital National Health Service (NHS) Foundation Trust with COVID-19 disease from 1 March to 30 April 2020. External validation cohorts included 6237 patients from five UK NHS Trusts (Guy's and St Thomas' Hospitals, University Hospitals Southampton, University Hospitals Bristol and Weston NHS Foundation Trust, University College London Hospitals, University Hospitals Birmingham), one hospital in Norway (Oslo University Hospital), and two hospitals in Wuhan, China (Wuhan Sixth Hospital and Taikang Tongji Hospital). The outcome was severe COVID-19 disease (transfer to intensive care unit (ICU) or death) at 14 days after hospital admission. Age, physiological measures, blood biomarkers, sex, ethnicity, and comorbidities (hypertension, diabetes, cardiovascular, respiratory and kidney diseases) measured at hospital admission were considered in the models. RESULTS A baseline model of 'NEWS2 + age' had poor-to-moderate discrimination for severe COVID-19 infection at 14 days (area under receiver operating characteristic curve (AUC) in training cohort = 0.700, 95% confidence interval (CI) 0.680, 0.722; Brier score = 0.192, 95% CI 0.186, 0.197). A supplemented model adding eight routinely collected blood and physiological parameters (supplemental oxygen flow rate, urea, age, oxygen saturation, C-reactive protein, estimated glomerular filtration rate, neutrophil count, neutrophil/lymphocyte ratio) improved discrimination (AUC = 0.735; 95% CI 0.715, 0.757), and these improvements were replicated across seven UK and non-UK sites. However, there was evidence of miscalibration with the model tending to underestimate risks in most sites. CONCLUSIONS NEWS2 score had poor-to-moderate discrimination for medium-term COVID-19 outcome which raises questions about its use as a screening tool at hospital admission. Risk stratification was improved by including readily available blood and physiological parameters measured at hospital admission, but there was evidence of miscalibration in external sites. This highlights the need for a better understanding of the use of early warning scores for COVID.
Collapse
Affiliation(s)
- Ewan Carr
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, 16 De Crespigny Park, London, SE5 8AF, UK.
| | - Rebecca Bendayan
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, 16 De Crespigny Park, London, SE5 8AF, UK
- NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
| | - Daniel Bean
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, 16 De Crespigny Park, London, SE5 8AF, UK
- Health Data Research UK London, University College London, London, UK
| | - Matt Stammers
- Clinical Informatics Research Unit, University of Southampton, Coxford Rd., Southampton, SO16 5AF, UK
- NIHR Biomedical Research Centre at University Hospital Southampton NHS Trust, Coxford Road, Southampton, UK
- UHS Digital, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Wenjuan Wang
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Huayu Zhang
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Thomas Searle
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, 16 De Crespigny Park, London, SE5 8AF, UK
- NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
| | - Zeljko Kraljevic
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, 16 De Crespigny Park, London, SE5 8AF, UK
| | - Anthony Shek
- Department of Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Hang T T Phan
- Clinical Informatics Research Unit, University of Southampton, Coxford Rd., Southampton, SO16 5AF, UK
- NIHR Biomedical Research Centre at University Hospital Southampton NHS Trust, Coxford Road, Southampton, UK
| | - Walter Muruet
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Rishi K Gupta
- UCL Institute for Global Health, University College London Hospitals NHS Trust, London, UK
| | - Anthony J Shinton
- UHS Digital, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Mike Wyatt
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Ting Shi
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Xin Zhang
- Department of Pulmonary and Critical Care Medicine, People's Liberation Army Joint Logistic Support Force 920th Hospital, Kunming, Yunnan, China
| | - Andrew Pickles
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, 16 De Crespigny Park, London, SE5 8AF, UK
- NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
| | - Daniel Stahl
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, 16 De Crespigny Park, London, SE5 8AF, UK
| | - Rosita Zakeri
- King's College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, SE5 9NU, UK
| | - Mahdad Noursadeghi
- UCL Division of Infection and Immunity, University College London Hospitals NHS Trust, London, UK
| | - Kevin O'Gallagher
- King's College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, SE5 9NU, UK
| | - Matt Rogers
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Amos Folarin
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, 16 De Crespigny Park, London, SE5 8AF, UK
- Health Data Research UK London, University College London, London, UK
- Institute of Health Informatics, University College London, London, UK
- NIHR Biomedical Research Centre at University College London Hospitals NHS Foundation Trust, London, UK
| | - Andreas Karwath
- College of Medical and Dental Sciences, Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Health Data Research UK Midlands, Birmingham, UK
| | - Kristin E Wickstrøm
- Department of Medical Biochemistry, Blood Cell Research Group, Oslo University Hospital, Oslo, Norway
| | - Alvaro Köhn-Luque
- Oslo Centre for Biostatistics and Epidemiology, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Luke Slater
- College of Medical and Dental Sciences, Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Health Data Research UK Midlands, Birmingham, UK
| | - Victor Roth Cardoso
- College of Medical and Dental Sciences, Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Health Data Research UK Midlands, Birmingham, UK
| | | | - Aleksander Rygh Holten
- Department of Acute Medicine, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Simon Ball
- Health Data Research UK Midlands, Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Chris McWilliams
- Department of Engineering Mathematics, University of Bristol, Bristol, UK
| | - Lukasz Roguski
- Health Data Research UK London, University College London, London, UK
- Institute of Health Informatics, University College London, London, UK
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Florina Borca
- Clinical Informatics Research Unit, University of Southampton, Coxford Rd., Southampton, SO16 5AF, UK
- NIHR Biomedical Research Centre at University Hospital Southampton NHS Trust, Coxford Road, Southampton, UK
- UHS Digital, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - James Batchelor
- Clinical Informatics Research Unit, University of Southampton, Coxford Rd., Southampton, SO16 5AF, UK
| | - Erik Koldberg Amundsen
- Department of Medical Biochemistry, Blood Cell Research Group, Oslo University Hospital, Oslo, Norway
| | - Xiaodong Wu
- Department of Pulmonary and Critical Care Medicine, Shanghai East Hospital, Tongji University, Shanghai, China
- Department of Pulmonary and Critical Care Medicine, Taikang Tongji Hospital, Wuhan, China
| | - Georgios V Gkoutos
- College of Medical and Dental Sciences, Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Health Data Research UK Midlands, Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jiaxing Sun
- Department of Pulmonary and Critical Care Medicine, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Ashwin Pinto
- UHS Digital, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Bruce Guthrie
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Cormac Breen
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Abdel Douiri
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Honghan Wu
- Health Data Research UK London, University College London, London, UK
- Institute of Health Informatics, University College London, London, UK
| | - Vasa Curcin
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - James T Teo
- Department of Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Ajay M Shah
- King's College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, SE5 9NU, UK
| | - Richard J B Dobson
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, 16 De Crespigny Park, London, SE5 8AF, UK
- NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
- Health Data Research UK London, University College London, London, UK
- Institute of Health Informatics, University College London, London, UK
- NIHR Biomedical Research Centre at University College London Hospitals NHS Foundation Trust, London, UK
| |
Collapse
|
116
|
García-Del-Valle S, Arnal-Velasco D, Molina-Mendoza R, Gómez-Arnau JI. Update on early warning scores. Best Pract Res Clin Anaesthesiol 2021; 35:105-113. [PMID: 33742570 DOI: 10.1016/j.bpa.2020.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/19/2020] [Indexed: 12/23/2022]
Abstract
Early warning scores (EWS) have the objective to provide a preventive approach for detecting those patients in general wards at risk of deterioration before it begins. Well implemented and combined with a tiered response, the EWS expect to be a relevant tool for patient safety. Most of the evidence for their use has been published for the general EWS. Their strengths, such as objectivity and systematic response, health provider training, universal applicability and automatization potential need to be highlighted to counterbalance the weakness and limitations that have also been described. The near future will probably increase availability of EWS, reliability and predictive value through the spread and acceptability of continuous monitoring in general ward, its integration in decision support algorithms with automatic alerts and the elaboration of temporal vital signs patterns that will finally allow to perform a personal modelling depending on individual patient characteristics.
Collapse
|
117
|
Huespe I, Carboni Bisso I, Gemelli NA, Terrasa SA, Di Stefano S, Burgos V, Sinner J, Oubiña M, Bezzati M, Delgado P, Las Heras M, Risk MR. Design and development of an early warning score for covid-19 hospitalized patients. Medicina (B Aires) 2021; 81:508-526. [PMID: 34453792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023] Open
Abstract
Pandemics pose a major challenge for public health preparedness, requiring a coordinated international response and the development of solid containment plans. Early and accurate identification of high-risk patients in the course of the current COVID-19 pandemic is vital for planning and making proper use of available resources. The purpose of this study was to identify the key variables that account for worse outcomes to create a predictive model that could be used effectively for triage. Through literature review, 44 variables that could be linked to an unfavorable course of COVID-19 disease were obtained, including clinical, laboratory, and X-ray variables. These were used for a 2-round modified Delphi processing with 14 experts to select a final list of variables with the greatest predictive power for the construction of a scoring system, leading to the creation of a new scoring system: the COVID-19 Severity Index. The analysis of the area under the curve for the COVID-19 Severity Index was 0.94 to predict the need for ICU admission in the following 24 hours against 0.80 for NEWS-2. Additionally, the digital medical record of the Hospital Italiano de Buenos Aires was electronically set for an automatic calculation and constant update of the COVID-19 Severity Index. Specifically designed for the current COVID-19 pandemic, COVID-19 Severity Index could be used as a reliable tool for strategic planning, organization, and administration of resources by easily identifying hospitalized patients with a greater need of intensive care.
Collapse
Affiliation(s)
- Iván Huespe
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina. E-mail:
- Instituto de Medicina Traslacional e Ingeniería Biomédica, HIBA, IUHI, CONICET, Buenos Aires, Argentina
| | | | | | | | | | - Valeria Burgos
- Instituto de Medicina Traslacional e Ingeniería Biomédica, HIBA, IUHI, CONICET, Buenos Aires, Argentina
| | - Jorge Sinner
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mailen Oubiña
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Marina Bezzati
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Pablo Delgado
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Marcelo R Risk
- Instituto de Medicina Traslacional e Ingeniería Biomédica, HIBA, IUHI, CONICET, Buenos Aires, Argentina
| |
Collapse
|
118
|
Manetti S, Vainieri M, Guidotti E, Zuccarino S, Ferré F, Morelli MS, Emdin M. Research protocol for the validation of a new portable technology for real-time continuous monitoring of Early Warning Score (EWS) in hospital practice and for an early-stage multistakeholder assessment. BMJ Open 2020; 10:e040738. [PMID: 33273048 PMCID: PMC7716668 DOI: 10.1136/bmjopen-2020-040738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION The real-time continuous monitoring of vital parameters in patients affected by multiple chronic conditions and/or COVID-19 can lead to several benefits to the Italian National Healthcare System (IT-NHS). The UBiquitous Integrated CARE (UBICARE) technology is a novel health digital platform at the validation stage in hospital setting. UBICARE might support the urgent need for digitalisation and early intervention, as well as minimise the face-to-face delivery of care in both hospital and community-based care settings. This research protocol aims to design an early-stage assessment of the multidimensional impact induced by UBICARE within the IT-NHS alongside technology validation in a hospital ward. METHODS AND ANALYSIS The targeted patients will be medium/high-risk hypertensive individuals as an illustrative first example of how UBICARE might bring benefits to susceptible patients. A mixed-method study will be applied to incorporate to the validation study a multistakeholder perspective, including perceived patient experiences and preferences, and facilitate technology adoption. First, semistructured interviews will be undertaken with a variety of stakeholders including clinicians, health managers and policy-makers to capture views on the likely technology utility, economic sustainability, impact of adoption in hospital practice and alternative adoption scenarios. Second, a monocentric, non-randomised and non-comparative clinical study, supplemented by the administration of standardised usability questionnaires to patients and health professionals, will validate the use of UBICARE in hospital practice. Finally, the results of the previous stages will be discussed in a multidisciplinary-facilitated workshop with IT-NHS relevant stakeholders to reconcile stakeholders' perspectives. Limitations include a non-random recruitment strategy in the clinical study, small sample size of the key stakeholders and potential stakeholder recruitment bias introduced by the research technique. ETHICS AND DISSEMINATION The Ethics Committee for Clinical Experimentation of Tuscany Region approved the protocol. Participation in this study is voluntary. Study results will be disseminated through peer-reviewed publications and academic conferences.
Collapse
Affiliation(s)
- Stefania Manetti
- Management and Health Laboratory, Institute of Management and EMbeDS Department, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Milena Vainieri
- Management and Health Laboratory, Institute of Management and EMbeDS Department, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Elisa Guidotti
- Management and Health Laboratory, Institute of Management and EMbeDS Department, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Sara Zuccarino
- Management and Health Laboratory, Institute of Management and EMbeDS Department, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Francesca Ferré
- Management and Health Laboratory, Institute of Management and EMbeDS Department, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- C.O.U of Cardiology and Cardiovascular Medicine, Gabriele Monasterio Foundation, Pisa, Italy
| |
Collapse
|
119
|
Greenhalgh T, Thompson P, Weiringa S, Neves AL, Husain L, Dunlop M, Rushforth A, Nunan D, de Lusignan S, Delaney B. What items should be included in an early warning score for remote assessment of suspected COVID-19? qualitative and Delphi study. BMJ Open 2020; 10:e042626. [PMID: 33184088 PMCID: PMC7662139 DOI: 10.1136/bmjopen-2020-042626] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND To develop items for an early warning score (RECAP: REmote COVID-19 Assessment in Primary Care) for patients with suspected COVID-19 who need escalation to next level of care. METHODS The study was based in UK primary healthcare. The mixed-methods design included rapid review, Delphi panel, interviews, focus groups and software development. Participants were 112 primary care clinicians and 50 patients recovered from COVID-19, recruited through social media, patient groups and snowballing. Using rapid literature review, we identified signs and symptoms which are commoner in severe COVID-19. Building a preliminary set of items from these, we ran four rounds of an online Delphi panel with 72 clinicians, the last incorporating fictional vignettes, collating data on R software. We refined the items iteratively in response to quantitative and qualitative feedback. Items in the penultimate round were checked against narrative interviews with 50 COVID-19 patients. We required, for each item, at least 80% clinician agreement on relevance, wording and cut-off values, and that the item addressed issues and concerns raised by patients. In focus groups, 40 clinicians suggested further refinements and discussed workability of the instrument in relation to local resources and care pathways. This informed design of an electronic template for primary care systems. RESULTS The prevalidation RECAP-V0 comprises a red flag alert box and 10 assessment items: pulse, shortness of breath or respiratory rate, trajectory of breathlessness, pulse oximeter reading (with brief exercise test if appropriate) or symptoms suggestive of hypoxia, temperature or fever symptoms, duration of symptoms, muscle aches, new confusion, shielded list and known risk factors for poor outcome. It is not yet known how sensitive or specific it is. CONCLUSIONS Items on RECAP-V0 align strongly with published evidence, clinical judgement and patient experience. The validation phase of this study is ongoing. TRIAL REGISTRATION NUMBER NCT04435041.
Collapse
Affiliation(s)
- Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul Thompson
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Sietse Weiringa
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ana Luisa Neves
- Institute of Global Health Innovation, Imperial College London, London, UK
| | - Laiba Husain
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Alexander Rushforth
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David Nunan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brendan Delaney
- Institute of Global Health Innovation, Imperial College London, London, UK
| |
Collapse
|
120
|
Bredie SJH, van Goor H. [ Early Warning Scores at the nursing ward: what do you really want to know?]. Ned Tijdschr Geneeskd 2020; 164:D5305. [PMID: 33331710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Early Warning Scores (EWSs) are based on the assumption that critical illness is preceded by physical deterioration. The question is whether measuring 5 vital parameters several times a day can predict changes in a highly complex and dynamic clinical condition. Little evidence has yet been found for clinical superiority of current EWSs over good clinical assessment. If we want to predict better and act structurally proactively, the measurement frequency of vital parameters must increase and much more complex scores are needed to identify specific changes in individual patients at an early stage. It is plausible that the many innovative developments in this area are the stepping stone to an era in which care in regular nursing wards is increasingly directed in the right direction by predictive algorithms. Integration of such super EWSs in new working methods may contribute to continuously adaptive care that is ultimately better and more efficient and relieves the care provider.
Collapse
Affiliation(s)
- S J H Bredie
- Radboudumc, afd. Interne Geneeskunde, Nijmegen
- Contact: S. J.H. Bredie
| | | |
Collapse
|
121
|
Dyess-Nugent P, Bouzid J, Roberson A, Quint-Bouzid M, Nelson DB. Development of a Quality Indicator to Measure Urgent Requests to the Bedside. Nurs Womens Health 2020; 24:404-412. [PMID: 33166492 DOI: 10.1016/j.nwh.2020.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 07/21/2020] [Accepted: 09/01/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To develop a quality indicator describing the response time to an urgent request for a physician to the bedside of a pregnant or postpartum woman and to identify opportunities for improvement in care timeliness for women with worsening serious clinical conditions. DESIGN Evidence-based quality improvement project using the Iowa Model-Revised framework to develop a maternal care quality indicator. SETTING Labor and delivery, antepartum, and mother/baby units in a large urban safety-net hospital preparing for a state level of maternal care designation survey. PARTICIPANTS All nurses and physicians caring for hospitalized pregnant and postpartum women participated in implementation. INTERVENTION/MEASUREMENTS Physician response time was measured as the elapsed time from a nurse's urgent request for a physician and the presence of a physician at the bedside of a woman in one of the identified units, as recorded in the electronic health record. RESULTS Physician response time to an urgent request to the bedside was documented 179 times during the first 3 months after implementation. Physician presence at the bedside within 30 minutes of a request was recorded in more than 99% of these events. CONCLUSION Physicians' responses to early warning signs within our facility were timely and within the parameters established by the Texas state-mandated criteria for a Level IV maternal care hospital. Response time as documented in the electronic health record provides an important quality indicator of maternal care in the inpatient setting.
Collapse
|
122
|
Covino M, Sandroni C, Santoro M, Sabia L, Simeoni B, Bocci MG, Ojetti V, Candelli M, Antonelli M, Gasbarrini A, Franceschi F. Predicting intensive care unit admission and death for COVID-19 patients in the emergency department using early warning scores. Resuscitation 2020; 156:84-91. [PMID: 32918985 PMCID: PMC7480278 DOI: 10.1016/j.resuscitation.2020.08.124] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/13/2020] [Accepted: 08/26/2020] [Indexed: 02/08/2023]
Abstract
AIMS To identify the most accurate early warning score (EWS) for predicting an adverse outcome in COVID-19 patients admitted to the emergency department (ED). METHODS In adult consecutive patients admitted (March 1-April 15, 2020) to the ED of a major referral centre for COVID-19, we retrospectively calculated NEWS, NEWS2, NEWS-C, MEWS, qSOFA, and REMS from physiological variables measured on arrival. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and the area under the receiver operating characteristic (AUROC) curve of each EWS for predicting admission to the intensive care unit (ICU) and death at 48 h and 7 days were calculated. RESULTS We included 334 patients (119 [35.6%] females, median age 66 [54-78] years). At 7 days, the rates of ICU admission and death were 56/334 (17%) and 26/334 (7.8%), respectively. NEWS was the most accurate predictor of ICU admission within 7 days (AUROC 0.783 [95% CI, 0.735-0.826]; sensitivity 71.4 [57.8-82.7]%; NPV 93.1 [89.8-95.3]%), while REMS was the most accurate predictor of death within 7 days (AUROC 0.823 [0.778-0.863]; sensitivity 96.1 [80.4-99.9]%; NPV 99.4[96.2-99.9]%). Similar results were observed for ICU admission and death at 48 h. NEWS and REMS were as accurate as the triage system used in our ED. MEWS and qSOFA had the lowest overall accuracy for both outcomes. CONCLUSION In our single-centre cohort of COVID-19 patients, NEWS and REMS measured on ED arrival were the most sensitive predictors of 7-day ICU admission or death. EWS could be useful to identify patients with low risk of clinical deterioration.
Collapse
Affiliation(s)
- Marcello Covino
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Michele Santoro
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Luca Sabia
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Benedetta Simeoni
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Maria Grazia Bocci
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | - Veronica Ojetti
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Marcello Candelli
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Massimo Antonelli
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Institute of Internal Medicine and Gastroenterology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Franceschi
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Institute of Emergency Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
123
|
Lee JR, Jung YK, Kim HJ, Koh Y, Lim CM, Hong SB, Huh JW. Derivation and validation of modified early warning score plus SpO2/FiO2 score for predicting acute deterioration of patients with hematological malignancies. Korean J Intern Med 2020; 35:1477-1488. [PMID: 32114753 PMCID: PMC7652654 DOI: 10.3904/kjim.2018.438] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 06/22/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND/AIMS Scoring systems play an important role in predicting intensive care unit (ICU) admission or estimating the risk of death in critically ill patients with hematological malignancies. We evaluated the modified early warning score (MEWS) for predicting ICU admissions and in-hospital mortality among at-risk patients with hematological malignancies and developed an optimized MEWS. METHODS We retrospectively analyzed derivation cohort patients with hematological malignancies who were managed by a medical emergency team (MET) in the general ward and prospectively validated the data. We compared the traditional MEWS with the MEWS plus SpO2/FiO2 (MEWS_SF) score, which were calculated at the time of MET contact. RESULTS In the derivation cohort, the areas under the receiver-operating characteristic (AUROC) curves were 0.81 for the MEWS (95% confidence interval [CI], 0.76 to 0.87) and 0.87 for the MEWS_SF score (95% CI, 0.87 to 0.92) for predicting ICU admission. The AUROC curves were 0.70 for the MEWS (95% CI, 0.63 to 0.77) and 0.76 for the MEWS_SF score (95% CI, 0.70 to 0.83) for predicting in-hospital mortality. In the validation cohort, the AUROC curves were 0.71 for the MEWS (95% CI, 0.66 to 0.77) and 0.83 for the MEWS_SF score (95% CI, 0.78 to 0.87) for predicting ICU admission. The AUROC curves were 0.64 for the MEWS (95% CI, 0.57 to 0.70) and 0.74 for the MEWS_SF score (95% CI, 0.69 to 0.80) for predicting in-hospital mortality. CONCLUSION Compared to the traditional MEWS, the MEWS_SF score may be a useful tool that can be used in the general ward to identify deteriorating patients with hematological malignancies.
Collapse
Affiliation(s)
- Ju-Ry Lee
- Medical Emergency Team, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Youn-Kyoung Jung
- Medical Emergency Team, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwa Jung Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Correspondence to Jin Won Huh, M.D. Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-3985 Fax: +82-2-3010-6968 E-mail:
| |
Collapse
|
124
|
Mitchell EJ, Qureshi ZP, Were F, Daniels J, Gwako G, Osoti A, Opira J, Bradshaw L, Oliver M, Pallotti P, Ojha S. Feasibility of using an Early Warning Score for preterm or low birthweight infants in a low-resource setting: results of a mixed-methods study at a national referral hospital in Kenya. BMJ Open 2020; 10:e039061. [PMID: 33115899 PMCID: PMC7594348 DOI: 10.1136/bmjopen-2020-039061] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Fifteen million babies are born prematurely, before 37 weeks gestational age, globally. More than 80% of these are in sub-Saharan Africa and Asia. 35% of all deaths in the first month of life are due to prematurity and the neonatal mortality rate is eight times higher in low-income and middle-income countries (LMICs) than in Europe. Early Warning Scores (EWS) are a way of recording vital signs using standardised charts to easily identify adverse clinical signs and escalate care appropriately. A range of EWS have been developed for neonates, though none in LMICs. This paper reports the findings of early work to examine if the use of EWS is feasible in LMICs. METHODS We conducted an observational study to understand current practices for monitoring of preterm infants at a large national referral hospital in Nairobi, Kenya. Using hospital records, data were collected over an 8-week period in 2019 on all live born infants born at <37 weeks and/or <2500 g (n=294, 255 mothers) in the first week of life. Using a chart adopted from the EWS developed by the British Association of Perinatal Medicine, we plotted infants' vital signs. In addition, we held group discussions with stakeholders in Kenya to examine opinions on use of EWS. RESULTS Recording of vital signs was variable; only 63% of infants had at least one temperature recorded and 53% had at least one heart rate and respiratory rate recorded. Stakeholders liked the traffic-light system and simplicity of the chart, though recognised challenges, such as staffing levels and ability to print in colour, to its adoption. CONCLUSION EWS may standardise documentation and identify infants who are at higher risk of an adverse outcome. However, human and non-human resource issues would need to be explored further before development of an EWS for LMICs.
Collapse
Affiliation(s)
- Eleanor J Mitchell
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, Nottingham, UK
| | - Zahida P Qureshi
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Nairobi, Kenya
| | - Fredrick Were
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Nairobi, Kenya
| | - Jane Daniels
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, Nottingham, UK
| | - George Gwako
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Nairobi, Kenya
| | - Alfred Osoti
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Nairobi, Kenya
| | | | - Lucy Bradshaw
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, Nottingham, UK
| | - Mary Oliver
- School of Education, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Phoebe Pallotti
- School of Health Sciences, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Shalini Ojha
- Division of Graduate Entry Medicine, School of Medicine, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, Nottingham, UK
- Neonatal Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| |
Collapse
|
125
|
Muttalib F, Clavel V, Yaeger LH, Shah V, Adhikari NKJ. Performance of Pediatric Mortality Prediction Models in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis. J Pediatr 2020; 225:182-192.e2. [PMID: 32439313 DOI: 10.1016/j.jpeds.2020.05.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/11/2020] [Accepted: 05/12/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To describe the performance of prognostic models for mortality or clinical deterioration events among hospitalized children developed or validated in low- and middle-income countries. STUDY DESIGN A medical librarian systematically searched EMBASE, Ovid Medline, Scopus, Cochrane Library, EBSCO Global Health, LILACS, African Index Medicus, African Journals Online, African Healthline, Med-Carib, and Global Index Medicus (from 2000 to October 2019). We included citations that described the development or validation of a pediatric prognostic model for hospital mortality or clinical deterioration events in low- and middle-income countries. In duplicate and independently, we extracted data on included populations and model prognostic performance and evaluated risk of bias using the Prediction model Risk Of Bias Assessment Tool. RESULTS Of 41 279 unique citations, we included 15 studies describing 15 prognostic models for mortality and 3 models for clinical deterioration events. Six models were validated in >1 external cohort. The Lambarene Organ Dysfunction Score (0.85 [0.77-0.92]) and Signs of Inflammation in Children that Kill (0.85 [0.82-0.88]) had the highest summary C-statistics (95% CI) for discrimination. Calibration and classification measures were poorly reported. All models were at high risk of bias owing to inappropriate selection of predictor variables and handling of missing data and incomplete performance measure reporting. CONCLUSIONS Several prognostic models for mortality and clinical deterioration events have been validated in single cohorts, with good discrimination. Rigorous validation that conforms to current standards for prediction model studies and updating of existing models are needed before clinical implementation.
Collapse
Affiliation(s)
- Fiona Muttalib
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Center for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Virginie Clavel
- Faculty of Medicine, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Lauren H Yaeger
- Becker Medical Library Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Vibhuti Shah
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Neill K J Adhikari
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
126
|
Tuyishime E, Ingabire H, Mvukiyehe JP, Durieux M, Twagirumugabe T. Implementing the Risk Identification (RI) and Modified Early Obstetric Warning Signs (MEOWS) tool in district hospitals in Rwanda: a cross-sectional study. BMC Pregnancy Childbirth 2020; 20:568. [PMID: 32993541 PMCID: PMC7523063 DOI: 10.1186/s12884-020-03187-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/17/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite reaching Millennium Development Goal (MDG) 3, the maternal mortality rate (MMR) is still high in Rwanda. Most deaths occur after transfer of patients with obstetric complications from district hospitals (DHs) to referral hospitals; timely detection and management may improve these outcomes. The RI and MEOWS tool has been designed to predict morbidity and decrease delay of transfer. Our study aimed: 1) to determine if the use of the RI and MEOWS tool is feasible in DHs in Rwanda and 2) to determine the role of the RI and MEOWS tool in predicting morbidity. METHODS A cross-sectional study enrolled parturient admitted to 4 district hospitals during the study period from April to July 2019. Data was collected on completeness rate (feasibility) to RI and MEOWS tool, and prediction of morbidity (hemorrhage, infection, and pre-eclampsia). RESULTS Among 478 RI and MEOWS forms used, 75.9% forms were fully completed suggesting adequate feasibility. In addition, the RI and MEOWS tool showed to predict morbidity with a sensitivity of 28.9%, a specificity of 93.5%, a PPV of 36.1%, a NPV of 91.1%, an accuracy of 86.2%, and a relative risk of 4.1 (95% Confidential Interval (CI), 2.4-7.1). When asked about challenges faced during use of the RI and MEOWS tool, most of the respondents reported that the tool was long, the staff to patient ratio was low, the English language was a barrier, and the printed forms were sometimes unavailable. CONCLUSION The RI and MEOWS tool is a feasible in the DHs of Rwanda. In addition, having moderate or high scores on the RI and MEOWS tool predict morbidity. After consideration of local context, this tool can be considered for scale up to other DHs in Rwanda or other low resources settings. TRIAL REGISTRATION This is not a clinical trial rather a quality improvement project. It will be registered retrospectively.
Collapse
Affiliation(s)
- Eugene Tuyishime
- Department of Anesthesia, Critical Care and Emergency Medicine, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Honorine Ingabire
- Department of Anesthesia, Critical Care and Emergency Medicine, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Jean Paul Mvukiyehe
- Department of Anesthesia, Critical Care and Emergency Medicine, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Theogene Twagirumugabe
- Department of Anesthesia, Critical Care and Emergency Medicine, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| |
Collapse
|
127
|
Ader F. Protocol for the DisCoVeRy trial: multicentre, adaptive, randomised trial of the safety and efficacy of treatments for COVID-19 in hospitalised adults. BMJ Open 2020; 10:e041437. [PMID: 32958495 PMCID: PMC7507250 DOI: 10.1136/bmjopen-2020-041437] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/14/2020] [Accepted: 08/19/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION To find effective and safe treatments for COVID-19, the WHO recommended to systemically evaluate experimental therapeutics in collaborative randomised clinical trials. As COVID-19 was spreading in Europe, the French national institute for Health and Medical Research (Inserm) established a transdisciplinary team to develop a multi-arm randomised controlled trial named DisCoVeRy. The objective of the trial is to evaluate the clinical efficacy and safety of different investigational re-purposed therapeutics relative to Standard of Care (SoC) in patients hospitalised with COVID-19. METHODS AND ANALYSIS DisCoVeRy is a phase III, open-label, adaptive, controlled, multicentre clinical trial in which hospitalised patients with COVID-19 in need of oxygen therapy are randomised between five arms: (1) a control group managed with SoC and four therapeutic arms with re-purposed antiviral agents: (2) remdesivir + SoC, (3) lopinavir/ritonavir + SoC, (4) lopinavir/ritonavir associated with interferon (IFN)-β-1a + SoC and (5) hydroxychloroquine + SoC. The primary endpoint is the clinical status at Day 15 on the 7-point ordinal scale of the WHO Master Protocol (V.3.0, 3 March 2020). This trial involves patients hospitalised in conventional departments or intensive care units both from academic or non-academic hospitals throughout Europe. A sample size of 3100 patients (620 patients per arm) is targeted. This trial has begun on 22 March 2020. Since 5 April 2020, DisCoVeRy has been an add-on trial of the Solidarity consortium of trials conducted by the WHO in Europe and worldwide. On 8 June 2020, 754 patients have been included. ETHICS AND DISSEMINATION Inserm is the sponsor of DisCoVeRy. Ethical approval has been obtained from the institutional review board on 13 March 2020 (20.03.06.51744) and from the French National Agency for Medicines and Health Products (ANSM) on 9 March 2020. Results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04315948 Eudra-CT 2020-000936-23.
Collapse
Affiliation(s)
- Florence Ader
- Infectious and tropical diseases department, Centre Hospitalier Universitaire de Lyon, F-69004 Lyon, and Inserm 1111-Centre International de Recherche en Infectiologie (CIRI), Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, F-69007, Lyon, France
| |
Collapse
|
128
|
DOĞU C, DOĞAN G, KAYIR S, YAĞAN Ö. Importance of the National Early Warning Score (NEWS) at the time of discharge from the intensive care unit. Turk J Med Sci 2020; 50:1203-1209. [PMID: 32659876 PMCID: PMC7491295 DOI: 10.3906/sag-1906-78] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/11/2020] [Indexed: 11/25/2022] Open
Abstract
Backround/aim To identify, at an early stage of intensive care, patients who will require readmission to the intensive care unit (ICU) based on their National Early Warning Score (NEWS-d) at discharge. Materials and methods Overall, 536 patients aged >18 years who stayed at a tertiary ICU for >24 h were included. Patients who readmitted and not readmitted to the intensive care within 48 h after discharge were compared. Results Mean patient age was 64.26 ± 18.50 years and 252 (44.7%) patients were male. Mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 21.86 ± 8.74; mean NEWS-d was 4.48 ± 2.53. Forty-nine (9.1%) were readmitted to ICU. The reasons for initial admission, age, and NEWS-d vvalues were significantly different between the 2 groups. The NEWS-d values of the readmitted group were significantly higher (9.16 ± 1.05) than nonreadmitted group (4.01 ± 2.13). Based on receiver operation curve analysis, sensitivity and specificity were 98% and 95%, respectively, considering a NEWS-d cut-off value of 7.5 as the limit value for estimating readmission. Conclusion A NEWS-d value of >7.5 demonstrated high sensitivity and specificity in identifying the risk of readmission for patients being discharged from ICU.
Collapse
Affiliation(s)
- Cihangir DOĞU
- Department of Intensive Care, Republic of Turkey Ministry of Health Ankara City Hospital, AnkaraTurkey
- * To whom correspondence should be addressed. E-mail:
| | - Güvenç DOĞAN
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Hitit University, ÇorumTurkey
| | - Selçuk KAYIR
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Hitit University, ÇorumTurkey
| | - Özgür YAĞAN
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Hitit University, ÇorumTurkey
| |
Collapse
|
129
|
El-Sharkawy AM, Devonald MAJ, Humes DJ, Sahota O, Lobo DN. Hyperosmolar dehydration: A predictor of kidney injury and outcome in hospitalised older adults. Clin Nutr 2020; 39:2593-2599. [PMID: 31801657 PMCID: PMC7403861 DOI: 10.1016/j.clnu.2019.11.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS Hospitalised older adults are vulnerable to dehydration. However, the prevalence of hyperosmolar dehydration (HD) and its impact on outcome is unknown. Serum osmolality is not measured routinely but osmolarity, a validated alternative, can be calculated using routinely measured serum biochemistry. This study aimed to use calculated osmolarity to measure the prevalence of HD (serum osmolarity >300 mOsm/l) and assess its impact on acute kidney injury (AKI) and outcome in hospitalised older adults. METHODS This retrospective cohort study used data from a UK teaching hospital retrieved from the electronic database relating to all medical emergency admissions of patients aged ≥ 65 years admitted between 1st May 2011 and 31st October 2013. Using these data, Charlson comorbidity index (CCI), National Early Warning Score (NEWS), length of hospital stay (LOS) and mortality were determined. Osmolarity was calculated using the equation of Krahn and Khajuria. RESULTS A total of 6632 patients were identified; 27% had HD, 39% of whom had AKI. HD was associated with a median (Q1, Q3) LOS of 5 (1, 12) days compared with 3 (1, 9) days in the euhydrated group, P < 0.001. Adjusted Cox-regression analysis demonstrated that patients with HD were four-times more likely to develop AKI 12-24 h after admission [Hazards Ratio (95% Confidence Interval) 4.5 (3.5-5.6), P < 0.001], and had 60% greater 30-day mortality [1.6 (1.4-1.9), P < 0.001], compared with those who were euhydrated. CONCLUSION HD is common in hospitalised older adults and is associated with increased LOS, risk of AKI and mortality. Further work is required to assess the validity of osmolality or osmolarity as an early predictor of AKI and the impact of HD on outcome prospectively.
Collapse
Affiliation(s)
- Ahmed M El-Sharkawy
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Mark A J Devonald
- Renal and Transplant Unit, Nottingham University Hospitals NHS Trust, City Campus, Nottingham, NG5 1PB, UK
| | - David J Humes
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; Division of Epidemiology and Public Health, University of Nottingham, City Campus, Nottingham NG5 1PB, UK
| | - Opinder Sahota
- Department of Elderly Medicine, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK.
| |
Collapse
|
130
|
Zachariasse JM, Nieboer D, Maconochie IK, Smit FJ, Alves CF, Greber-Platzer S, Tsolia MN, Steyerberg EW, Avillach P, van der Lei J, Moll HA. Development and validation of a Paediatric Early Warning Score for use in the emergency department: a multicentre study. Lancet Child Adolesc Health 2020; 4:583-591. [PMID: 32710839 DOI: 10.1016/s2352-4642(20)30139-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Paediatric Early Warning Scores (PEWSs) are being used increasingly in hospital wards to identify children at risk of clinical deterioration, but few scores exist that were designed for use in emergency care settings. To improve the prioritisation of children in the emergency department (ED), we developed and validated an ED-PEWS. METHODS The TrIAGE project is a prospective European observational study based on electronic health record data collected between Jan 1, 2012, and Nov 1, 2015, from five diverse EDs in four European countries (Netherlands, the UK, Austria, and Portugal). This study included data from all consecutive ED visits of children under age 16 years. The main outcome measure was a three-category reference standard (high, intermediate, low urgency) that was developed as part of the TrIAGE project as a proxy for true patient urgency. The ED-PEWS was developed based on an ordinal logistic regression model, with cross-validation by setting. After completing the study, we fully externally validated the ED-PEWS in an independent cohort of febrile children from a different ED (Greece). FINDINGS Of 119 209 children, 2007 (1·7%) were of high urgency and 29 127 (24·4%) of intermediate urgency, according to our reference standard. We developed an ED-PEWS consisting of age and the predictors heart rate, respiratory rate, oxygen saturation, consciousness, capillary refill time, and work of breathing. The ED-PEWS showed a cross-validated c-statistic of 0·86 (95% prediction interval 0·82-0·90) for high-urgency patients and 0·67 (0·61-0·73) for high-urgency or intermediate-urgency patients. A cutoff of score of at least 15 was useful for identifying high-urgency patients with a specificity of 0·90 (95% CI 0·87-0·92) while a cutoff score of less than 6 was useful for identifying low-urgency patients with a sensitivity of 0·83 (0·81-0·85). INTERPRETATION The proposed ED-PEWS can assist in identifying high-urgency and low-urgency patients in the ED, and improves prioritisation compared with existing PEWSs. FUNDING Stichting de Drie Lichten, Stichting Sophia Kinderziekenhuis Fonds, and the European Union's Horizon 2020 research and innovation programme.
Collapse
Affiliation(s)
- Joany M Zachariasse
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ian K Maconochie
- Department of Paediatric Emergency Medicine, Imperial College NHS Healthcare Trust, London, UK
| | - Frank J Smit
- Department of Paediatrics, Maasstad Hospital, Rotterdam, Netherlands
| | - Claudio F Alves
- Department of Paediatrics, Emergency Unit, Hospital Professor Doutor Fernando da Fonseca, Lisbon, Portugal
| | - Susanne Greber-Platzer
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - Maria N Tsolia
- National and Kapodistrian University of Athens, Second Department of Paediatrics, P and A Kyriakou Children's Hospital, Athens, Greece
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Paul Avillach
- Department of Medical Informatics, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands; Harvard Medical School, Department of Biomedical Informatics, Boston, MA, USA
| | - Johan van der Lei
- Department of Medical Informatics, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Henriëtte A Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands.
| |
Collapse
|
131
|
Endo T, Yoshida T, Shinozaki T, Motohashi T, Hsu HC, Fukuda S, Tsukuda J, Naito T, Morisawa K, Shimozawa N, Taira Y, Fujitani S. Efficacy of prehospital National Early Warning Score to predict outpatient disposition at an emergency department of a Japanese tertiary hospital: a retrospective study. BMJ Open 2020; 10:e034602. [PMID: 32546488 PMCID: PMC7299041 DOI: 10.1136/bmjopen-2019-034602] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES The National Early Warning Score (NEWS) was originally developed to assess hospitalised patients in the UK. We examined whether the NEWS could be applied to patients transported by ambulance in Japan. DESIGN This retrospective study assessed patients and calculated the NEWS from paramedic records. Emergency department (ED) disposition data were categorised into the following groups: discharged from the ED, admitted to the ward, admitted to the intensive care unit (ICU) or died in the ED. The predictive performance of NEWS for patient disposition was assessed using receiver operating characteristic curve analysis. Patient dispositions were compared among NEWS-based categories after adjusting for age, sex and presence of traumatic injury. SETTING A tertiary hospital in Japan. PARTICIPANTS Overall, 2847 patients transported by ambulance between April 2017 and March 2018 were included. RESULTS The mean (±SD) NEWS differed significantly among patients discharged from the ED (n=1330, 3.7±2.9), admitted to the ward (n=1263, 60.3±3.8), admitted to the ICU (n=232, 9.4±4.0) and died in the ED (n=22, 110.7±2.9) (p<0.001). The prehospital NEWS C-statistics (95% CI) for admission to the ward, admission to the ICU or death in the ED; admission to the ICU or death in the ED; and death in the ED were 0.73 (0.72-0.75), 0.81 (0.78-0.83) and 0.90 (0.87-0.93), respectively. After adjusting for age, sex and trauma, the OR (95% CI) of admission to the ICU or death in the ED for the high-risk (NEWS ≥7) and medium-risk (NEWS 5-6) categories was 13.8 (8.9-21.6) and 4.2 (2.5-7.1), respectively. CONCLUSION The findings from this Japanese tertiary hospital setting showed that prehospital NEWS could be used to identify patients at a risk of adverse outcomes. NEWS stratification was strongly correlated with patient disposition.
Collapse
Affiliation(s)
- Takuro Endo
- Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
- Department of Emergency Medicine, International University of Health and Welfare, Narita, Chiba, Japan
| | - Toru Yoshida
- Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Tomohiro Shinozaki
- Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Katsushika-ku, Tokyo, Japan
| | - Takako Motohashi
- Department of Preventive Medicine, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Hsiang-Chin Hsu
- Emergency Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Shunsuke Fukuda
- Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Jumpei Tsukuda
- Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Takaki Naito
- Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Kenichiro Morisawa
- Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Nobuhiko Shimozawa
- Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Yasuhiko Taira
- Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Shigeki Fujitani
- Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| |
Collapse
|
132
|
Abstract
Sepsis is a life-threatening disease in the intensive care unit (ICU). The current diagnostic criteria for sequential organ failure assessment (SOFA) scores do not reflect the current understanding of sepsis. We developed a novel and convenient score to aid early prognosis.Retrospective multivariable regression analysis of 185 infected emergency ICU (EICU) patients was conducted to identify independent variables associated with death, to develop the new "STAPLAg" score; STAPLAg was then validated in an internal cohort (n = 106) and an external cohort (n = 78) and its predictive efficacy was compared with that of the initial SOFA score.Age, and initial serum albumin, sodium, PLR, troponin, and lactate tests in the emergency department were independent predictors of death in infected EICU patients, and were used to establish the STAPLAg score (area under the curve [AUC] 0.865). The initial SOFA score on admission was predictive of death (AUC 0.782). Applying the above categories to the derivation cohort yielded mortality risks of 7.7% for grade I, 56.3% for grade II, and 75.0% for grade III. Internal (AUC 0.884) and external (AUC 0.918) cohort validation indicated that the score had good predictive power.The STAPLAg score can be determined early in infected EICU patients, and exhibited better prognostic capacity than the initial SOFA score on admission in both internal and external cohorts. STAPLAg constitutes a new resource for use in the clinical diagnosis of sepsis and can also predict mortality in infected EICU patients. REGISTRATION NUMBER:: ChinCTR-PNC-16010288.
Collapse
Affiliation(s)
| | | | - Yuxiao Deng
- Department of Surgery Intensive Care Unit, Ren Ji Hospital
| | | | - Yuan Gao
- Department of Surgery Intensive Care Unit, Ren Ji Hospital
| | - Yuan Huang
- Department of Critical Care Medicine, Shanghai General Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | | |
Collapse
|
133
|
Gerry S, Bonnici T, Birks J, Kirtley S, Virdee PS, Watkinson PJ, Collins GS. Early warning scores for detecting deterioration in adult hospital patients: systematic review and critical appraisal of methodology. BMJ 2020; 369:m1501. [PMID: 32434791 PMCID: PMC7238890 DOI: 10.1136/bmj.m1501] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To provide an overview and critical appraisal of early warning scores for adult hospital patients. DESIGN Systematic review. DATA SOURCES Medline, CINAHL, PsycInfo, and Embase until June 2019. ELIGIBILITY CRITERIA FOR STUDY SELECTION Studies describing the development or external validation of an early warning score for adult hospital inpatients. RESULTS 13 171 references were screened and 95 articles were included in the review. 11 studies were development only, 23 were development and external validation, and 61 were external validation only. Most early warning scores were developed for use in the United States (n=13/34, 38%) and the United Kingdom (n=10/34, 29%). Death was the most frequent prediction outcome for development studies (n=10/23, 44%) and validation studies (n=66/84, 79%), with different time horizons (the most frequent was 24 hours). The most common predictors were respiratory rate (n=30/34, 88%), heart rate (n=28/34, 83%), oxygen saturation, temperature, and systolic blood pressure (all n=24/34, 71%). Age (n=13/34, 38%) and sex (n=3/34, 9%) were less frequently included. Key details of the analysis populations were often not reported in development studies (n=12/29, 41%) or validation studies (n=33/84, 39%). Small sample sizes and insufficient numbers of event patients were common in model development and external validation studies. Missing data were often discarded, with just one study using multiple imputation. Only nine of the early warning scores that were developed were presented in sufficient detail to allow individualised risk prediction. Internal validation was carried out in 19 studies, but recommended approaches such as bootstrapping or cross validation were rarely used (n=4/19, 22%). Model performance was frequently assessed using discrimination (development n=18/22, 82%; validation n=69/84, 82%), while calibration was seldom assessed (validation n=13/84, 15%). All included studies were rated at high risk of bias. CONCLUSIONS Early warning scores are widely used prediction models that are often mandated in daily clinical practice to identify early clinical deterioration in hospital patients. However, many early warning scores in clinical use were found to have methodological weaknesses. Early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care. Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017053324.
Collapse
Affiliation(s)
- Stephen Gerry
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Timothy Bonnici
- Critical Care Division, University College London Hospitals NHS Trust, London, UK
| | - Jacqueline Birks
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Pradeep S Virdee
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Peter J Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| |
Collapse
|
134
|
Ahn JH, Jung YK, Lee JR, Oh YN, Oh DK, Huh JW, Lim CM, Koh Y, Hong SB. Predictive powers of the Modified Early Warning Score and the National Early Warning Score in general ward patients who activated the medical emergency team. PLoS One 2020; 15:e0233078. [PMID: 32407344 PMCID: PMC7224474 DOI: 10.1371/journal.pone.0233078] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 04/28/2020] [Indexed: 01/12/2023] Open
Abstract
Background The current early warning scores may be insufficient for medical emergency teams (METs) to use in assessing the severity and the prognosis of activated patients. We evaluated the predictive powers of the Modified Early Warning Score (MEWS) and the National Early Warning Score (NEWS) for 28-day mortality and to analyze predictors of 28-day mortality in general ward patients who activate the MET. Methods Adult general ward inpatients who activated the MET in a tertiary referral teaching hospital between March 2009 and December 2016 were included. The demographic and clinical characteristics and physiologic parameters at the time of MET activation were collected, and MEWS and NEWS were calculated. Results A total of 6,729 MET activation events were analyzed. Patients who died within 28 days were younger (mean age 60 vs 62 years), were more likely to have malignancy (72% vs 53%), were more likely to be admitted to the medical department rather than the surgical department (93% vs 80%), had longer intervals from admission to MET activation (median, 7 vs 5 days), and were less likely to activate the MET during nighttime hours (5 PM to 8 AM) (61% vs 66%) compared with those who did not die within 28 days (P < 0.001 for all comparisons). The areas under the receiver operating characteristic curves of MEWS and NEWS for 28-day mortality were 0.58 (95% CI, 0.56–0.59) and 0.60 (95% CI, 0.59–0.62), which were inferior to that of the logistics regression model (0.73; 95% CI, 0.72–0.74; P < 0.001 for both comparisons). Conclusions Both the MEWS and NEWS had poor predictive powers for 28-day mortality in patients who activated the MET. A new scoring system is needed to stratify the severity and prognosis of patients who activated the MET.
Collapse
Affiliation(s)
- Jee Hwan Ahn
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Youn Kyung Jung
- Medical Emergency Team, Asan Medical Center, Seoul, Republic of Korea
| | - Ju-Ry Lee
- Medical Emergency Team, Asan Medical Center, Seoul, Republic of Korea
| | - You Na Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong Kyu Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- * E-mail:
| |
Collapse
|
135
|
Liu VX, Lu Y, Carey KA, Gilbert ER, Afshar M, Akel M, Shah NS, Dolan J, Winslow C, Kipnis P, Edelson DP, Escobar GJ, Churpek MM. Comparison of Early Warning Scoring Systems for Hospitalized Patients With and Without Infection at Risk for In-Hospital Mortality and Transfer to the Intensive Care Unit. JAMA Netw Open 2020; 3:e205191. [PMID: 32427324 PMCID: PMC7237982 DOI: 10.1001/jamanetworkopen.2020.5191] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Risk scores used in early warning systems exist for general inpatients and patients with suspected infection outside the intensive care unit (ICU), but their relative performance is incompletely characterized. OBJECTIVE To compare the performance of tools used to determine points-based risk scores among all hospitalized patients, including those with and without suspected infection, for identifying those at risk for death and/or ICU transfer. DESIGN, SETTING, AND PARTICIPANTS In a cohort design, a retrospective analysis of prospectively collected data was conducted in 21 California and 7 Illinois hospitals between 2006 and 2018 among adult inpatients outside the ICU using points-based scores from 5 commonly used tools: National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), Between the Flags (BTF), Quick Sequential Sepsis-Related Organ Failure Assessment (qSOFA), and Systemic Inflammatory Response Syndrome (SIRS). Data analysis was conducted from February 2019 to January 2020. MAIN OUTCOMES AND MEASURES Risk model discrimination was assessed in each state for predicting in-hospital mortality and the combined outcome of ICU transfer or mortality with area under the receiver operating characteristic curves (AUCs). Stratified analyses were also conducted based on suspected infection. RESULTS The study included 773 477 hospitalized patients in California (mean [SD] age, 65.1 [17.6] years; 416 605 women [53.9%]) and 713 786 hospitalized patients in Illinois (mean [SD] age, 61.3 [19.9] years; 384 830 women [53.9%]). The NEWS exhibited the highest discrimination for mortality (AUC, 0.87; 95% CI, 0.87-0.87 in California vs AUC, 0.86; 95% CI, 0.85-0.86 in Illinois), followed by the MEWS (AUC, 0.83; 95% CI, 0.83-0.84 in California vs AUC, 0.84; 95% CI, 0.84-0.85 in Illinois), qSOFA (AUC, 0.78; 95% CI, 0.78-0.79 in California vs AUC, 0.78; 95% CI, 0.77-0.78 in Illinois), SIRS (AUC, 0.76; 95% CI, 0.76-0.76 in California vs AUC, 0.76; 95% CI, 0.75-0.76 in Illinois), and BTF (AUC, 0.73; 95% CI, 0.73-0.73 in California vs AUC, 0.74; 95% CI, 0.73-0.74 in Illinois). At specific decision thresholds, the NEWS outperformed the SIRS and qSOFA at all 28 hospitals either by reducing the percentage of at-risk patients who need to be screened by 5% to 20% or increasing the percentage of adverse outcomes identified by 3% to 25%. CONCLUSIONS AND RELEVANCE In all hospitalized patients evaluated in this study, including those meeting criteria for suspected infection, the NEWS appeared to display the highest discrimination. Our results suggest that, among commonly used points-based scoring systems, determining the NEWS for inpatient risk stratification could identify patients with and without infection at high risk of mortality.
Collapse
Affiliation(s)
- Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Yun Lu
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Kyle A. Carey
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Emily R. Gilbert
- Department of Medicine, Loyola University Medical Center, Chicago, Illinois
| | - Majid Afshar
- Department of Medicine, Loyola University Medical Center, Chicago, Illinois
| | - Mary Akel
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Nirav S. Shah
- Department of Medicine, University of Chicago, Chicago, Illinois
- NorthShore University HealthSystem, Evanston, Illinois
| | - John Dolan
- NorthShore University HealthSystem, Evanston, Illinois
| | | | - Patricia Kipnis
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Dana P. Edelson
- Department of Medicine, University of Chicago, Chicago, Illinois
| | | | | |
Collapse
|
136
|
Fu LH, Schwartz J, Moy A, Knaplund C, Kang MJ, Schnock KO, Garcia JP, Jia H, Dykes PC, Cato K, Albers D, Rossetti SC. Development and validation of early warning score system: A systematic literature review. J Biomed Inform 2020; 105:103410. [PMID: 32278089 PMCID: PMC7295317 DOI: 10.1016/j.jbi.2020.103410] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 03/19/2020] [Accepted: 03/21/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES This review aims to: 1) evaluate the quality of model reporting, 2) provide an overview of methodology for developing and validating Early Warning Score Systems (EWSs) for adult patients in acute care settings, and 3) highlight the strengths and limitations of the methodologies, as well as identify future directions for EWS derivation and validation studies. METHODOLOGY A systematic search was conducted in PubMed, Cochrane Library, and CINAHL. Only peer reviewed articles and clinical guidelines regarding developing and validating EWSs for adult patients in acute care settings were included. 615 articles were extracted and reviewed by five of the authors. Selected studies were evaluated based on the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) checklist. The studies were analyzed according to their study design, predictor selection, outcome measurement, methodology of modeling, and validation strategy. RESULTS A total of 29 articles were included in the final analysis. Twenty-six articles reported on the development and validation of a new EWS, while three reported on validation and model modification. Only eight studies met more than 75% of the items in the TRIPOD checklist. Three major techniques were utilized among the studies to inform their predictive algorithms: 1) clinical-consensus models (n = 6), 2) regression models (n = 15), and 3) tree models (n = 5). The number of predictors included in the EWSs varied from 3 to 72 with a median of seven. Twenty-eight models included vital signs, while 11 included lab data. Pulse oximetry, mental status, and other variables extracted from electronic health records (EHRs) were among other frequently used predictors. In-hospital mortality, unplanned transfer to the intensive care unit (ICU), and cardiac arrest were commonly used clinical outcomes. Twenty-eight studies conducted a form of model validation either within the study or against other widely-used EWSs. Only three studies validated their model using an external database separate from the derived database. CONCLUSION This literature review demonstrates that the characteristics of the cohort, predictors, and outcome selection, as well as the metrics for model validation, vary greatly across EWS studies. There is no consensus on the optimal strategy for developing such algorithms since data-driven models with acceptable predictive accuracy are often site-specific. A standardized checklist for clinical prediction model reporting exists, but few studies have included reporting aligned with it in their publications. Data-driven models are subjected to biases in the use of EHR data, thus it is particularly important to provide detailed study protocols and acknowledge, leverage, or reduce potential biases of the data used for EWS development to improve transparency and generalizability.
Collapse
Affiliation(s)
- Li-Heng Fu
- Department of Biomedical Informatics, Columbia University, New York, NY, United States.
| | - Jessica Schwartz
- School of Nursing, Columbia University, New York, NY, United States
| | - Amanda Moy
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Chris Knaplund
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Min-Jeoung Kang
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Kumiko O Schnock
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Jose P Garcia
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States
| | - Haomiao Jia
- School of Nursing, Columbia University, New York, NY, United States; Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Patricia C Dykes
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Kenrick Cato
- School of Nursing, Columbia University, New York, NY, United States
| | - David Albers
- Department of Biomedical Informatics, Columbia University, New York, NY, United States; Department of Pediatrics, Section of Informatics and Data Science, University of Colorado, Aurora, CO, United States
| | - Sarah Collins Rossetti
- Department of Biomedical Informatics, Columbia University, New York, NY, United States; School of Nursing, Columbia University, New York, NY, United States
| |
Collapse
|
137
|
Xie R, Khalil I, Badsha S, Atiquzzaman M. An intelligent healthcare system with data priority based on multi vital biosignals. Comput Methods Programs Biomed 2020; 185:105126. [PMID: 31678795 DOI: 10.1016/j.cmpb.2019.105126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/14/2019] [Accepted: 10/08/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVE Home-based personal healthcare systems are becoming popular and affordable due to the development of Internet of Things (IoT) devices. However, with an increasing number of users, such healthcare systems are challenged to store and process enormous volumes of data. For instance, multi-biosignal data are collected continuously from patients using IoT device like body sensors and are sent to the server by portable devices for further analysis (e.g., knowledge discovery or the clinical event prediction). These enormous amount of data from large number of patients are causing the transmission overhead and high latency in the network which are responsible for inefficiency issues in clinical event prediction. To address these problems, in this paper, data assessment method is introduced to improve the efficiency in data collection and data prediction. METHODS The assessment algorithm is inspired by National Early Warning Score (NEWS) used in Emergency Department. In our method, only the abnormal time-sequence data for analysis are sent to the server. Thus, the waiting time of data before prediction can be optimized because data with higher priority are processed in front of those with lower priority, which helps our system to provide diagnostic decisions in a proper time according to patients' urgency. RESULTS Our experiments show that the proposed model ideally can save 20% volume of data in the collection and can reduce 75% waiting time of data with the highest priority before predicting. In addition, the waiting time of data for further analysis is optimized compared to the normal processing flow. CONCLUSION The paper introduces an enhanced healthcare system with assessing data priority in order to optimize the data collection and the prediction in terms of data size and waiting time.
Collapse
Affiliation(s)
| | | | - Shahriar Badsha
- University of Nevada, Reno 1664 N. Virginia St. M/S 171 Reno, NV 89557, United States.
| | | |
Collapse
|
138
|
Butler ZA. Implementing the National Early Warning Score 2 into pre-registration nurse education. Nurs Stand 2020; 35:70-75. [PMID: 32064796 DOI: 10.7748/ns.2020.e11470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2019] [Indexed: 06/10/2023]
Abstract
Recognising signs of deteriorating health in patients and responding to them appropriately are crucial nursing competencies. In acute care, failure to detect and act promptly on deterioration can lead to the patient's death. To achieve clinical competence, nursing students require training in the use of techniques for monitoring physiological observations as well as protocols that enable them to respond to deterioration. The use of early warning scores has been advocated to standardise the methods and frequency of patient monitoring in acute care settings. In 2012, the Royal College of Physicians developed the National Early Warning Score (NEWS), which was updated in 2017 and known as NEWS2. This early warning score is used in acute hospitals in England, Scotland, Wales and Northern Ireland. This article explores the benefits and challenges of using NEWS2 as an educational tool in pre-registration nursing programmes to support nursing students in recognising and responding to deteriorating health.
Collapse
Affiliation(s)
- Zoe Abigail Butler
- Department of Nursing, Health and Professional Practice, University of Cumbria, Lancaster, Lancashire, England
| |
Collapse
|
139
|
Foy KE, Pearson J, Kettley L, Lal N, Blackwood H, Bould MD. Four early warning scores predict mortality in emergency surgical patients at University Teaching Hospital, Lusaka: a prospective observational study. Can J Anaesth 2020; 67:203-212. [PMID: 31598906 DOI: 10.1007/s12630-019-01503-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/26/2019] [Accepted: 07/26/2019] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The value of early warning scoring systems has been established in high-income countries. There is little evidence for their use in low-resource settings. We aimed to compare existing early warning scores to predict 30-day mortality. METHODS University Teaching Hospital is a tertiary center in Lusaka, Zambia. Adult surgical patients, excluding obstetrics, admitted for > 24 hr were included in this prospective observational study. On days 1 to 3 of admission, we collected data on patient demographics, heart rate, blood pressure, oxygen saturation, oxygen administration, temperature, consciousness level, and mobility. Two-, three-, and 30-day mortality were recorded with their associated variables analyzed using area under receiver operating curves (AUROC) for the National Early Warning Score (NEWS); the Modified Early Warning Score (MEWS); a modified Hypotension, Oxygen Saturation, Temperature, ECG, Loss of Independence (mHOTEL) score; and the Tachypnea, Oxygen saturation, Temperature, Alertness, Loss of Independence (TOTAL) score. RESULTS Data were available for 254 patients from March 2017 to July 2017. Eighteen (7.5%) patients died at 30 days. The four early warning scores were found to be predictive of 30-day mortality: MEWS (AUROC, 0.76; 95% confidence interval [CI], 0.63 to 0.88; P < 0.001), NEWS (AUROC 0.805; 95% CI, 0.688 to 0.92; P < 0.001), mHOTEL (AUROC 0.759; 95% CI, 0.63 to 0.89, P < 0.001), and TOTAL (AUROC 0.782; 95% CI, 0.66 to 0.90; P < 0.001). CONCLUSIONS We validated four scoring systems in predicting mortality in a Zambian surgical population. Further work is required to assess if implementation of these scoring systems can improve outcomes.
Collapse
Affiliation(s)
- Katie Ellen Foy
- Department of Anaesthesia, Bristol Royal Infirmary, Bristol, UK
| | - Janaki Pearson
- Department of Anaesthesia, Sunderland Royal Hospital, Sunderland, UK
| | - Laura Kettley
- Department of Anaesthesia, Bristol Royal Infirmary, Bristol, UK
| | - Niharika Lal
- Department of Anaesthesia, Royal Alexandra Hospital, Paisley, UK
| | - Holly Blackwood
- Department of Pediatrics, Pinderfields Hospital, Wakefield, UK
| | - M Dylan Bould
- Department of Anesthesiology and Pain Medicine, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.
| |
Collapse
|
140
|
Nielsen PB, Schultz M, Langkjaer CS, Kodal AM, Pedersen NE, Petersen JA, Lange T, Arvig MD, Meyhoff CS, Bestle M, Hølge-Hazelton B, Bunkenborg G, Lippert A, Andersen O, Rasmussen LS, Iversen KK. Adjusting Early Warning Score by clinical assessment: a study protocol for a Danish cluster-randomised, multicentre study of an Individual Early Warning Score (I-EWS). BMJ Open 2020; 10:e033676. [PMID: 31915173 PMCID: PMC6955532 DOI: 10.1136/bmjopen-2019-033676] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 11/13/2019] [Accepted: 11/27/2019] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Track and trigger systems (TTSs) based on vital signs are implemented in hospitals worldwide to identify patients with clinical deterioration. TTSs may provide prognostic information but do not actively include clinical assessment, and their impact on severe adverse events remain uncertain. The demand for prospective, multicentre studies to demonstrate the effectiveness of TTSs has grown the last decade. Individual Early Warning Score (I-EWS) is a newly developed TTS with an aggregated score based on vital signs that can be adjusted according to the clinical assessment of the patient. The objective is to compare I-EWS with the existing National Early Warning Score (NEWS) algorithm regarding clinical outcomes and use of resources. METHOD AND ANALYSIS In a prospective, multicentre, cluster-randomised, crossover, non-inferiority study. Eight hospitals are randomised to use either NEWS in combination with the Capital Region of Denmark NEWS Override System (CROS) or implement I-EWS for 6.5 months, followed by a crossover. Based on their clinical assessment, the nursing staff can adjust the aggregated score with a maximum of -4 or +6 points. We expect to include 150 000 unique patients. The primary endpoint is all-cause mortality at 30 days. Coprimary endpoint is the average number of times per day a patient is NEWS/I-EWS-scored, and secondary outcomes are all-cause mortality at 48 hours and at 7 days as well as length of stay. ETHICS AND DISSEMINATION The study was presented for the Regional Ethics committee who decided that no formal approval was needed according to Danish law (J.no. 1701733). The I-EWS study is a large prospective, randomised multicentre study that investigates the effect of integrating a clinical assessment performed by the nursing staff in a TTS, in a head-to-head comparison with the internationally used NEWS with the opportunity to use CROS. TRIAL REGISTRATION NUMBER NCT03690128.
Collapse
Affiliation(s)
- Pernille B Nielsen
- Department of Emergency Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Martin Schultz
- Department of Emergency Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | | | - Anne Marie Kodal
- Department of Anaesthesiology and Intensive Care, Nordsjaellands Hospital, Hillerod, Denmark
| | - Niels Egholm Pedersen
- Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - John Asger Petersen
- Department of Day Surgery, Amager and Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Theis Lange
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
- Center for Statistical Science, Peking University, Beijing, China
| | - Michael Dan Arvig
- Department of Emergency Medicine, Slagelse Hospital, Slagelse, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Sahlholt Meyhoff
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Morten Bestle
- Department of Anaesthesiology and Intensive Care, Nordsjaellands Hospital, Hillerod, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Bibi Hølge-Hazelton
- Research Support Unit, Zealand University Hospital Roskilde, Roskilde, Denmark
- Department of Regional Studies, University of Southern Denmark, Odense, Denmark
| | - Gitte Bunkenborg
- Department of Anesthesiology, Holbaek Hospital, Holbaek, Denmark
| | - Anne Lippert
- Copenhagen Academy for Medical Education and Simulation, Herlev, Denmark
| | - Ove Andersen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Clinical Research Centre, Amager and Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Lars Simon Rasmussen
- Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Karmark Iversen
- Department of Emergency Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
141
|
Abstract
BACKGROUND The Modified Early Warning System (MEWS) is a well-validated tool used by hospitals to identify patients at high risk for an adverse event to occur. However, there has been little evaluation into whether a low MEWS score can be predictive of patients with a low likelihood of an adverse event. AIM The present study aims to evaluate the MEWS score as a method of identifying patients at low risk for adverse events. DESIGN Retrospective cohort study of 5676 patient days and analysis of associated MEWS scores, medical comorbidities and adverse events. The primary outcome was the association of average daily MEWS scores in those who had an adverse event compared with those who did not. RESULTS Those with an average MEWS score of >2 were over 9 times more likely to have an adverse event compared with those with an average MEWS score of 1-2, and over 15 times more likely to have an adverse event compared to those with an average MEWS score of <1. CONCLUSIONS Our study shows that those with average daily MEWS scores <2 are at a significantly lower likelihood of having an adverse event compared with a score of >2, deeming them 'low-risk patients'. Formal recognition of such patients can have major implications in a hospital setting, including more efficient resource allocation in hospitals and better patient satisfaction and safety by adjusting patient monitoring according to their individual risk profile.
Collapse
Affiliation(s)
- J Mizrahi
- Department of Medicine at Stony Brook University Hospital at Stony Brook, Stony Brook, NY, USA
| | - J Kott
- Department of Medicine at Stony Brook University Hospital at Stony Brook, Stony Brook, NY, USA
| | - E Taub
- Department of Biostatistics at Stony Brook University Hospital at Stony Brook, Stony Brook, NY, USA
| | - N Goolsarran
- Department of Medicine at Stony Brook University Hospital at Stony Brook, Stony Brook, NY, USA
| |
Collapse
|
142
|
Monzon LDR, Boniatti MM. Use of the Modified Early Warning Score in intrahospital transfer of
patients. Rev Bras Ter Intensiva 2020; 32:439-443. [PMID: 33053035 PMCID: PMC7595720 DOI: 10.5935/0103-507x.20200074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/23/2020] [Indexed: 11/20/2022] Open
Abstract
Objective To verify whether there is an association between the Modified Early Warning Score before the transfer from the emergency room to the ward and death or admission to the intensive care unit within 30 days. Methods This is a historical cohort study conducted in a high-complexity hospital in southern Brazil with patients who were transferred from the emergency room to the ward between January and June 2017. The following data were collected: sociodemographic variables; comorbidities, as determined by the Charlson index; reason for hospitalization; Modified Early Warning Score at the time of transfer; admission to the intensive care unit; care by the Rapid Response Team; mortality within 30 days; and hospital mortality. Results A total of 278 patients were included in the study. Regarding the Modified Early Warning Score, patients who died within 30 days had a significantly higher score than surviving patients during this period (2.0 [1.0 - 3.0] versus 1.0 [1.0 - 2.0], respectively; p = 0.006). The areas under the receiver operating characteristic curve for death within 30 days and for ICU admission were 0.67 (0.55 - 0.80; p = 0.012) and 0.72 (0.59 - 0.84; p = 0.02), respectively, with a Modified Early Warning Score cutoff of ≥ 2. In the Cox regression, the Modified Early Warning Score was independently associated with mortality within 30 days after multivariate adjustment (hazard ratio 2.91; 95% confidence interval 1.04 - 8.13). Conclusion The Modified Early Warning Score before intrahospital transfer from the emergency room to the ward is associated with admission to the intensive care unit and death within 30 days. The Modified Early Warning Score can be an important indicator for monitoring these patients and can prompt the receiving team to take specific actions.
Collapse
Affiliation(s)
| | - Márcio Manozzo Boniatti
- Universidade La Salle - Canoas (RS), Brazil
- Corresponding author: Márcio Manozzo Boniatti, Universidade La Salle, Avenida Victor Barreto, 2.288, Zip code: 92010-000 - Canoas (RS), Brazil. E-mail:
| |
Collapse
|
143
|
Ehara J, Hiraoka E, Hsu HC, Yamada T, Homma Y, Fujitani S. The effectiveness of a national early warning score as a triage tool for activating a rapid response system in an outpatient setting: A retrospective cohort study. Medicine (Baltimore) 2019; 98:e18475. [PMID: 31876731 PMCID: PMC6946364 DOI: 10.1097/md.0000000000018475] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Rapid response system (RRS) efficacy and national early warning score (NEWS) performances have largely been reported in inpatient settings, with few such reports undertaken in outpatient settings.This study aimed to investigate NEWS validity in predicting poor clinical outcomes among outpatients who had activated the RRS using single-parameter criteria.A single-center retrospective cohort studyFrom April 1, 2014 to November 30, 2017 in an urban 350-bed referral hospital in JapanWe collected patient characteristics such as activation triggers, interventions, arrival times, dispositions, final diagnoses, and patient outcomes. Poor clinical outcomes were defined as unplanned intensive care unit transfers or deaths within 24 hours. Correlations between the NEWS and clinical outcomes at the time of deterioration and disposition were analyzed.Among 31 outpatients, the NEWS value decreased significantly after a medical emergency team intervention (median, 8 vs 4, P < .001). The difference in the NEWS at the time of deterioration and at disposition was significantly less in patients with poor clinical outcomes (median 3 vs 1.5, P = .03). The area under the curve (AUC) for the NEWS high-risk patient group at the time of deterioration for predicting hospital admission was 0.85 (95% confidence interval [CI], 0.67-1.0), while the AUC for the NEWS high-risk patient group at disposition for predicting poor clinical outcomes was 0.83 (95% CI, 0.62-1.0).The difference between the NEWS at the time of deterioration and at disposition might usefully predict admissions and poor clinical outcomes in RRS outpatient settings.
Collapse
Affiliation(s)
- Jun Ehara
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Hsiang-Chin Hsu
- Department of Emergency Medicine, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Toru Yamada
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Yosuke Homma
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba
| | - Shigeki Fujitani
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine Hospital, Kanagawa-ken, Japan
| |
Collapse
|
144
|
Shamout F, Zhu T, Clifton L, Briggs J, Prytherch D, Meredith P, Tarassenko L, Watkinson PJ, Clifton DA. Early warning score adjusted for age to predict the composite outcome of mortality, cardiac arrest or unplanned intensive care unit admission using observational vital-sign data: a multicentre development and validation. BMJ Open 2019; 9:e033301. [PMID: 31748313 PMCID: PMC6887005 DOI: 10.1136/bmjopen-2019-033301] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Early warning scores (EWS) alerting for in-hospital deterioration are commonly developed using routinely collected vital-sign data from the whole in-hospital population. As these in-hospital populations are dominated by those over the age of 45 years, resultant scores may perform less well in younger age groups. We developed and validated an age-specific early warning score (ASEWS) derived from statistical distributions of vital signs. DESIGN Observational cohort study. SETTING Oxford University Hospitals (OUH) July 2013 to March 2018 and Portsmouth Hospitals (PH) NHS Trust January 2010 to March 2017 within the Hospital Alerting Via Electronic Noticeboard database. PARTICIPANTS Hospitalised patients with electronically documented vital-sign observations OUTCOME: Composite outcome of unplanned intensive care unit admission, mortality and cardiac arrest. METHODS AND RESULTS Statistical distributions of vital signs were used to develop an ASEWS to predict the composite outcome within 24 hours. The OUH development set consisted of 2 538 099 vital-sign observation sets from 142 806 admissions (mean age (SD): 59.8 (20.3)). We compared the performance of ASEWS to the National Early Warning Score (NEWS) and our previous EWS (MCEWS) on an OUH validation set consisting of 581 571 observation sets from 25 407 emergency admissions (mean age (SD): 63.0 (21.4)) and a PH validation set consisting of 5 865 997 observation sets from 233 632 emergency admissions (mean age (SD): 64.3 (21.1)). ASEWS performed better in the 16-45 years age group in the OUH validation set (AUROC 0.820 (95% CI 0.815 to 0.824)) and PH validation set (AUROC 0.840 (95% CI 0.839 to 0.841)) than NEWS (AUROC 0.763 (95% CI 0.758 to 0.768) and AUROC 0.836 (95% CI 0.835 to 0.838) respectively) and MCEWS (AUROC 0.808 (95% CI 0.803 to 0.812) and AUROC 0.833 (95% CI 0.831 to 0.834) respectively). Differences in performance were not consistent in the elder age group. CONCLUSIONS Accounting for age-related vital sign changes can more accurately detect deterioration in younger patients.
Collapse
Affiliation(s)
- Farah Shamout
- Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - Tingting Zhu
- Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - Lei Clifton
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jim Briggs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - David Prytherch
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Paul Meredith
- Research and Innovation Department, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Lionel Tarassenko
- Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - Peter J Watkinson
- Nuffield Department of Clinical Neurosciences, Oxford University Hospitals NHS Trust, Oxford, UK
| | - David A Clifton
- Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| |
Collapse
|
145
|
Faisal M, Richardson D, Scally A, Howes R, Beatson K, Mohammed M. Performance of externally validated enhanced computer-aided versions of the National Early Warning Score in predicting mortality following an emergency admission to hospital in England: a cross-sectional study. BMJ Open 2019; 9:e031596. [PMID: 31678949 PMCID: PMC6830690 DOI: 10.1136/bmjopen-2019-031596] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES In the English National Health Service, the patient's vital signs are monitored and summarised into a National Early Warning Score (NEWS) to support clinical decision making, but it does not provide an estimate of the patient's risk of death. We examine the extent to which the accuracy of NEWS for predicting mortality could be improved by enhanced computer versions of NEWS (cNEWS). DESIGN Logistic regression model development and external validation study. SETTING Two acute hospitals (YH-York Hospital for model development; NH-Northern Lincolnshire and Goole Hospital for external model validation). PARTICIPANTS Adult (≥16 years) medical admissions discharged over a 24-month period with electronic NEWS (eNEWS) recorded on admission are used to predict mortality at four time points (in-hospital, 24 hours, 48 hours and 72 hours) using the first electronically recorded NEWS (model M0) versus a cNEWS model which included age+sex (model M1) +subcomponents of NEWS (including diastolic blood pressure) (model M2). RESULTS The risk of dying in-hospital following emergency medical admission was 5.8% (YH: 2080/35 807) and 5.4% (NH: 1900/35 161). The c-statistics for model M2 in YH for predicting mortality (in-hospital=0.82, 24 hours=0.91, 48 hours=0.88 and 72 hours=0.88) was higher than model M0 (in-hospital=0.74, 24 hours=0.89, 48 hours=0.86 and 72 hours=0.85) with higher Positive Predictive Value (PPVs) for in-hospital mortality (M2 19.3% and M0 16.6%). Similar findings were seen in NH. Model M2 performed better than M0 in almost all major disease subgroups. CONCLUSIONS An externally validated enhanced computer-aided NEWS model (cNEWS) incrementally improves on the performance of a NEWS only model. Since cNEWS places no additional data collection burden on clinicians and is readily automated, it may now be carefully introduced and evaluated to determine if it can improve care in hospitals that have eNEWS systems.
Collapse
Affiliation(s)
- Muhammad Faisal
- Faculty of Health Studies, University of Bradford, Bradford, UK
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | | | - Andy Scally
- School of Clinical Therapies, University College Cork National University of Ireland, Cork, Ireland
| | - Robin Howes
- Department of Strategy & Planning, Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, Grimsby, UK
| | - Kevin Beatson
- IT Department, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Mohammed Mohammed
- Faculty of Health Studies, University of Bradford, Bradford, UK
- NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| |
Collapse
|
146
|
Arnold J, Davis A, Fischhoff B, Yecies E, Grace J, Klobuka A, Mohan D, Hanmer J. Comparing the predictive ability of a commercial artificial intelligence early warning system with physician judgement for clinical deterioration in hospitalised general internal medicine patients: a prospective observational study. BMJ Open 2019; 9:e032187. [PMID: 31601602 PMCID: PMC6797436 DOI: 10.1136/bmjopen-2019-032187] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Our study compares physician judgement with an automated early warning system (EWS) for predicting clinical deterioration of hospitalised general internal medicine patients. DESIGN Prospective observational study of clinical predictions made at the end of the daytime work-shift for an academic general internal medicine floor team compared with the risk assessment from an automated EWS collected at the same time. SETTING Internal medicine teaching wards at a single tertiary care academic medical centre in the USA. PARTICIPANTS Intern physicians working on the internal medicine wards and an automated EWS (Rothman Index by PeraHealth). OUTCOME Clinical deterioration within 24 hours including cardiac or pulmonary arrest, rapid response team activation or unscheduled intensive care unit transfer. RESULTS We collected predictions for 1874 patient days and saw 35 clinical deteriorations (1.9%). The area under the receiver operating curve (AUROC) for the EWS was 0.73 vs 0.70 for physicians (p=0.571). A linear regression model combining physician and EWS predictions had an AUROC of 0.75, outperforming physicians (p=0.016) and the EWS (p=0.05). CONCLUSIONS There is no significant difference in the performance of the EWS and physicians in predicting clinical deterioration at 24 hours on an inpatient general medicine ward. A combined model outperformed either alone. The EWS and physicians identify partially overlapping sets of at-risk patients suggesting they rely on different cues or decision rules for their predictions. TRIAL REGISTRATION NUMBER NCT02648828.
Collapse
Affiliation(s)
- Jonathan Arnold
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alex Davis
- Engineering and Public Policy, Carnegie Mellon University College of Engineering, Pittsburgh, Pennsylvania, USA
| | - Baruch Fischhoff
- Engineering and Public Policy, Carnegie Mellon University College of Engineering, Pittsburgh, Pennsylvania, USA
| | - Emmanuelle Yecies
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jon Grace
- Division of Pulmonary & Critical Care Medicine, University of Michigan Department of Internal Medicine, Ann Arbor, Michigan, USA
| | - Andrew Klobuka
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Deepika Mohan
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Janel Hanmer
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
147
|
Caramello V, Marulli G, Reimondo G, Fanto' F, Boccuzzi A. Comparison of Reverse Triage with National Early Warning Score, Sequential Organ Failure Assessment and Charlson Comorbidity Index to classify medical inpatients of an Italian II level hospital according to their resource's need. Intern Emerg Med 2019; 14:1073-1082. [PMID: 30778758 DOI: 10.1007/s11739-019-02049-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 02/09/2019] [Indexed: 10/27/2022]
Abstract
Resource allocation in our overcrowded hospitals would require classification of inpatients according to the severity of illness, the evolving risk and the clinical complexity. Reverse triage (RT) is a method used in disasters to identify inpatients according to their use of hospital resources. The aim of this observational prospective study is to evaluate the use of RT in medical inpatients of an Italian Hospital and to compare the RT score with National Early Warning Score, Sequential Organ Failure Assessment and Charlson Comorbidity Index. Cluster sampling was performed on high dependency unit (HDU), geriatrics (Ger) and internal medicine (IM) wards. We calculate RT, NEWS, SOFA and CCI from inpatient charts. Length of stay (LOS), transfer to a higher level of care, death and discharge date were collected after 30 days. We obtained demographics, comorbidities, severity and clinical complexity of 260 inpatients. We highlighted differences in NEWS, SOFA and CCI in the three divisions. On the contrary RT score was uniformly high (median 7), with 85% of patients with RT = 8. NEWS, SOFA and CCI were higher in patients with higher RT score. We used the sum of the interventions listed by RT (RT sum) as a proxy of the level of care needed. RT-sum showed moderate correlation with NEWS (r = 0.52 Spearman, p < 0.001). RT-sum was the highest in HDU, related to the evolving severity of HDU patients. Ger patients that showed the highest CCI score (with all patients in the CCI ≥ 3 category) had the second highest RT-sum. RT score showed similar values in the majority of the inpatients regardless of differences in NEWS, SOFA and CCI in different ward subgroups. RT-sum is related both to evolving severity (NEWS) and to clinical complexity (CCI). RT and NEWS could predict inpatient level of care and resource need associated with CCI.
Collapse
Affiliation(s)
- Valeria Caramello
- Emergency Department, San Luigi Gonzaga University Hospital, Regione Gonzole 10, 10043, Orbassano, Turin, Italy.
| | - Giulia Marulli
- Emergency Department, San Luigi Gonzaga University Hospital, Regione Gonzole 10, 10043, Orbassano, Turin, Italy
| | - Giuseppe Reimondo
- Internal Medicine Department, San Luigi Gonzaga University Hospital, Regione Gonzole 10, 10043, Orbassano, Turin, Italy
| | - Fausto Fanto'
- Geriatric Department, San Luigi Gonzaga University Hospital, Regione Gonzole 10, 10043, Orbassano, Turin, Italy
| | - Adriana Boccuzzi
- Emergency Department, San Luigi Gonzaga University Hospital, Regione Gonzole 10, 10043, Orbassano, Turin, Italy
| |
Collapse
|
148
|
Van Velthoven MH, Adjei F, Vavoulis D, Wells G, Brindley D, Kardos A. ChroniSense National Early Warning Score Study (CHESS): a wearable wrist device to measure vital signs in hospitalised patients-protocol and study design. BMJ Open 2019; 9:e028219. [PMID: 31542738 PMCID: PMC6756348 DOI: 10.1136/bmjopen-2018-028219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The National Early Warning Score is used as standard clinical practice in the UK as a track and trigger system to monitor hospitalised patients. Currently, nurses are tasked to take routine vital signs measurements and manually record these on a clinical chart. Wearable devices could provide an easier, reliable, more convenient and cost-effective method of monitoring. Our aim is to evaluate the clinical validity of Polso (ChroniSense Medical, Yokneam Illit, Israel), a wrist-based device, to provide National Early Warning Scores. METHODS AND ANALYSIS We will compare Polso National Early Warning Score measurements to the currently used manual measurements in a UK Teaching District General Hospital. Patients aged 18 years or above who require recordings of observations of vital signs at least every 6 hours will be enrolled after consenting. The sample size for the study was calculated to be 300 participants based on the assumption that the final dataset will include four pairs of measurements per-patient and per-vital sign, resulting in a total of 1200 pairs of data points per vital sign. The primary outcome is the agreement on the individual parameter scores and values of the National Early Warning Score: (1) respiratory rate, (2) oxygen saturation, (3) body temperature, (4) systolic blood pressure and (5) heart rate. Secondary outcomes are the agreement on the aggregate National Early Warning Score. The incidence of adverse events will be recorded. The measurements by the device will not be used for the clinical decision-making in this study. ETHICS AND DISSEMINATION We obtained ethical approval, reference number 18/LO/0123 from London-Hampstead Research Ethics Committee, through the Integrated Research Application System, (reference number: 235 034. The study received no objection from the Medicine and Health Regulatory Authority, reference number: CI/20018/005 and has National Institute for Health Research portfolio adoption status CPMS number: 32 532. TRIAL REGISTRATION NUMBER NCT03448861; Pre-results.
Collapse
Affiliation(s)
| | - Felicia Adjei
- Department of Cardiology, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | | | - Glenn Wells
- Oxford Academic Health Science Centre, Oxford, UK
| | - David Brindley
- Department of Paediatrics, University of Oxford, Oxford, UK
- Said Buisness School, University of Oxford, Oxford, Oxfordshire, UK
| | - Attila Kardos
- Department of Cardiology, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
- Faculty of Life Sciences, University of Buckingham, Buckingham, United Kingdom
| |
Collapse
|
149
|
Shamout FE, Zhu T, Sharma P, Watkinson PJ, Clifton DA. Deep Interpretable Early Warning System for the Detection of Clinical Deterioration. IEEE J Biomed Health Inform 2019; 24:437-446. [PMID: 31545746 DOI: 10.1109/jbhi.2019.2937803] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Assessment of physiological instability preceding adverse events on hospital wards has been previously investigated through clinical early warning score systems. Early warning scores are simple to use yet they consider data as independent and identically distributed random variables. Deep learning applications are able to learn from sequential data, however they lack interpretability and are thus difficult to deploy in clinical settings. We propose the 'Deep Early Warning System' (DEWS), an interpretable end-to-end deep learning model that interpolates temporal data and predicts the probability of an adverse event, defined as the composite outcome of cardiac arrest, mortality or unplanned ICU admission. The model was developed and validated using routinely collected vital signs of patients admitted to the the Oxford University Hospitals between 21st March 2014 and 31st March 2018. We extracted 45 314 vital-sign measurements as a balanced training set and 359 481 vital-sign measurements as an imbalanced testing set to mimic a real-life setting of emergency admissions. DEWS achieved superior accuracy than the state-of-the-art that is currently implemented in clinical settings, the National Early Warning Score, in terms of the overall area under the receiver operating characteristic curve (AUROC) (0.880 vs. 0.866) and when evaluated independently for each of the three outcomes. Our attention-based architecture was able to recognize 'historical' trends in the data that are most correlated with the predicted probability. With high sensitivity, improved clinical utility and increased interpretability, our model can be easily deployed in clinical settings to supplement existing EWS systems.
Collapse
|
150
|
Jones D, Cameron A, Lowe DJ, Mason SM, O'Keeffe CA, Logan E. Multicentre, prospective observational study of the correlation between the Glasgow Admission Prediction Score and adverse outcomes. BMJ Open 2019; 9:e026599. [PMID: 31401591 PMCID: PMC6701614 DOI: 10.1136/bmjopen-2018-026599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES To assess whether the Glasgow Admission Prediction Score (GAPS) is correlated with hospital length of stay, 6-month hospital readmission and 6-month all-cause mortality. This study represents a 6-month follow-up of patients who were included in an external validation of the GAPS' ability to predict admission at the point of triage. SETTING Sampling was conducted between February and May 2016 at two separate emergency departments (EDs) in Sheffield and Glasgow. PARTICIPANTS Data were collected prospectively at triage for consecutive adult patients who presented to the ED within sampling times. Any patients who avoided formal triage were excluded from the study. In total, 1420 patients were recruited. PRIMARY OUTCOMES GAPS was calculated following triage and did not influence patient management. Length of hospital stay, hospital readmission and mortality against GAPS were modelled using survival analysis at 6 months. RESULTS Of the 1420 patients recruited, 39.6% of these patients were initially admitted to hospital. At 6 months, 30.6% of patients had been readmitted and 5.6% of patients had died. For those admitted at first presentation, the chance of being discharged fell by 4.3% (95% CI 3.2% to 5.3%) per GAPS point increase. Cox regression indicated a 9.2% (95% CI 7.3% to 11.1%) increase in the chance of 6-month hospital readmission per point increase in GAPS. An association between GAPS and 6-month mortality was demonstrated, with a hazard increase of 9.0% (95% CI 6.9% to 11.2%) for every point increase in GAPS. CONCLUSION A higher GAPS is associated with increased hospital length of stay, 6-month hospital readmission and 6-month all-cause mortality. While GAPS's primary application may be to predict admission and support clinical decision making, GAPS may provide valuable insight into inpatient resource allocation and bed planning.
Collapse
Affiliation(s)
- Dominic Jones
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Allan Cameron
- Acute Medicine, Glasgow Royal Infirmary, Glasgow, UK
| | - David J Lowe
- Emergency Department, Queen Elizabeth University Hospital Campus, Glasgow, UK
| | - Suzanne M Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Colin A O'Keeffe
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Eilidh Logan
- University of Glasgow School of Life Sciences, Glasgow, UK
| |
Collapse
|