Effectiveness of Early Warning Scores for Early Severity Assessment in Outpatient Emergency Care: A Systematic Review

Background and Objectives

Patient assessment and possible deterioration prediction are a healthcare priority. Increasing demand for outpatient emergency care services requires the implementation of simple, quick, and effective systems of patient evaluation and stratification. The purpose of this review is to identify the most effective Early Warning Score (EWS) for the early detection of the risk of complications when screening emergency outpatients for a potentially serious condition.

Materials and Methods

Systematic review of the bibliography made in 2022. Scientific articles in Spanish and English were collected from the databases and search engines of Pubmed, Cochrane, and Dialnet, which were published between 2017 and 2021 about EWSs and their capacity to predict complications.

Results

For analysis eleven articles were selected. Eight dealt with the application of different early warning scores in outpatient situations, concluding that all the scoring systems they studied were applicable. Three evaluated the predictive ability of various scoring systems and found no significant differences in their results. The eight articles evaluated the suitability of NEWS/NEWS2 to outpatient conditions and concluded it was the most suitable in pre-hospital emergency settings.

Conclusions

The early warning scores that were studied can be applied at the pre-hospital level, as they can predict patient mortality in the short term (24 or 48 h) and support clinical patient evaluation and medical decision making. Among them, NEWS2 is the most suitable for screening potentially deteriorating medical emergency outpatients.

Understanding the use of the National Early Warning Score 2 in acute care settings: a realist review protocol

INTRODUCTION

Failure to recognise and respond to patient deterioration in an appropriate and timely manner has been highlighted as a global patient safety concern. Early Warning Scores (EWSs) using vital signs were introduced to address this concern, with the aim of getting the patient timely and appropriate treatment. The National Early Warning Score 2 (NEWS2) is in use across the NHS, and many other settings globally. While patient improvements have been shown, research has identified that the NEWS2 is not always used as intended. Therefore, this review will use a realist approach to understand what the mechanisms are that influence appropriate use (or not) of the NEWS2 in acute care settings, how, for whom and in which contexts. The findings will inform clinicians of what helps and/or hinders appropriate use of the NEWS2 in clinical practice, thus helping to facilitate successful implementation.

METHODS AND ANALYSIS

Our realist review will follow Pawson's iterative six step process: (1) Development of initial programme theory. (2) Searching the literature; an information scientist will develop, pilot and refine the search strategy. A systematic search will be completed, based on subject relevancy on the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Embase (OvidSP), Web of Science (Science Citation Index and Social Science Citation), Cochrane Database of Systematic Reviews, Joanna Briggs Institute, Ethos, Proquest Dissertations and Theses Global, and Google Scholar for documents dating from 1997 (date of the first published EWS) to present. To retrieve additional relevant data 'snowballing' (finding references and authors by hand, contacting authors, searching reference lists and citation-tracking using Google Scholar) will be used. Inclusion criteria include all documents (including grey literature) that relate to the use of EWSs/NEWS2 in the English language only. Documents set in the paediatric, maternity and primary care settings will be excluded. (3) Selecting documents and quality appraisal. (4) Extracting and organising the data. (5) Synthesising the data. (6) Disseminating the findings. We will recruit a group of stakeholders comprised of experienced clinicians who use the NEWS2 as part of their clinical practice to provide feedback throughout the review. Step 1 has already begun with the development of an initial programme theory. This initial programme theory presents how the NEWS2 is supposed to work (or not), it will now be developed, tested and refined.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study as it is secondary research. Dissemination will include a peer-reviewed publication and conference presentations. Findings will also be amplified through social media platforms with user friendly summaries. Our stakeholder group will also contribute to dissemination of findings in their clinical areas and among existing networks.

PROSPERO REGISTRATION NUMBER

CRD42022304497.

The impact of pediatric early warning score and rapid response algorithm training and implementation on interprofessional collaboration in a resource-limited setting

Introduction

Improved teamwork and communication have been associated with improved quality of care. Early Warning Scores (EWS) and rapid response algorithms are a way of identifying deteriorating patients and providing a common framework for communication and response between physicians and nurses. The impact of EWS implementation on interprofessional collaboration (IPC) has been minimally studied, especially in resource-limited settings.

Methods

The study took place in the Pediatric Department of the main academic referral hospital in Rwanda between April 2019 and January 2020. Pediatric nurses and residents were trained on the use of the Pediatric Warning Score for Resource-Limited Settings (PEWS-RL) and a rapid response algorithm. Training included vital sign collection, PEWS-RL calculation, IPC and rapid response algorithm implementation. Prior to training, participants completed surveys on IPC with Likert scale responses (from “strongly disagree” to “strongly agree”). Follow-up surveys were then administered nine months later and also included an open-response question on the impact of the PEWS-RL implementation on IPC.

Results

Sixty-five (96%) nurses were trained and completed the pre-survey and thirty-seven (54%) of the trained nurses completed the post-survey. Twenty-two (59%) pediatric residents were trained in the workshop and completed the pre-survey and twenty-four physicians (4 pediatricians (40%) and 20 pediatric residents (53%)) completed the post-implementation survey. There was a statistically significant increase in the percent of nurses indicating strong agreement across all domains of communication and collaboration from the pre- to the post-survey. Although the percent of physicians indicating strong agreement increased in the post-survey for all items, only the “share information” item was statistically significant.

Conclusion

Training and implementation of a PEWS-RL and a rapid response algorithm at a tertiary hospital in Rwanda resulted in significant improvement of nurse and physician ratings of IPC nine months later.

Prediction of Pediatric Patient Admission/Discharge in the Emergency Department: Irish Pediatric Early Warning Score, Pediatric Observation Priority Score, and Irish Children's Triage System

OBJECTIVE

The aim of this study was to evaluate the ability of the Irish Paediatric Early Warning Score (PEWS), the Paediatric Observation Priority Score (POPS), and the Irish Children's Triage System (ICTS) to predict patient disposition pathways in an emergency department (ED) setting.

METHODS

Data were prospectively collected on patients aged less than 16 years presenting to an Irish mixed adult/pediatric ED over 3 weeks during December 2018. After calculating a once-off PEWS, POPS, and ICTS, we investigated the ability of the scoring systems to predict admission or discharge from the ED. Primary comparison of the index tests was conducted using receiver operating characteristic (ROC) curves.

RESULTS

A total of 550 patients were included in this study. There were 114 admissions (20.7%) and 436 discharges (79.3%). The POPS had an area under the ROC curve of 0.7 [95% confidence interval (CI), 0.65-0.75]. The PEWS had an area under the ROC curve of 0.58 (95% CI, 0.53-0.64). The ICTS had an area under the ROC curve of 0.58 (95% CI, 0.53-0.63).

CONCLUSIONS

The POPS has greater accuracy as a predictor of admission from the ED than PEWS and ICTS. Possible future implementation of POPS into pediatric EDs as a cognitive prompt before admission decision seems to be merited. Further multicenter validation in Ireland would be helpful.

Evaluation of a Pediatric Early Warning Score as a Predictor of Occult Invasive Bacterial Infection in the Pediatric Emergency Department

OBJECTIVES

The aims of the study were to evaluate the diagnostic performance of Pediatric Early Warning Score (PEWS) to predict occult invasive bacterial infection (IBI) in well-appearing pediatric emergency department (PED) patients without known risk factors for bacterial infection and to compare PEWS to heart rate (HR) and Emergency Severity Index (ESI).

METHODS

We performed a retrospective case-control analysis of febrile PED patients aged 60 days to 18 years over a 2-year period. Subjects were excluded if they were ill appearing, admitted to an intensive care unit, or had a known high-risk condition. Cases of occult IBI were included if they had a noncontaminant positive culture other than an isolated positive urine culture. Two febrile control subjects were identified for each case. Odds ratios and receiver operating characteristic curves were evaluated to determine performance characteristics of PEWS at triage and disposition, age-adjusted HR at triage and disposition, and ESI at triage.

RESULTS

Compared with 178 controls, 89 cases had higher disposition PEWS, higher disposition HR, lower ESI, and higher rate of hospital admission. Disposition PEWS ≥3 (odds ratio, 2.57; 95% confidence interval, 1.08-6.18), disposition HR > 99th percentile, and ESI demonstrated increased odds of occult IBI. Area under the receiver operating characteristic curve for disposition PEWS (0.56) was similar to triage PEWS (0.54), triage HR (0.54), disposition HR (0.58), and ESI (0.65).

CONCLUSIONS

Subjects with PEWS ≥3 at PED disposition have increased odds of occult IBI; however, PEWS has poor discriminative ability at all cutoffs. We cannot recommend PEWS used in isolation to predict occult IBI.

Ability of the National Early Warning Score and its respiratory and haemodynamic subcomponents to predict short-term mortality on general wards: a prospective three-centre observational study in Finland

OBJECTIVES

To validate the ability of the National Early Warning Score (NEWS) to predict short-term mortality on hospital wards, with a special reference to the NEWS's respiratory and haemodynamic subcomponents.

DESIGN

A large, 1-year, prospective, observational three-centre study. First measured vital sign datasets on general wards were prospectively collected using a mobile solution system during routine patient care. Area under receiver operator characteristic curves were constructed, and comparisons between ROC curves were conducted with Delong's test for two correlated ROC curves.

SETTING

One university hospital and two regional hospitals in Finland.

PARTICIPANTS

All 19 001 adult patients admitted to 45 general wards in the three hospitals over the 1-year study period. After excluding 102/19 001 patients (0.53%) with data on some vital signs missing, the final cohort consisted of 18 889 patients with full datasets.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was 1-day mortality and secondary outcomes were 2-day and 30-day mortality rates.

RESULTS

Patients' median age was 70 years, 51% were male and 31% had a surgical reason for admission. The 1-day mortality was 0.36% and the 30-day mortality was 3.9%. The NEWS discriminated 1-day non-survivors with excellent accuracy (AUROC 0.91, 95% CI 0.87 to 0.95) and 30-day mortality with acceptable accuracy (0.75, 95% CI 0.73 to 0.77). The NEWS's respiratory rate component discriminated 1-day non-survivors better (0.78, 95% CI 0.72 to 0.84) as compared with the oxygen saturation (0.66, 95% CI 0.59 to 0.73), systolic blood pressure (0.65, 95% CI 0.59 to 0.72) and heart rate (0.67, 95% CI 0.61 to 0.74) subcomponents (p<0.01 in all ROC comparisons). As with the total NEWS, the discriminative performance of the individual score components decreased substantially for the 30-day mortality.

CONCLUSIONS

NEWS discriminated general ward patients at risk for acute death with excellent statistical accuracy. The respiratory rate component is especially strongly associated with short-term mortality.

TRIAL REGISTRATION NUMBER

NCT04055350.

Quick Sequential Organ Failure Assessment Score and the Modified Early Warning Score for Predicting Clinical Deterioration in General Ward Patients Regardless of Suspected Infection

BACKGROUND

The quick sequential organ failure assessment (qSOFA) score is suggested to use for screening patients with a high risk of clinical deterioration in the general wards, which could simply be regarded as a general early warning score. However, comparison of unselected admissions to highlight the benefits of introducing qSOFA in hospitals already using Modified Early Warning Score (MEWS) remains unclear. We sought to compare qSOFA with MEWS for predicting clinical deterioration in general ward patients regardless of suspected infection.

METHODS

The predictive performance of qSOFA and MEWS for in-hospital cardiac arrest (IHCA) or unexpected intensive care unit (ICU) transfer was compared with the areas under the receiver operating characteristic curve (AUC) analysis using the databases of vital signs collected from consecutive hospitalized adult patients over 12 months in five participating hospitals in Korea.

RESULTS

Of 173,057 hospitalized patients included for analysis, 668 (0.39%) experienced the composite outcome. The discrimination for the composite outcome for MEWS (AUC, 0.777; 95% confidence interval [CI], 0.770-0.781) was higher than that for qSOFA (AUC, 0.684; 95% CI, 0.676-0.686; P < 0.001). In addition, MEWS was better for prediction of IHCA (AUC, 0.792; 95% CI, 0.781-0.795 vs. AUC, 0.640; 95% CI, 0.625-0.645; P < 0.001) and unexpected ICU transfer (AUC, 0.767; 95% CI, 0.760-0.773 vs. AUC, 0.716; 95% CI, 0.707-0.718; P < 0.001) than qSOFA. Using the MEWS at a cutoff of ≥ 5 would correctly reclassify 3.7% of patients from qSOFA score ≥ 2. Most patients met MEWS ≥ 5 criteria 13 hours before the composite outcome compared with 11 hours for qSOFA score ≥ 2.

CONCLUSION

MEWS is more accurate that qSOFA score for predicting IHCA or unexpected ICU transfer in patients outside the ICU. Our study suggests that qSOFA should not replace MEWS for identifying patients in the general wards at risk of poor outcome.

Comparison of Quick Sequential Organ Failure Assessment (Qsofa) and National Early Warning Score (News) in Covid-19 Patients and its Correlation with the Outcome

The recent outbreak of COVID 19 is a great threat to public health. Because of limitation of resources, the number of patients that can be monitored and treated in Intensive Care Units is restricted. Hence identifying medical patients at risk of deterioration at the initial stage by means of simple protocols based on physiological parameters is crucial. The qSOFA score was introduced as a rapid bedside clinical score to identify patients with a suspected infection that are at greater risk for a poor outcome. The National Early Warning Score (NEWS) was developed to improve the detection of and response to clinical deterioration in patients with acute illness. There is paucity of literature regarding the use of these scores in patients with COVID 19 infection. This study aims at comparing the scoring systems qSOFA and NEWS in the setting of COVID-19 infection and its correlation with the final outcome of the illness.

MATERIAL

It is a retrospective study in which patients presenting with COVID 19 infection(diagnosed by RT-PCR testing of nasopharyngeal and oral swab) between April 2021 to June 2021 were included. Scoring was done using both the scores at admission and the patients were followed up till the outcome. Outcome was defined as 5-day, 10-day and 15-day mortality after presentation. Predictive performance was expressed as discrimination (AUC). Subsequently, sensitivity and specificity were calculated.

OBSERVATION

A total of 100 patients were included in the study, of whom 17 died within 5 days and 37 died within 10 days and 30 died within 15 days after presentation. q SOFA had the best performance, compared to NEWS (5 day auc : .668, .621, 10-day auc: .580, .569, 15-day auc: .625, .511) with q SOFA having sensitivity of 90.2% while that of news being 95.1% where as specificity of q SOFA is 40.7% and that of NEWS is 47.5%.

CONCLUSION

qSOFA score is more accurate in predicting 5, 10 and 15-day mortality than NEWS score in COVID 19 patients. In resource limited settings, it is an inexpensive and simple tool for early identification of high risk COVID 19 patients.

A systematic review of the discrimination and absolute mortality predicted by the National Early Warning Scores according to different cut-off values and prediction windows

BACKGROUND

Although early warning scores were intended to simply identify patients in need of life-saving interventions, prediction has become their commonest metric. This review examined variation in the ability of the National Early Warning Scores (NEWS) in adult patients to predict absolute mortality at different times and cut-offs values.

METHOD

Following PRISMA guidelines, all studies reporting NEWS and NEWS2 providing enough information to fulfil the review's aims were included.

RESULTS

From 121 papers identified, the average area under the Receiver Operating Characteristic curve (AUC) for mortality declined from 0.90 at 24-hours to 0.76 at 30-days. Studies with a low overall mortality had a higher AUC for 24-hour mortality, as did general ward patients compared to patients seen earlier in their treatment. 24-hour mortality increased from 1.8% for a NEWS ≥3 to 7.8% for NEWS ≥7. Although 24-hour mortality for NEWS <3 was only 0.07% these deaths accounted for 9% of all deaths within 24-hours; for NEWS <7 24-hour mortality was 0.23%, which accounted for 44% of all 24-hour deaths. Within 30-days of a NEWS recording 22% of all deaths occurred in patients with a NEWS <3, 52% in patients with a NEWS <5, and 75% in patient with a NEWS <7.

CONCLUSION

NEWS reliably identifies patients most and least likely to die within 24-hours, which is what it was designed to do. However, many patients identified to have a low risk of imminent death die within 30-days. NEWS mortality predictions beyond 24-hours are unreliable.

Evaluation of NEWS2 response thresholds in a retrospective observational study from a UK acute hospital

OBJECTIVE

Use of National Early Warning Score 2 (NEWS2) has been mandated in adults admitted to acute hospitals in England. Urgent clinical review is recommended at NEWS2 ≥5. This policy is recognised as requiring ongoing evaluation. We assessed NEWS2 acquisition, alerting at key thresholds and patient outcomes, to understand how response recommendations would affect clinical resource allocation.

SETTING

Adult acute hospital in England.

DESIGN

Retrospective observational cohort study.

PARTICIPANTS

100 362 consecutive admissions between November 2018 and July 2019.

OUTCOME

Death or admission to intensive care unit within 24 hours of a score.

METHODS

NEWS2 were assembled as single scores from consecutive 24-hour time frames, (the first NEWS2 termed 'Index-NEWS2'), or as all scores from the admission (termed All-NEWS2). Scores were excluded when a patient was in intensive care, in the presence of a decision not to attempt cardiopulmonary resuscitation, or on day 1 of elective admission.

RESULTS

A mean of 4.5 NEWS2 were acquired per patient per day. The outcome rate following an Index-NEWS2 was 0.22/100 patient-days. The sensitivity of outcome prediction at Index-NEWS2 ≥5=0.46, and number needed to evaluate (NNE)=52. At this threshold, a mean of 37.6 alerts/100 patient-days would be generated, occurring in 12.3% of patients on any single day. Threshold changes to increase sensitivity by 0.1, would result in a twofold increase in alert rate and 1.5-fold increase in NNE. Overall, NEWS2 classification performance was significantly worse on Index-scores than All-scores (c-statistic=0.78 vs 0.85; p<0.001).

CONCLUSIONS

The combination of low event-rate, high alert-rate and low sensitivity, in patients for cardiopulmonary resuscitation, means that at current NEWS2 thresholds, resource demand would be sufficient to meaningfully compete with other pathways to clinical evaluation. In analyses that epitomise in-patient screening, NEWS2 performance suggests a need for re-evaluation of current response recommendations in this population.

Performance Assessment of the Universal Vital Assessment Score vs Other Illness Severity Scores for Predicting Risk of In-Hospital Death Among Adult Febrile Inpatients in Northern Tanzania, 2016-2019

IMPORTANCE

Severity scores are used to improve triage of hospitalized patients in high-income settings, but the scores may not translate well to low- and middle-income settings such as sub-Saharan Africa.

OBJECTIVE

To assess the performance of the Universal Vital Assessment (UVA) score, derived in 2017, compared with other illness severity scores for predicting in-hospital mortality among adults with febrile illness in northern Tanzania.

DESIGN, SETTING, AND PARTICIPANTS

This prognostic study used clinical data collected for the duration of hospitalization among patients with febrile illness admitted to Kilimanjaro Christian Medical Centre or Mawenzi Regional Referral Hospital in Moshi, Tanzania, from September 2016 through May 2019. All adult and pediatric patients with a history of fever within 72 hours or a tympanic temperature of 38.0 °C or higher at screening were eligible for enrollment. Of 3761 eligible participants, 1132 (30.1%) were enrolled in the parent study; of those, 597 adults 18 years or older were included in this analysis. Data were analyzed from December 2019 to September 2021.

EXPOSURES

Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), quick Sequential Organ Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome (SIRS) assessment, and UVA.

MAIN OUTCOMES AND MEASURES

The main outcome was in-hospital mortality during the same hospitalization as the participant's enrollment. Crude risk ratios and 95% CIs for in-hospital death were calculated using log-binomial risk regression for proposed score cutoffs for each of the illness severity scores. The area under the receiver operating characteristic curve (AUROC) for estimating the risk of in-hospital death was calculated for each score.

RESULTS

Among 597 participants, the median age was 43 years (IQR, 31-56 years); 300 participants (50.3%) were female, 198 (33.2%) were HIV-infected, and in-hospital death occurred in 55 (9.2%). By higher risk score strata for each score, compared with lower risk strata, risk ratios for in-hospital death were 3.7 (95% CI, 2.2-6.2) for a MEWS of 5 or higher; 2.7 (95% CI, 0.9-7.8) for a NEWS of 5 or 6; 9.6 (95% CI, 4.2-22.2) for a NEWS of 7 or higher; 4.8 (95% CI, 1.2-20.2) for a qSOFA score of 1; 15.4 (95% CI, 3.8-63.1) for a qSOFA score of 2 or higher; 2.5 (95% CI, 1.2-5.2) for a SIRS score of 2 or higher; 9.1 (95% CI, 2.7-30.3) for a UVA score of 2 to 4; and 30.6 (95% CI, 9.6-97.8) for a UVA score of 5 or higher. The AUROCs, using all ordinal values, were 0.85 (95% CI, 0.80-0.90) for the UVA score, 0.81 (95% CI, 0.75-0.87) for the NEWS, 0.75 (95% CI, 0.69-0.82) for the MEWS, 0.73 (95% CI, 0.67-0.79) for the qSOFA score, and 0.63 (95% CI, 0.56-0.71) for the SIRS score. The AUROC for the UVA score was significantly greater than that for all other scores (P < .05 for all comparisons) except for NEWS (P = .08).

CONCLUSIONS AND RELEVANCE

This prognostic study found that the NEWS and the UVA score performed favorably compared with other illness severity scores in predicting in-hospital mortality among a hospitalized cohort of adults with febrile illness in northern Tanzania. Given its reliance on readily available clinical data, the UVA score may have utility in the triage and prognostication of patients admitted to the hospital with febrile illness in low- to middle-income settings such as sub-Saharan Africa.

The Effect of Pediatric Early Warning Score Use on Emergency Response Calls After Admission From the Pediatric Emergency Department

OBJECTIVES

Pediatric Early Warning Scores (PEWS) are an easy-to-use diagnostic tool for patient evaluation. The goal of this study was to determine if using PEWS in our pediatric emergency department (PED) at the time of admission to the hospital was associated with a decrease in the number of emergency response calls within 6 hours of admission.

METHODS

A retrospective chart review of 6 months before (May 2013-October 2013) and after (December 2013-May 2014) initiation of PEWS upon inpatient admission from our urban, tertiary care PED was conducted to determine the number of patients who had emergency response calls within 6 hours of admission.

RESULTS

The percentage of patients admitted from the PED who required an emergency response call within 6 hours of admission dropped from 1.77% in the 6 months before assigning PEWS to 0.79% in the 6 months after, a 55% reduction (P = 0.0070).

CONCLUSIONS

Assigning PEWS to patients being admitted to our hospital from the PED was associated with a reduced number of emergency response calls in the period immediately after admission.

Can Routinely Collected, Patient-Reported Wellness Predict National Early Warning Scores? A Multilevel Modeling Approach

OBJECTIVE

Measures exist to improve early recognition of and response to deteriorating patients in hospital. However, management of critical illness remains a problem globally; in the United Kingdom, 7% of the deaths reported to National Reporting and Learning System from acute hospitals in 2015 related to failure to recognize or respond to deterioration. The current study explored whether routinely recording patient-reported wellness is associated with objective measures of physiology to support early recognition of hospitalized deteriorating patients.

METHODS

A prospective observation study design was used. Nurses on four inpatient wards were invited to participate and record patient-reported wellness during every routine observation (where possible) using an electronic observation system. Linear multilevel modeling was used to examine the relationship between patient-reported wellness, and national early warning scores (NEWS), and whether patient-reported wellness predicted subsequent NEWS.

RESULTS

A significant positive relationship was found between patient-reported wellness and NEWS recorded at the next observation while controlling for baseline NEWS (β = 0.180, P = 0.033). A significant positive relationship between patient-reported wellness and NEWS (β = 0.229, P = 0.005) recorded during an observation 24 hours later while controlling for baseline NEWS was also found. Patient-reported wellness added to the predictive model for subsequent NEWS.

CONCLUSIONS

The preliminary findings suggest that patient-reported wellness may predict subsequent improvement or decline in their condition as indicated by objective measurements of physiology (NEWS). Routinely recording patient-reported wellness during observation shows promise for supporting the early recognition of clinical deterioration in practice, although confirmation in larger-scale studies is required.

Early warning scores to assess the probability of critical illness in patients with COVID-19

OBJECTIVE

Validated clinical risk scores are needed to identify patients with COVID-19 at risk of severe disease and to guide triage decision-making during the COVID-19 pandemic. The objective of the current study was to evaluate the performance of early warning scores (EWS) in the ED when identifying patients with COVID-19 who will require intensive care unit (ICU) admission for high-flow-oxygen usage or mechanical ventilation.

METHODS

Patients with a proven SARS-CoV-2 infection with complete resuscitate orders treated in nine hospitals between 27 February and 30 July 2020 needing hospital admission were included. Primary outcome was the performance of EWS in identifying patients needing ICU admission within 24 hours after ED presentation.

RESULTS

In total, 1501 patients were included. Median age was 71 (range 19-99) years and 60.3% were male. Of all patients, 86.9% were admitted to the general ward and 13.1% to the ICU within 24 hours after ED admission. ICU patients had lower peripheral oxygen saturation (86.7% vs 93.7, p≤0.001) and had a higher body mass index (29.2 vs 27.9 p=0.043) compared with non-ICU patients. National Early Warning Score 2 (NEWS2) ≥ 6 and q-COVID Score were superior to all other studied clinical risk scores in predicting ICU admission with a fair area under the receiver operating characteristics curve of 0.740 (95% CI 0.696 to 0.783) and 0.760 (95% CI 0.712 to 0.800), respectively. NEWS2 ≥6 and q-COVID Score ≥3 discriminated patients admitted to the ICU with a sensitivity of 78.1% and 75.9%, and specificity of 56.3% and 61.8%, respectively.

CONCLUSION

In this multicentre study, the best performing models to predict ICU admittance were the NEWS2 and the Quick COVID-19 Severity Index Score, with fair diagnostic performance. However, due to the moderate performance, these models cannot be clinically used to adequately predict the need for ICU admission within 24 hours in patients with SARS-CoV-2 infection presenting at the ED.

Validation of the National Early Warning Score (NEWS)-2 for adults in the emergency department in a tertiary-level clinic in Colombia: Cohort study

The National Early Warning Score (NEWS)-2 is an early warning scale that is used in emergency departments to identify patients at risk of clinical deterioration and to help establish rapid and timely management. The objective of this study was to determine the validity and prediction of mortality using the NEWS2 scale for adults in the emergency department of a tertiary clinic in Colombia.A prospective observational study was conducted between August 2018 and June 2019 at the Universidad de La Sabana Clinic.The nursing staff in the triage classified the patients admitted to the emergency room according to Emergency Severity Index and NEWS2. Demographic data, physiological variables, admission diagnosis, mortality outcome, and comorbidities were extracted.Three thousand nine hundred eighty-six patients were included in the study. Ninety-two (2%) patients required intensive care unit management, with a mean NEWS2 score of 7. A total of 158 patients died in hospital, of which 63 were women (40%). Of these 65 patients required intensive care unit management. The receiver operating characteristic curve for NEWS2 had an area of 0.90 (CI 95%: 0.87-0.92). A classification and score equivalency analysis was performed between triage and the NEWS2 scale in terms of mortality. Of the patients classified as triage I, 32.3% died, and those who obtained a NEWS2 score greater than or equal to 10 had a mortality of 38.6%.Among our population, NEWS2 was not inferior in its area under the receiver operating characteristic curve when predicting mortality than triage, and the cutoff point for NEWS2 to predict in-hospital mortality was higher.

A Trend-Based Early Warning Score Can Be Implemented in a Hospital Electronic Medical Record to Effectively Predict Inpatient Deterioration

OBJECTIVES

To determine whether a statistically derived, trend-based, deterioration index is superior to other early warning scores at predicting adverse events and whether it can be integrated into an electronic medical record to enable real-time alerts.

DESIGN

Forty-three variables and their trends from cases and controls were used to develop a logistic model and deterioration index to predict patient deterioration greater than or equal to 1 hour prior to an adverse event.

SETTING

Two large Australian teaching hospitals.

PATIENTS

Cases were considered as patients who suffered adverse events (unexpected death, unplanned ICU transfer, urgent surgery, and rapid-response alert) between August 1, 2016, and April 1, 2019.

INTERVENTIONS

The logistic model and deterioration index were tested on historical data and then integrated into an electronic medical record for a 6-month prospective "silent" validation.

MEASUREMENTS AND MAIN RESULTS

Data were acquired from 258,732 admissions. There were 8,002 adverse events. The addition of vital sign and laboratory trend values to the logistic model increased the area under the curve from 0.84 to 0.89 and the sensitivity to predict an adverse event 1-48 hours prior from 0.35 to 0.41. A 48-hour simulation showed that the logistic model had a higher area under the curve than the Modified Early Warning Score and National Early Warning Score (0.87 vs 0.74 vs 0.71). During the silently run prospective trial, the sensitivity of the deterioration index to detect adverse event any time prior to the adverse event was 0.474, 0.369 1 hour prior, and 0.327 4 hours prior, with a specificity of 0.972.

CONCLUSIONS

A deterioration prediction model was developed using patient demographics, ward-based observations, laboratory values, and their trends. The model's outputs were converted to a deterioration index that was successfully integrated into a live hospital electronic medical record. The sensitivity and specificity of the tool to detect inpatient deterioration were superior to traditional early warning scores.

National Early Warning Score 2 Lactate (NEWS2-L) in Predicting Early Clinical Deterioration in Patients with Dyspnoea in Prehospital Care

OBJECTIVES

To evaluate the ability of the NEWS2-L (National Early Warning Score 2 Lactate) scale to predict the risk of early clinical deterioration (mortality within 48 hours) in patients with dyspnoea treated by the Medical Emergency Services compared with NEWS2 and lactate in isolation.

METHODS

Prospective, multi-centre study of a cohort of 638 patients with dyspnoea treated in the ambulance and priority-transferred to a hospital emergency service in the cities of Valladolid, Salamanca, Segovia or Burgos (Spain). We collected clinical, analytical and demographic data. The main outcome measure was all-cause mortality within 48 hours. The recommendations of the Royal College of Physicians were followed to calculate NEWS2. When NEWS2 and LA prehospital values were obtained, the two values were added together to obtain the NEWS2-L.

RESULTS

Mortality within 48 hours was fifty-six patients (8.8%). The NEWS2-L scale obtained an area under the curve (AUC) of the receiver operating characteristics (ROC) for mortality within 48 hours of 0.854 (CI 95% 0.790-0.917), at seven days of 0.788 (CI 95% 0.729-0.848) and at 30 days of 0.744 (CI 95% 0.692-0.796); in all cases p<0.001, with a significant decrease between the value at 48 hours and at 30 days.

CONCLUSIONS

The NEWS2-L scale was found to be significantly superior to the NEWS2 scale and similar to lactate in predicting early clinical deterioration in patients with dyspnoea. This scale can help a nurse detect these patients early, as part of their regular practice, and thus guide therapeutic efforts.

National Early Warning Scores and COVID-19 deaths in care homes: an ecological time-series study

OBJECTIVES

To investigate whether National Early Warning Scores (NEWS/NEWS2) could contribute to COVID-19 surveillance in care homes.

SETTING

460 care home units using the same software package to collect data on residents, from 46 local authority areas in England.

PARTICIPANTS

6464 care home residents with at least one NEWS recording.

EXPOSURE MEASURE

29 656 anonymised person-level NEWS from 29 December 2019 to 20 May 2020 with component physiological measures: systolic blood pressure, respiratory rate, pulse rate, temperature and oxygen saturation. Baseline values for each measure calculated using 80th and 20th centile scores before March 2020.

OUTCOME MEASURE

Cross-correlation comparison of time series with Office for National Statistics weekly reported registered deaths of care home residents where COVID-19 was the underlying cause of death, and all other deaths (excluding COVID-19) up to 10 May 2020.

RESULTS

Deaths due to COVID-19 were registered from 23 March 2020 in the local authority areas represented in the study. Between 23 March 2020 and 10 May 2020, there were 5753 deaths (1532 involving COVID-19 and 4221 other causes). We observed a rise in the proportion of above-baseline NEWS beginning 16 March 2020, followed 2 weeks later by an increase in registered deaths (cross-correlation of r=0.82, p<0.05 for a 2 week lag) in corresponding local authorities. The proportion of above-baseline oxygen saturation, respiratory rate and temperature measurements also increased approximately 2 weeks before peaks in deaths.

CONCLUSIONS

NEWS could contribute to COVID-19 disease surveillance in care homes during the pandemic. Oxygen saturation, respiratory rate and temperature could be prioritised as they appear to signal rise in mortality almost as well as NEWS. This study reinforces the need to collate data from care homes, to monitor and protect residents' health. Further work using individual level outcome data is needed to evaluate the role of NEWS in the early detection of resident illness.

Establishing a warning index for evaluating the physiological stress of sanitation workers in high temperature weather

High temperature weather occurs frequently in recent years. As a heat-vulnerable group, sanitation workers suffer great physiological safety risks in high temperature weather. In this paper, a physiological warning index (PWI) is established to quantify the physiological stress of the sanitation workers. Firstly, the dynamic weights of the physiological parameters are calculated by the norm grey correlation method. Secondly, the PWI is established by the efficacy coefficient method and the warning level of the PWI is divided based on the relationships between the PWI and thermal sensation vote (TSV). Finally, the reasonability of the PWI is verified. The results show that the weights of the physiological parameters are dynamic, changing with the environments and the physiological states. The weight ranges of the mean skin temperature (MST), tympanic temperature (TT), systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) are 0.036-0.538, 0.000-0.369, 0.000-0.362, 0.018-0.367 and 0.009-0.348. And the MST and DBP are more affected by the high temperature than the TT, SBP and HR. The warning interval of PWI is: (0, 0.25] (no warning), (0.25, 0.45] (mild warning), (0.45, 0.7] (moderate warning), and (0.7, 1.0] (severe warning). The PWI can provide simple real-time physiological warning and guarantee physiological health for sanitation workers in high temperature weather.

Prognostic accuracy of emergency department triage tools for adults with suspected COVID-19: the PRIEST observational cohort study

BACKGROUND

The WHO and National Institute for Health and Care Excellence recommend various triage tools to assist decision-making for patients with suspected COVID-19. We aimed to compare the accuracy of triage tools for predicting severe illness in adults presenting to the ED with suspected COVID-19.

METHODS

We undertook a mixed prospective and retrospective observational cohort study in 70 EDs across the UK. We collected data from people attending with suspected COVID-19 and used presenting data to determine the results of assessment with the WHO algorithm, National Early Warning Score version 2 (NEWS2), CURB-65, CRB-65, Pandemic Modified Early Warning Score (PMEWS) and the swine flu adult hospital pathway (SFAHP). We used 30-day outcome data (death or receipt of respiratory, cardiovascular or renal support) to determine prognostic accuracy for adverse outcome.

RESULTS

We analysed data from 20 891 adults, of whom 4611 (22.1%) died or received organ support (primary outcome), with 2058 (9.9%) receiving organ support and 2553 (12.2%) dying without organ support (secondary outcomes). C-statistics for the primary outcome were: CURB-65 0.75; CRB-65 0.70; PMEWS 0.77; NEWS2 (score) 0.77; NEWS2 (rule) 0.69; SFAHP (6-point rule) 0.70; SFAHP (7-point rule) 0.68; WHO algorithm 0.61. All triage tools showed worse prediction for receipt of organ support and better prediction for death without organ support. At the recommended threshold, PMEWS and the WHO criteria showed good sensitivity (0.97 and 0.95, respectively) at the expense of specificity (0.30 and 0.27, respectively). The NEWS2 score showed similar sensitivity (0.96) and specificity (0.28) when a lower threshold than recommended was used.

CONCLUSION

CURB-65, PMEWS and the NEWS2 score provide good but not excellent prediction for adverse outcome in suspected COVID-19, and predicted death without organ support better than receipt of organ support. PMEWS, the WHO criteria and NEWS2 (using a lower threshold than usually recommended) provide good sensitivity at the expense of specificity.

TRIAL REGISTRATION NUMBER

ISRCTN56149622.

Experiences of a National Early Warning Score (NEWS) intervention in care homes during the COVID-19 pandemic: a qualitative interview study

BACKGROUND

The COVID-19 pandemic has taken a heavy toll on the care home sector, with residents accounting for up to half of all deaths in Europe. The response to acute illness in care homes plays a particularly important role in the care of residents during a pandemic. Digital recording of a National Early Warning Score (NEWS), which involves the measurement of physical observations, started in care homes in one area of England in 2016. Implementation of a NEWS intervention (including equipment, training and support) was accelerated early in the pandemic, despite limited evidence for its use in the care home setting.

OBJECTIVES

To understand how a NEWS intervention has been used in care homes in one area of North-East England during the COVID-19 pandemic, and how it has influenced resident care, from the perspective of stakeholders involved in care delivery and commissioning.

METHODS

A qualitative interview study with care home (n=10) and National Health Service (n=7) staff. Data were analysed using thematic analysis.

RESULTS

Use of the NEWS intervention in care homes in this area accelerated during the COVID-19 pandemic. Stakeholders felt that NEWS, and its associated education and support package, improved the response of care homes and healthcare professionals to deterioration in residents' health during the pandemic. Healthcare professionals valued the ability to remotely monitor resident observations, which facilitated triage and treatment decisions. Care home staff felt empowered by NEWS, providing a common clinical language to communicate concerns with external services, acting as an adjunct to staff intuition of resident deterioration.

CONCLUSIONS

The NEWS intervention formed an important part of the care home response to COVID-19 in the study area. Positive staff perceptions now need to be supplemented with data on the impact on resident health and well-being, workload, and service utilisation, during the pandemic and beyond.