NEWS2 is a valuable tool for appropriate clinical management of COVID-19 patients

Modifications to the National Early Warning Score 2: a Scoping Review

BACKGROUND

The National Early Warning Score 2 (NEWS2) has been adopted as the standard approach for early detection of deterioration in clinical settings in the UK, and is also used in many non-UK settings. Limitations have been identified, including a reliance on 'normal' physiological parameters without accounting for individual variation.

OBJECTIVE

This review aimed to map how the NEWS2 has been modified to improve its predictive accuracy while placing minimal additional burden on clinical teams.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-ScR) and the Population, Intervention, Comparator, Outcome, and Study (PICOS) frameworks were followed to structure the review. Six databases (CINAHL, PubMed, Embase, ScienceDirect, Cochrane Library and Web of Science) were searched for studies which reported the predictive accuracy of a modified version of NEWS2. The references were screened based on keywords using EndNote 21. Title, abstract and full-text screening were performed by 2 reviewers independently in Rayyan. Data was extracted into a pre-established form and synthesised in a descriptive analysis.

RESULTS

Twelve studies were included from 12,867 references. In 11 cases, modified versions of NEWS2 demonstrated higher predictive accuracy for at least one outcome. Modifications that incorporated demographic variables, trend data and adjustments to the weighting of the score's components were found to be particularly conducive to enhancing the predictive accuracy of NEWS2.

CONCLUSIONS

Three key modifications to NEWS2-incorporating age, nuanced treatment of FiO2 data and trend analysis-have the potential to improve predictive accuracy without adding to clinician burden. Future research should validate these modifications and explore their composite impact to enable substantial improvements to the performance of NEWS2.

NEWS-2 Accuracy in Predicting Mortality and Severe Morbidity Among Hospitalized COVID-19 Patients: A Prospective Cohort Study

Background: Early risk stratification tools for COVID-19 patients have been indicated yet there are few data about their ability to effectively detect clinical deterioration among COVID-19 patients. Objectives: To evaluate the NEWS-2 to predict severe morbidity and mortality for COVID-19 patients admitted to hospitals. Methods: We conducted a prospective cohort study among adult COVID-19 patients with a confirmed diagnosis who were admitted to the inpatient units at COVID-19 Martyrs Medical Military Complex Hospital, from 1 March 2022, until 29 February 2023. NEWS-2 scores were measured at admission and 6, 12, 24, and 48 h after their admission to the hospital using receiver operating characteristic (ROC) curves. Results: Overall, 192 adult COVID-19 patients aged 25-94 years (mean = 62.1, SD = 13.9) were enrolled. Of those, 49.0% were males, 47.4% were vaccinated, and 53.6% had diabetes. The 192 enrolled patients were classified into NEWS-2 score categories, with almost 13% (12.5%) falling into the high-risk category already upon admission. The mean NEWS-2 scores were excellent predictors of mechanical ventilation, admission to the ICU, and mortality, as indicated by an AUROC of 0.94 (95% CI: 0.88-1.00, p < 0.001), 0.91 (95% CI: 0.87-0.96, p < 0.001), and 0.96 (95% CI: 0.92-1.00, p < 0.001), respectively. Significant differences in mean NEWS-2 scores were found between the participating patients, both with and without comorbidity in the course of the patient's stay in the ICU, and mortality (p = 0.004, p = 0.043, respectively). Positive correlations of the high NEWS-2 scores were revealed using a multiple linear regression model, indicating the necessity of administering non-invasive ventilatory assistance (p = 0.013), hospitalization for a minimum of six days (p = 0.013), and admission to the ICU (p = 0.006). Nonetheless, there was a negative association between mortality and the NEWS-2 score (p < 0.001). Conclusions: The NEWS-2 had moderate sensitivity and specificity in predicting the deterioration of patients with COVID-19 whereas there was high sensitivity and specificity in predicting the mortality for patients with COVID-19, both with and without comorbidity. Our findings support the utility of NEWS-2 monitoring as a sensitive approach for initially assessing COVID-19 patients. It could be helpful to enhance the accuracy of predictive performance by supplementing the score parameters by adding biological parameters in addition to clinical judgment.

Long-term brain fog and cognitive impairment in previously hospitalized COVID-19 patients

OBJECTIVES

Limited research exists on COVID-19 associated brain fog, and on the long-term cognitive and psychiatric sequelae in racially and ethnically diverse patients. We characterize the neuropsychological sequelae of post-acute COVID-19 in a diverse cohort and investigate whether COVID-19 clinical severity remains associated with brain fog and cognitive deficits approximately 2 years post infection.

METHODS

A cross-sectional study of patients with a history of COVID-19 hospitalization (March-September 2020). COVID-19 clinical severity was indexed using the National Early Warning Score 2 and a comprehensive neuropsychological tele-battery was administered 2 years post discharge. Pearson's r correlations assessed association, while independent sample t-tests examined group differences. Significant outcomes were further analyzed using multiple regression and ANCOVAs, adjusting for key covariates.

RESULTS

In 41 adult patients (19 female, 30 Hispanic, 13 Black, mean age of 65 (SD = 15), COVID-19 level of severity was associated with greater number of endorsed brain fog symptoms (Pearson's r = .34, 95% CI [.04, .59]), worse overall cognitive functioning (global cognition: r = -.36, 95% CI [-.61, -.05]) and reduced performance on an attention and working memory task (digit span backwards: r = -.41, 95% CI [-.66, -.09]) at 2-year follow-up. Brain fog symptoms most associated with COVID-19 severity included difficulty focusing (r = .46, 95% CI [.18, .67]), detached (r = .41, 95% CI [.12, .64]) and feeling sleepy (r = .40, 95% CI [.11, .63]). Patients' cognitive performance was generally below average (global cognition z-score: M = -.96, SD = .66), with group differences based on sex and ethnicity evidenced on individual cognitive tests.

DISCUSSION

This study emphasizes the importance of continued research on the long-term effects of COVID-19 infection on neuropsychological outcomes, particularly among underrepresented, health-disparate groups. Greater understanding of these associations could improve detection and treatment of those at increased risk of cognitive decline or impairment.

"Long COVID" results after hospitalization for SARS-CoV-2 infection

Long-term sequelae of symptomatic infection caused by SARS-CoV-2 are largely undiscovered. We performed a prospective cohort study on consecutively hospitalized Sars-CoV-2 patients (March–May 2020) for evaluating COVID-19 outcomes at 6 and 12 months. After hospital discharge, patients were addressed to two follow-up pathways based on respiratory support needed during hospitalization. Outcomes were assessed by telephone consultation or ambulatory visit. Among 471 patients, 80.9% received no respiratory support during hospitalization; 19.1% received non-invasive ventilation (NIV) or invasive mechanical ventilation (IMV). 58 patients died during hospitalization, therefore 413 were enrolled for follow-up. At 6 months, among 355 patients, the 30.3% had any symptoms, 18.0% dyspnea, 6.2% neurological symptoms. Fifty-two out of 105 had major damages in interstitial computed tomography images. NIV/IMV patients had higher probability to suffer of symptoms (aOR = 4.00, 95%CI:1.99–8.05), dyspnea (aOR = 2.80, 95%CI:1.28–6.16), neurological symptoms (aOR = 9.72, 95%CI:2.78–34.00). At 12 months, among 344, the 25.3% suffered on any symptoms, 12.2% dyspnea, 10.1% neurological symptoms. Severe interstitial lesions were present in 37 out of 47 investigated patients. NIV/IMV patients in respect to no respiratory support, had higher probability of experiencing symptoms (aOR = 3.66, 95%CI:1.73–7.74), neurological symptoms (aOR = 8.96, 95%CI:3.22–24.90). COVID-19 patients showed prolonged sequelae up to 12 months, highlighting the need of follow-up pathways for post-COVID-19 syndrome.

Prospective predictive performance comparison between clinical gestalt and validated COVID-19 mortality scores

Most COVID-19 mortality scores were developed at the beginning of the pandemic and clinicians now have more experience and evidence-based interventions. Therefore, we hypothesized that the predictive performance of COVID-19 mortality scores is now lower than originally reported. We aimed to prospectively evaluate the current predictive accuracy of six COVID-19 scores and compared it with the accuracy of clinical gestalt predictions. 200 patients with COVID-19 were enrolled in a tertiary hospital in Mexico City between September and December 2020. The area under the curve (AUC) of the LOW-HARM, qSOFA, MSL-COVID-19, NUTRI-CoV, and NEWS2 scores and the AUC of clinical gestalt predictions of death (as a percentage) were determined. In total, 166 patients (106 men and 60 women aged 56±9 years) with confirmed COVID-19 were included in the analysis. The AUC of all scores was significantly lower than originally reported: LOW-HARM 0.76 (95% CI 0.69 to 0.84) vs 0.96 (95% CI 0.94 to 0.98), qSOFA 0.61 (95% CI 0.53 to 0.69) vs 0.74 (95% CI 0.65 to 0.81), MSL-COVID-19 0.64 (95% CI 0.55 to 0.73) vs 0.72 (95% CI 0.69 to 0.75), NUTRI-CoV 0.60 (95% CI 0.51 to 0.69) vs 0.79 (95% CI 0.76 to 0.82), NEWS2 0.65 (95% CI 0.56 to 0.75) vs 0.84 (95% CI 0.79 to 0.90), and neutrophil to lymphocyte ratio 0.65 (95% CI 0.57 to 0.73) vs 0.74 (95% CI 0.62 to 0.85). Clinical gestalt predictions were non-inferior to mortality scores, with an AUC of 0.68 (95% CI 0.59 to 0.77). Adjusting scores with locally derived likelihood ratios did not improve their performance; however, some scores outperformed clinical gestalt predictions when clinicians' confidence of prediction was <80%. Despite its subjective nature, clinical gestalt has relevant advantages in predicting COVID-19 clinical outcomes. The need and performance of most COVID-19 mortality scores need to be evaluated regularly.

National Early Warning Score 2 (NEWS2) to predict poor outcome in hospitalised COVID-19 patients in India

BACKGROUND

While several parameters have emerged as predictors of prognosis of COVID-19, a simple clinical score at baseline might help early risk stratification. We determined the ability of National Early Warning Score 2 (NEWS2) to predict poor outcomes among adults with COVID-19.

METHODS

A prospective study was conducted on 399 hospitalised adults with confirmed SARS-CoV-2 infection between August and December 2020. Baseline NEWS2 score was determined. Primary outcome was poor outcomes defined as need for mechanical ventilation or death within 28 days. The sensitivity, specificity and Area under the curve were determined for NEWS2 scores of 5 and 6.

RESULTS

Mean age of patients was 55.5 ± 14.8 years and 275 of 399 (68.9%) were male. Overall mortality was 3.8% and 7.5% had poor outcomes. Median (interquartile range) NEWS2 score at admission was 2 (0-6). Sensitivity and specificity of NEWS 2 of 5 or more in predicting poor outcomes was 93.3% (95% CI: 76.5-98.8) and 70.7% (95% CI: 65.7-75.3) respectively [area under curve 0.88 (95% CI: 0.847-0.927)]. Age, baseline pulse rate, baseline oxygen saturation, need for supplemental oxygen and ARDS on chest X ray were independently associated with poor outcomes.

CONCLUSIONS

NEWS2 score of 5 or more at admission predicts poor outcomes in patients with COVID-19 with good sensitivity and can easily be applied for risk stratification at baseline. Further studies are needed in the Indian setting to validate this simple score and recommend widespread use.

How did COVID-19 affect medical and cardiology journals? A pandemic in literature

BACKGROUND AND AIMS

The spreading speed of the COVID-19 pandemic forced the medical community to produce efforts in updating and sharing the evidence about this new disease, trying to preserve the accuracy of the data but at the same time avoiding the potentially harmful delay from discovery to implementation. The aim of our analysis was to assess the impact of the COVID-19 pandemic on medical literature in terms of proportion of COVID-19-related published papers and temporal patterns of publications within a sample of general/internal medicine and cardiology journals.

METHODS

We searched through PubMed scientific papers published from 1 January 2020 to 31 January 2021 about COVID-19 in ten major medical journals, of which five were in general/internal medicine and five in the cardiology field. We analyzed the proportion of COVID-19-related papers, and we examined temporal trends in the number of published papers.

RESULTS

Overall, the proportion of COVID-19-related papers was 18.5% (1986/10 756). This proportion was higher among the five selected general/internal medicine journals, compared with cardiology journals (23.8% vs 9.5%). The vast majority of papers were not original articles; in particular, in cardiology journals, there were 28% 'original articles', 17% 'review articles' and 55.1% 'miscellaneous', compared with 20.2%, 5.1% and 74.7% in general/internal medicine journals, respectively.

CONCLUSIONS

Our analysis highlights the big impact of the COVID-19 pandemic on international scientific literature. General and internal medicine journals were mainly involved, with cardiology journals only at a later time.

Chest Radiograph Scoring Alone or Combined with Other Risk Scores for Predicting Outcomes in COVID-19

Background

Radiographic severity may help predict patient deterioration and outcomes from COVID-19 pneumonia.

Purpose

To assess the reliability and reproducibility of three chest radiograph reporting systems (radiographic assessment of lung edema [RALE], Brixia, and percentage opacification) in patients with proven SARS-CoV-2 infection and examine the ability of these scores to predict adverse outcomes both alone and in conjunction with two clinical scoring systems, National Early Warning Score 2 (NEWS2) and International Severe Acute Respiratory and Emerging Infection Consortium: Coronavirus Clinical Characterization Consortium (ISARIC-4C) mortality.

Materials and Methods

This retrospective cohort study used routinely collected clinical data of patients with polymerase chain reaction–positive SARS-CoV-2 infection admitted to a single center from February 2020 through July 2020. Initial chest radiographs were scored for RALE, Brixia, and percentage opacification by one of three radiologists. Intra- and interreader agreement were assessed with intraclass correlation coefficients. The rate of admission to the intensive care unit (ICU) or death up to 60 days after scored chest radiograph was estimated. NEWS2 and ISARIC-4C mortality at hospital admission were calculated. Daily risk for admission to ICU or death was modeled with Cox proportional hazards models that incorporated the chest radiograph scores adjusted for NEWS2 or ISARIC-4C mortality.

Results

Admission chest radiographs of 50 patients (mean age, 74 years ± 16 [standard deviation]; 28 men) were scored by all three radiologists, with good interreader reliability for all scores, as follows: intraclass correlation coefficients were 0.87 for RALE (95% CI: 0.80, 0.92), 0.86 for Brixia (95% CI: 0.76, 0.92), and 0.72 for percentage opacification (95% CI: 0.48, 0.85). Of 751 patients with a chest radiograph, those with greater than 75% opacification had a median time to ICU admission or death of just 1–2 days. Among 628 patients for whom data were available (median age, 76 years [interquartile range, 61–84 years]; 344 men), opacification of 51%–75% increased risk for ICU admission or death by twofold (hazard ratio, 2.2; 95% CI: 1.6, 2.8), and opacification greater than 75% increased ICU risk by fourfold (hazard ratio, 4.0; 95% CI: 3.4, 4.7) compared with opacification of 0%–25%, when adjusted for NEWS2 score.

Conclusion

Brixia, radiographic assessment of lung edema, and percentage opacification scores all reliably helped predict adverse outcomes in SARS-CoV-2 infection.

© RSNA, 2021

Online supplemental material is available for this article.

See also the editorial by Little in this issue.

Effect of National Early Warning Scoring System Implementation on Cardiopulmonary Arrest, Unplanned ICU Admission, Emergency Surgery, and Acute Kidney Injury in an Emergency Hospital, Egypt

Purpose

To evaluate the effect of national early warning scoring system (NEWS) implementation in identifying patients at risk of clinical deterioration at an emergency hospital.

Background

Early warning score has been developed to facilitate early detection of deterioration by categorizing a patients’ severity of illness and prompting nursing staff to request a medical review at specific trigger points.

Patients and Methods

A prospective, control/intervention groups’, quasi-experimental design was utilized. A sample of 364 adult patients were admitted to the inpatient unit at an emergency hospital for six months. The patients were divided into a study group (174 patients) and a control group (190 patients). All study patients were followed up to either death or hospital discharge before and after implementing a new observation chart. The patients’ outcomes were compared and analyzed between both groups.

Results

In the intervention period, compared to the control period, a significant reduction was seen in the number of cardiopulmonary arrest (4.7% vs 1.1%, p = 0.046), unplanned ICU admission (5.3% vs 1.7%, p = 0.049), emergency surgery (6.3% vs 0%, p = 0.001), acute kidney injury (6.8% vs 1.1%, p = 0.006). As well, there was a significant increase in the number of patients receiving medical reviews following clinical deterioration in terms of escalation plan (3.2% vs 26.4%, p = <0.001).

Conclusion

The implementation of NEWS was associated with a significant improvement in patients’ outcomes in hospital wards, increases in the frequency of vital signs measurements, and an increase in the number of medical reviews following clinical instability.

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