A single-centre observational cohort study of admission National Early Warning Score (NEWS)

Unveiling the performance of the prehospital Rapid Emergency Medicine Score (pREMS): How the predictive score impacts in-hospital outcomes in traumatic brain injury (TBI): A retrospective observational cohort study

INTRODUCTION

This study aimed to evaluate the predictive accuracy of the prehospital rapid emergency medicine score (pREMS) for predicting the outcomes of hospitalized patients with traumatic brain injury (TBI) who died, were discharged, were admitted to the intensive care unit (ICU), or were admitted to the operating room (OR) within 72 h.

METHODS

A retrospective cohort analysis was performed on a sample of 513 TBI patients admitted to the emergency department (ED) of Besat Hospital in 2023. Only patients of both sexes aged 18 years or older who were not pregnant and had adequate documentation of vital signs were included in the analysis. Patients who died during transport and patients who were transferred from other hospitals were excluded. The predictive power of the pREMS for each outcome was assessed by calculating the sensitivity and specificity curves and by analyzing the area under the receiver operating characteristic curve (AUROC).

RESULTS

The mean pREMS scores for hospital discharge, death, ICU admission and OR admission were 11.97 ± 3.84, 6.32 ± 3.15, 8.24 ± 5.17 and 9.88 ± 2.02, respectively. pREMS accurately predicted hospital discharge and death (AOR = 1.62, P < 0.001) but was not a good predictor of ICU or OR admission (AOR = 1.085, P = 0.603). The AUROCs for the ability of the pREMS to predict outcomes in hospitalized TBI patients were 0.618 (optimal cutoff point = 7) for ICU admission and OR and 0.877 (optimal cutoff point = 9.5) for hospital discharge and death at 72 h.

CONCLUSION

The results indicate that the pREMS, a new preclinical trauma score for traumatic brain injury, is a useful tool for prehospital risk stratification (RST) in TBI patients. The pREMS showed good discriminatory power for predicting in-hospital mortality within 72 h in patients with traumatic brain injury.

Indicators of patient deterioration in poorly resourced private hospitals: Which vital sign to watch? A retrospective case-control study

BACKGROUND

Patient vital signs are a measure of wellness if monitored regularly and accurately. Staff shortages in poorly resourced regional hospitals often result in inadequate patient monitoring, putting patients at risk of undetected deterioration.

OBJECTIVE

This study aims to explore the pattern and completeness of vital sign monitoring and the contribution of each vital sign in predicting clinical deterioration events in resource-poor regional/rural hospitals.

METHOD

Using a retrospective case-control study design, we compared 24 h of vital sign data from deteriorating and nondeteriorating patients from two poorly-resourced regional hospitals. Descriptive statistics, t-tests, and analysis of variance are used to compare patient-monitoring frequency and completeness. The contribution of each vital sign in predicting patient deterioration was determined using the Area Under the Receiver Operator Characteristic curve and binary logistical regression analysis.

RESULTS

Deteriorating patients were monitored more frequently (9.58 [7.02] times) in the 24-h period than nondeteriorating patients (4.93 [2.66] times). However, the completeness of vital sign documentation was higher in nondeteriorating (85.2%) than in deteriorating patients (57.7%). Body temperature was the most frequently omitted vital sign. Patient deterioration was positively linked to the frequency of abnormal vital signs and the number of abnormal vital signs per set (Area Under the Receiver Operator Characteristic curve: 0.872 and 0.867, respectively). No single vital sign strongly predicts patient outcomes. However, a supplementary oxygen value of >3 L/min and a heart rate of >139 beats/min were the best predictors of patient deterioration.

CONCLUSION

Given the poor resourcing and often geographical remoteness of small regional hospitals, it is prudent that the nursing staff are made aware of the vital signs that best indicate deterioration for the cohort of patients in their care. Tachycardic patients on supplementary oxygen are at high risk of deterioration.

Safer and more efficient vital signs monitoring protocols to identify the deteriorating patients in the general hospital ward: an observational study

Background

The frequency at which patients should have their vital signs (e.g. blood pressure, pulse, oxygen saturation) measured on hospital wards is currently unknown. Current National Health Service monitoring protocols are based on expert opinion but supported by little empirical evidence. The challenge is finding the balance between insufficient monitoring (risking missing early signs of deterioration and delays in treatment) and over-observation of stable patients (wasting resources needed in other aspects of care).

Objective

Provide an evidence-based approach to creating monitoring protocols based on a patient's risk of deterioration and link these to nursing workload and economic impact.

Design

Our study consisted of two parts: (1) an observational study of nursing staff to ascertain the time to perform vital sign observations; and (2) a retrospective study of historic data on patient admissions exploring the relationships between National Early Warning Score and risk of outcome over time. These were underpinned by opinions and experiences from stakeholders.

Setting and participants

Observational study: observed nursing staff on 16 randomly selected adult general wards at four acute National Health Service hospitals. Retrospective study: extracted, linked and analysed routinely collected data from two large National Health Service acute trusts; data from over 400,000 patient admissions and 9,000,000 vital sign observations.

Results

Observational study found a variety of practices, with two hospitals having registered nurses take the majority of vital sign observations and two favouring healthcare assistants or student nurses. However, whoever took the observations spent roughly the same length of time. The average was 5:01 minutes per observation over a 'round', including time to locate and prepare the equipment and travel to the patient area. Retrospective study created survival models predicting the risk of outcomes over time since the patient was last observed. For low-risk patients, there was little difference in risk between 4 hours and 24 hours post observation.

Conclusions

We explored several different scenarios with our stakeholders (clinicians and patients), based on how 'risk' could be managed in different ways. Vital sign observations are often done more frequently than necessary from a bald assessment of the patient's risk, and we show that a maximum threshold of risk could theoretically be achieved with less resource. Existing resources could therefore be redeployed within a changed protocol to achieve better outcomes for some patients without compromising the safety of the rest. Our work supports the approach of the current monitoring protocol, whereby patients' National Early Warning Score 2 guides observation frequency. Existing practice is to observe higher-risk patients more frequently and our findings have shown that this is objectively justified. It is worth noting that important nurse-patient interactions take place during vital sign monitoring and should not be eliminated under new monitoring processes. Our study contributes to the existing evidence on how vital sign observations should be scheduled. However, ultimately, it is for the relevant professionals to decide how our work should be used.

Study registration

This study is registered as ISRCTN10863045.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/03) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 6. See the NIHR Funding and Awards website for further award information.

Comparing the prehospital NEWS with in-hospital ESI in predicting 30-day severe outcomes in emergency patients

BACKGROUND

In Iran, the emergency departments (EDs) have largely adopted the emergency severity index (ESI) to prioritize the emergency patients, however emergency medical services (EMS) mainly triage the patients based on the paramedics' gestalt. The National Early Warning Score (NEWS) is a recommended prehospital triage in the UK. We aimed to compare prehospital NEWS and ED ESI for predicting severe outcomes in emergency patients.

METHODS

An observational study was conducted in a university-affiliated ED between January and April 2021. Adult patients who arrived in the ED by EMS were included. EMS providers calculated the patients' NEWS upon arriving on the scene using an Android NEWS application. In the ED, triage nurses utilized the ESI algorithm to prioritize patients with higher clinical risk. Then, Research nurses recorded patients' 30-day severe outcomes (death or ICU admission). Finally, The prognostic properties of ESI and NEWS were evaluated.

RESULTS

One thousand forty-eight cases were included in the final analysis, of which 29 (2.7%) patients experienced severe outcomes. The difference between the prehospital NEWS and ED ESI in predicting severe outcomes was not statistically significant (AUC = 0.825, 95% CI: 0.74-0.91 and 0.897, 95% CI, 0.83-0.95, for prehospital NEWS and ESI, respectively).

CONCLUSION

Our findings indicated that prehospital NEWS compares favorably with ED ESI in predicting 30-day severe outcomes in emergency patients.

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.

Using NEWS2 to triage newly admitted patients with COVID-19

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has spread globally and caused a major worldwide health crisis. Patients who are affected more seriously by COVID-19 usually deteriorate rapidly and need further intensive care.

AIMS AND OBJECTIVES

We aimed to assess the performance of the National Early Warning Score 2 (NEWS2) as a risk stratification tool to discriminate newly admitted patients with COVID-19 at risk of serious events.

DESIGN

We conducted a retrospective single-centre case-control study on 200 unselected patients consecutively admitted in March 2020 in a public general hospital in Wuhan, China.

METHODS

The following serious events were considered: mortality, unplanned intensive care unit (ICU) admission, and non-invasive ventilation treatment. Receiver operating characteristic (ROC) analysis and logistic regression analysis were used to quantify the association between outcomes and NEWS2.

RESULTS

There were 12 patients (6.0%) who had serious events, where 7 patients (3.5%) experienced unplanned ICU admissions. The area under the ROC curve (AUROC) and cut-off of NEWS2 for the composite outcome were 0.83 and 3, respectively. For patients with NEWS2 ≥ 4, the odds of being at risk for serious events was 16.4 (AUROC = 0.74), while for patients with NEWS2 ≥ 7, the odds of being at risk for serious events was 18.2 (AUROC = 0.71).

CONCLUSIONS

NEWS2 has an appropriate ability to triage newly admitted patients with COVID-19 into three levels of risk: low risk (NEWS2 = 0-3), medium risk (NEWS2 = 4-6), and high risk (NEWS2 ≥ 7).

RELEVANCE TO CLINICAL PRACTICE

Using NEWS2 may help nurses in early identification of at-risk COVID-19 patients and clinical nursing decision-making. Using NEWS2 to triage new patients with COVID-19 may help nurses provide more appropriate level of care and medical resources allocation for patients safety.

Outcome prediction value of National Early Warning Score in septic patients with community-acquired pneumonia in emergency department: A single-center retrospective cohort study

BACKGROUND

To evaluate the accuracy of National Early Warning Score (NEWS) in predicting clinical outcomes (28-day mortality, intensive care unit [ICU] admission, and mechanical ventilation use) for septic patients with community-acquired pneumonia (CAP) compared with other commonly used severity scores (CURB65, Pneumonia Severity Index [PSI], Sequential Organ Failure Assessment [SOFA], quick SOFA [qSOFA], and Mortality in Emergency Department Sepsis [MEDS]) and admission lactate level.

METHODS

Adult patients diagnosed with CAP admitted between January 2017 and May 2019 with admission SOFA ≥2 from baseline were enrolled. Demographic characteristics were collected. The primary outcome was the 28-day mortality after admission, and the secondary outcome included ICU admission and mechanical ventilation use. Outcome prediction value of parameters above was compared using receiver operating characteristics (ROC) curves. Cox regression analyses were carried out to determine the risk factors for the 28-day mortality. Kaplan-Meier survival curves were plotted and compared using optimal cut-off values of qSOFA and NEWS.

RESULTS

Among the 340 enrolled patients, 90 patients were dead after a 28-day follow-up, 62 patients were admitted to ICU, and 84 patients underwent mechanical ventilation. Among single predictors, NEWS achieved the largest area under the receiver operating characteristic (AUROC) curve in predicting the 28-day mortality (0.861), ICU admission (0.895), and use of mechanical ventilation (0.873). NEWS+lactate, similar to MEDS+lactate, outperformed other combinations of severity score and admission lactate in predicting the 28-day mortality (AUROC 0.866) and ICU admission (AUROC 0.905), while NEWS+lactate did not outperform other combinations in predicting mechanical ventilation (AUROC 0.886). Admission lactate only improved the predicting performance of CURB65 and qSOFA in predicting the 28-day mortality and ICU admission.

CONCLUSIONS

NEWS could be a valuable predictor in septic patients with CAP in emergency departments. Admission lactate did not predict well the outcomes or improve the severity scores. A qSOFA ≥2 and a NEWS ≥9 were strongly associated with the 28-day mortality, ICU admission, and mechanical ventilation of septic patients with CAP in the emergency departments.

Early warning scores for detecting deterioration in adult hospital patients: systematic review and critical appraisal of methodology

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.

Can the prehospital National Early Warning Score 2 identify patients at risk of in-hospital early mortality? A prospective, multicenter cohort study

BACKGROUND

The National Early Warning Score 2 (NEWS2) scores can help identify clinical deterioration.

OBJECTIVE

To assess the predictive capacity of the NEWS2 at prehospital level for the detection of early mortality in the hospital.

METHODS

Prospective multicenter cohort study, in which we compiled a database of observed vital signs between March 1, 2018 and May 30, 2019. We collected demographic data, vital signs (respiration rate, oxygen saturation, supplemental oxygen, temperature, systolic blood pressure, heart rate and level of consciousness), prehospital diagnosis and hospital mortality data. We calculated the AUROC of the NEWS2 for early mortality.

RESULTS

We included a total of 2335 participants. Median age was 69 years (IQR 54-81 years). The AUC for mortality within one day was 0.862 (95%CI:0.78-0.93), within two days 0.885 (95%CI:0.84-0.92) and within seven days 0.835 (95%CI:0.79-0.87) (in all cases, p<0.001).

CONCLUSIONS

The NEWS2 performed at prehospital level is a bedside tool for predicting early hospital mortality.

Symptom Management and Supportive Care of Serious COVID-19 Patients and their Families in India

Coronavirus disease-19 (COVID-19) pandemic is causing a worldwide humanitarian crisis. Old age, comorbid conditions, end-stage organ impairment, and advanced cancer, increase the risk of mortality in serious COVID-19. A subset of serious COVID-19 patients with serious acute respiratory illness may be triaged not to receive aggressive intensive care unit (ICU) treatment and ventilation or may be discontinued from ventilation due to their underlying conditions. Those not eligible for aggressive ICU measures should receive appropriate symptom management. Early warning scores (EWS), oxygen saturation, and respiratory rate, can facilitate categorizing COVID-19 patients as stable, unstable, and end of life. Breathlessness, delirium, respiratory secretions, and pain, are the key symptoms that need to be assessed and palliated. Palliative sedation measures are needed to manage intractable symptoms. Goals of care should be discussed, and advance care plan should be made in patients who are unlikely to benefit from aggressive ICU measures and ventilation. For patients who are already in an ICU, either ventilated or needing ventilation, a futility assessment is made. If there is a consensus on futility, a family meeting is conducted either virtually or face to face depending on the infection risk and infection control protocol. The family should be sensitively communicated about the futility of ICU measures and foregoing life-sustaining treatment. Family meeting outcomes are documented, and consent for foregoing life-sustaining treatment is obtained. Appropriate symptom management enables comfort at the end of life to all serious COVID-19 patients not receiving or not eligible to receive ICU measures and ventilation.

How to cite this article: Salins N, Mani RK, Gursahani R, Simha S, Bhatnagar S. Symptom Management and Supportive Care of Serious COVID-19 Patients and their Families in India. Indian J Crit Care Med 2020;24(6):435–444.

Minimal Impact of Implemented Early Warning Score and Best Practice Alert for Patient Deterioration

OBJECTIVES

Previous studies have looked at National Early Warning Score performance in predicting in-hospital deterioration and death, but data are lacking with respect to patient outcomes following implementation of National Early Warning Score. We sought to determine the effectiveness of National Early Warning Score implementation on predicting and preventing patient deterioration in a clinical setting.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care academic facility and a community hospital.

PATIENTS

Patients 18 years old or older hospitalized from March 1, 2014, to February 28, 2015, during preimplementation of National Early Warning Score to August 1, 2015, to July 31, 2016, after National Early Warning Score was implemented.

INTERVENTIONS

Implementation of National Early Warning Score within the electronic health record and associated best practice alert.

MEASUREMENTS AND MAIN RESULTS

In this study of 85,322 patients (42,402 patients pre-National Early Warning Score and 42,920 patients post-National Early Warning Score implementation), the primary outcome of rate of ICU transfer or death did not change after National Early Warning Score implementation, with adjusted hazard ratio of 0.94 (0.84-1.05) and 0.90 (0.77-1.05) at our academic and community hospital, respectively. In total, 175,357 best practice advisories fired during the study period, with the best practice advisory performing better at the community hospital than the academic at predicting an event within 12 hours 7.4% versus 2.2% of the time, respectively. Retraining National Early Warning Score with newly generated hospital-specific coefficients improved model performance.

CONCLUSIONS

At both our academic and community hospital, National Early Warning Score had poor performance characteristics and was generally ignored by frontline nursing staff. As a result, National Early Warning Score implementation had no appreciable impact on defined clinical outcomes. Refitting of the model using site-specific data improved performance and supports validating predictive models on local data.

A Comparison of the Quick Sequential (Sepsis-Related) Organ Failure Assessment Score and the National Early Warning Score in Non-ICU Patients With/Without Infection

OBJECTIVES

The Sepsis-3 task force recommended the quick Sequential (Sepsis-Related) Organ Failure Assessment score for identifying patients with suspected infection who are at greater risk of poor outcomes, but many hospitals already use the National Early Warning Score to identify high-risk patients, irrespective of diagnosis. We sought to compare the performance of quick Sequential (Sepsis-Related) Organ Failure Assessment and National Early Warning Score in hospitalized, non-ICU patients with and without an infection.

DESIGN

Retrospective cohort study.

SETTING

Large U.K. General Hospital.

PATIENTS

Adults hospitalized between January 1, 2010, and February 1, 2016.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We applied the quick Sequential (Sepsis-Related) Organ Failure Assessment score and National Early Warning Score to 5,435,344 vital signs sets (241,996 hospital admissions). Patients were categorized as having no infection, primary infection, or secondary infection using International Classification of Diseases, 10th Edition codes. National Early Warning Score was significantly better at discriminating in-hospital mortality, irrespective of infection status (no infection, National Early Warning Score 0.831 [0.825-0.838] vs quick Sequential [Sepsis-Related] Organ Failure Assessment 0.688 [0.680-0.695]; primary infection, National Early Warning Score 0.805 [0.799-0.812] vs quick Sequential [Sepsis-Related] Organ Failure Assessment 0.677 [0.670-0.685]). Similarly, National Early Warning Score performed significantly better in all patient groups (all admissions, emergency medicine admissions, and emergency surgery admissions) for all outcomes studied. Overall, quick Sequential (Sepsis-Related) Organ Failure Assessment performed no better, and often worse, in admissions with infection than without.

CONCLUSIONS

The National Early Warning Score outperforms the quick Sequential (Sepsis-Related) Organ Failure Assessment score, irrespective of infection status. These findings suggest that quick Sequential (Sepsis-Related) Organ Failure Assessment should be reevaluated as the system of choice for identifying non-ICU patients with suspected infection who are at greater risk of poor outcome.

A Prospective International Multicentre Cohort Study of Intraoperative Heart Rate and Systolic Blood Pressure and Myocardial Injury After Noncardiac Surgery: Results of the VISION Study

BACKGROUND

The association between intraoperative cardiovascular changes and perioperative myocardial injury has chiefly focused on hypotension during noncardiac surgery. However, the relative influence of blood pressure and heart rate (HR) remains unclear. We investigated both individual and codependent relationships among intraoperative HR, systolic blood pressure (SBP), and myocardial injury after noncardiac surgery (MINS).

METHODS

Secondary analysis of the Vascular Events in Noncardiac Surgery Cohort Evaluation (VISION) study, a prospective international cohort study of noncardiac surgical patients. Multivariable logistic regression analysis tested for associations between intraoperative HR and/or SBP and MINS, defined by an elevated serum troponin T adjudicated as due to an ischemic etiology, within 30 days after surgery. Predefined thresholds for intraoperative HR and SBP were: maximum HR >100 beats or minimum HR <55 beats per minute (bpm); maximum SBP >160 mm Hg or minimum SBP <100 mm Hg. Secondary outcomes were myocardial infarction and mortality within 30 days after surgery.

RESULTS

After excluding missing data, 1197 of 15,109 patients (7.9%) sustained MINS, 454 of 16,031 (2.8%) sustained myocardial infarction, and 315 of 16,061 patients (2.0%) died within 30 days after surgery. Maximum intraoperative HR >100 bpm was associated with MINS (odds ratio [OR], 1.27 [1.07-1.50]; P < .01), myocardial infarction (OR, 1.34 [1.05-1.70]; P = .02), and mortality (OR, 2.65 [2.06-3.41]; P < .01). Minimum SBP <100 mm Hg was associated with MINS (OR, 1.21 [1.05-1.39]; P = .01) and mortality (OR, 1.81 [1.39-2.37]; P < .01), but not myocardial infarction (OR, 1.21 [0.98-1.49]; P = .07). Maximum SBP >160 mm Hg was associated with MINS (OR, 1.16 [1.01-1.34]; P = .04) and myocardial infarction (OR, 1.34 [1.09-1.64]; P = .01) but, paradoxically, reduced mortality (OR, 0.76 [0.58-0.99]; P = .04). Minimum HR <55 bpm was associated with reduced MINS (OR, 0.70 [0.59-0.82]; P < .01), myocardial infarction (OR, 0.75 [0.58-0.97]; P = .03), and mortality (OR, 0.58 [0.41-0.81]; P < .01). Minimum SBP <100 mm Hg with maximum HR >100 bpm was more strongly associated with MINS (OR, 1.42 [1.15-1.76]; P < .01) compared with minimum SBP <100 mm Hg alone (OR, 1.20 [1.03-1.40]; P = .02).

CONCLUSIONS

Intraoperative tachycardia and hypotension are associated with MINS. Further interventional research targeting HR/blood pressure is needed to define the optimum strategy to reduce MINS.

A Multicenter Observational Prospective Cohort Study of Association of the Prehospital National Early Warning Score 2 and Hospital Triage with Early Mortality

Aim of the Study

To evaluate the ability of the prehospital National Early Warning Score 2 scale (NEWS2) to predict early mortality (within 48 hours) after the index event based on the triage priority assigned for any cause in the emergency department.

Methods

This is a multicenter longitudinal observational cohort study on patients attending Advanced Life Support units and transferred to the emergency department of their reference hospital. We collected demographic, physiological, and clinical variables, main diagnosis, and hospital triage level as well as mortality. The main outcome variable was mortality from any cause within two days of the index event.

Results

Between April 1 and November 30, 2018, a total of 1054 patients were included in our study. Early mortality within the first 48 hours after the index event affected 55 patients (5.2%), of which 23 cases (41.8%) had causes of cardiovascular origin. In the stratification by triage levels, the AUC of the NEWS2 obtained for short-term mortality varied between 0.77 (95% CI: 0.65-0.89) for level I and 0.94 (95% CI: 0.79-1) for level III.

Conclusions

The Prehospital Emergency Medical Services should evaluate the implementation of the NEWS2 as a routine evaluation, which, together with the structured hospital triage system, effectively serves to predict early mortality and detect high-risk patients.

Can mid-regional pro-adrenomedullin (MR-proADM) increase the prognostic accuracy of NEWS in predicting deterioration in patients admitted to hospital with mild to moderately severe illness? A prospective single-centre observational study

OBJECTIVE

To assess the value added to the National Early Warning Score (NEWS) by mid-regional pro-adrenomedullin (MR-proADM) blood level in predicting deterioration in mild to moderately ill people.

DESIGN

Prospective observational study.

SETTING

The Medical Admissions Suite of the Royal Victoria Infirmary, Newcastle.

PARTICIPANTS

300 adults with NEWS between 2 and 5 on admission. Exclusion criteria included receiving palliative care, or admitted for social reasons or self-harming. Patients were enrolled between September and December 2015, and followed up for 30 days after discharge.

OUTCOME MEASURE

The primary outcome measure was the proportion of patients who, within 72 hours, had an acuity increase, defined as any combination of an increase of at least 2 in the NEWS; transfer to a higher-dependency bed or monitored area; death; or for those discharged from hospital, readmission for medical reasons.

RESULTS

NEWS and MR-proADM together predicted acuity increase more accurately than NEWS alone, increasing the area under the curve (AUC) to 0.61 (95% CI 0.54 to 0.69) from 0.55 (95% CI 0.48 to 0.62). When the confounding effects of presence of chronic obstructive pulmonary disease or heart failure and interaction with MR-proADM were included, the prognostic accuracy further increased the AUC to 0.69 (95% CI 0.63 to 0.76).

CONCLUSIONS

MR-proADM is potentially a clinically useful biomarker for deterioration in patients admitted to hospital with a mild to moderately severe acute illness, that is, with NEWS between 2 and 5. As a growing number of National Health Service hospitals are routinely recording the NEWS on their clinical information systems, further research should assess the practicality and use of developing a decision aid based on admission NEWS, MR-proADM level, and possibly other clinical data and other biomarkers that could further improve prognostic accuracy.

Post-intensive care unit respiratory failure in older patients liberated from intensive care unit and ventilator: The predictive value of the National Early Warning Score on intensive care unit discharge

AIM

The older adult population is continuously growing worldwide and there is increasing use of medical recourse in older patients, especially for those requiring intensive care unit (ICU) care and mechanical ventilation (MV). The present study aimed to investigate the burden and predictors of post-ICU respiratory failure in older ICU patients weaned from MV.

METHODS

In the present retrospective study, older ICU patients aged ≥60 years, who were successfully weaned from MV and discharged to the general ward from the ICU of Taipei Veterans General Hospital, Taipei, Taiwan, in 2011, were included. Biomarkers on ICU discharge, as well as the National Early Warning Score (NEWS) were recorded and calculated. The outcome measure was post-ICU respiratory failure before day 14 (PIRF-14) requiring reinstitution of MV. Logistical regression was used to assess the predictors for PIRF-14.

RESULTS

Of 272 patients included, 23 (8.5%) developed PIRF-14. The post-ICU in-hospital mortality rates were 47.8% and 6.8% in patients with and without PIRF-14 (adjusted OR 12.597, 95% CI 4.368-36.331). In a multivariate analysis, the levels of NEWS and hemoglobin on ICU discharge were independent predictors for PIRF-14 (adjusted OR 1.273, 95% CI 1.076-1.507 and 0.645, 95% CI 0.474-0.879). In particular, patients with a NEWS of ≥10 and subsequent PIRF-14 had a 15-fold increased risk of mortality as compared with those without both factors (adjusted OR 15.418, 95% CI 4.344-54.720).

CONCLUSIONS

PIRF-14 is associated with high mortality in older ICU patients, and NEWS is a significant predictor for PIRF-14, which could be used to early identify patients at risk of post-ICU respiratory failure in the specific population. Geriatr Gerontol Int 2019; 19: 317-322.

Emergency Department Triage Early Warning Score (TREWS) predicts in-hospital mortality in the emergency department

AIM

The purpose is to assess the adequacy of the National Early Warning Score (NEWS) in the emergency department (ED) and the usefulness of the Triage in Emergency Department Early Warning Score (TREWS) that has been developed using the NEWS in the ED.

METHODS

In this retrospective observational cohort study, we performed univariable and multivariable regression analyses with 81,520 consecutive ED patients to develop a new scoring system, the TREWS. The primary outcome was in-hospital mortality within 24 h, and secondary outcomes were in-hospital mortality within 48 h, 7 days, and 30 days. The prognostic properties of the TREWS were compared with those of the NEWS, Modified Early Warning Score (MEWS), and Rapid Emergency Medicine Score (REMS) using the area under the receiver operating characteristic curve (AUC) technique.

RESULTS

The AUC of the TREWS for in-hospital mortality within 24 h was 0.906 (95% CI, 0.903-0.908), those of the NEWS, MEWS, and REMS were 0.878 (95% CI, 0.875-0.881), 0.857 (95% CI, 0.854-0.860), and 0.834 (95% CI, 0.831-0.837), respectively. Differences in the AUC between the TREWS and NEWS, the TREWS and MEWS, and the TREWS and REMS were 0.028 (95% CI, 0.022-0.033; p < .001), 0.049 (95% CI, 0.041-0.057; p < .001), and 0.072 (95% CI, 0.063-0.080; p < .001), respectively. The TREWS showed significantly superior performance in predicting secondary outcomes.

CONCLUSION

The TREWS predicts in-hospital mortality within 24 h, 48 h, 7 days, and 30 days better than the NEWS, MEWS, and REMS for patients arriving at the ED.

National early warning score (NEWS) in a Finnish multidisciplinary emergency department and direct vs. late admission to intensive care

OBJECTIVES

We investigated the national early warning scores (NEWSs) and related outcomes of patients in a tertiary referral center's multidisciplinary emergency department (ED). Patients were further categorized into three groups: triaged directly to intensive care unit (EDICU), triaged to general ward with later ICU admission (EDwardICU) and triaged to general ward (EDward). NEWSs and subsequent outcomes among these sub groups were compared.

METHODS

We conducted a prospective one-month cohort study in Tampere University Hospital's ED, Finland. ED-NEWSs were obtained for all adult patients without treatment limitations, and control (ward) NEWSs were further obtained for the EDwardICU and EDward patients.

RESULTS

Cohort consisted of 1,354 patients with a median ED-NEWS of 2, and higher ED-NEWS was associated with in-hospital mortality (OR 1.26, 95% CI 1.11-1.42; AUROC 0.75, 0.64‒0.86, p < 0.001) and 30-day mortality (OR 1.27, 1.17-1.39; AUROC 0.78, 0.71‒0.84, p < 0.001) irrespective of age and comorbidity. There were 64 patients in EDICU group, 12 patients in EDwardICU group and 1,278 patients in EDward group with median ED-NEWSs of 7, 3 and 2 (p < 0.001), respectively. After the first 24 h in wards, median NEWSs of the EDwardICU patients had substantially increased as compared with EDward patients (6 vs. 2, p < 0.001). There were no statistical differences in last NEWS before ICU admission between the EDICU and EDwardICU patients (7 vs. 8, p = 0.534), or in ICU severity-of-illness scores or patient outcomes.

CONCLUSIONS

ED-NEWS is independently associated with in-hospital and 30-day mortality with acceptable discrimination capability. Direct and late ICU admissions occurred with comparable NEWSs at admission.

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis

BACKGROUND

The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool.

METHODS

Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals.

RESULTS

We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality [odds ratio (OR) 0.49 (0.32-0.77); P<0.01], but no difference in complication rates [OR 1.02 (0.88-1.19); P=0.75]. In a systematic review, we screened 3732 records and identified 11 eligible studies of 453 292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality [OR 0.75 (0.62-0.92); P<0.01; I²=87%] and reduced complication rates [OR 0.73 (0.61-0.88); P<0.01; I²=89%).

CONCLUSIONS

Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine.

Pre-hospital National Early Warning Score (NEWS) is associated with in-hospital mortality and critical care unit admission: A cohort study

Background

National Early Warning Score (NEWS) is increasingly used in UK hospitals. However, there is only limited evidence to support the use of pre-hospital early warning scores. We hypothesised that pre-hospital NEWS was associated with death or critical care escalation within the first 48 h of hospital stay.

Methods

Planned secondary analysis of a prospective cohort study at a single UK teaching hospital. Consecutive medical ward admissions over a 20-day period were included in the study. Data were collected from ambulance report forms, medical notes and electronic patient records. Pre-hospital NEWS was calculated retrospectively. The primary outcome was a composite of death or critical care unit escalation within 48 h of hospital admission. The secondary outcome was length of hospital stay.

Results

189 patients were included in the analysis. The median pre-hospital NEWS was 3 (IQR 1–5). 13 patients (6.9%) died or were escalated to the critical care unit within 48 h of hospital admission. Pre-hospital NEWS was associated with death or critical care unit escalation (OR, 1.25; 95% CI, 1.04–1.51; p = 0.02), but NEWS on admission to hospital was more strongly associated with this outcome (OR, 1.52; 95% CI, 1.18–1.97, p < 0.01). Neither was associated with hospital length of stay.

Conclusion

Pre-hospital NEWS was associated with death or critical care unit escalation within 48 h of hospital admission. NEWS could be used by ambulance crews to assist in the early triage of patients requiring hospital treatment or rapid transport. Further cohort studies or trials in large samples are required before implementation.

•

NEWS has a growing dominance in UK hospitals but is not widely used in ambulances.

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NEWS calculated using ambulance observations is associated with in-hospital death and critical care unit admission.

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NEWS could be used by ambulance crews as an objective tool to triage patients with acute illness.

•

A large scale trial should be carried out before widespread implementation of NEWS in ambulances.

•

It is unclear if NEWS could be used by a call-taker or bystander to triage a patient before the ambulance arrives.

Prognostic value of early warning scores in the emergency department (ED) and acute medical unit (AMU): A narrative review

BACKGROUND

A wide array of early warning scores (EWS) have been developed and are used in different settings to detect which patients are at risk of deterioration. The aim of this review is to provide an overview of studies conducted on the value of EWS on predicting intensive care (ICU) admission and mortality in the emergency department (ED) and acute medical unit (AMU).

METHODS

A literature search was conducted in the bibliographic databases PubMed and EMBASE, from inception to April 2017. Two reviewers independently screened all potentially relevant titles and abstracts for eligibility.

RESULTS

42 studies were included. 36 studies reported on mortality as an endpoint, 13 reported ICU admission and 9 reported the composite outcome of mortality and ICU admission. For mortality prediction National Early Warning Score (NEWS) was the most accurate score in the general ED population and in those with respiratory distress, Mortality in Emergency Department Sepsis score (MEDS) had the best accuracy in patients with an infection or sepsis. ICU admission was best predicted with NEWS, however in patients with an infection or sepsis Modified Early Warning Score (MEWS) yielded better results for this outcome.

CONCLUSION

MEWS and NEWS generally had favourable results in the ED and AMU for all endpoints. Many studies have been performed on ED and AMU populations using heterogeneous prognostic scores. However, future studies should concentrate on a simple and easy to use prognostic score such as NEWS with the aim of introducing this throughout the (pre-hospital and hospital) acute care chain.

The accuracy of acuity scoring tools to predict 24-h mortality in traumatic brain injury patients: A guide to triage criteria

BACKGROUND AND AIM

Prompt identification of traumatic brain injury (TBI) is vital for patients in critical condition; however, it is not clear which acuity scoring tools are associated with short-term mortality. The aim of this study was to determine the accuracy of acuity scoring tools and 24-h mortality among TBI patients in both prehospital and hospital settings.

METHODS

This study was an observational, prospective cohort, in which patients with TBI were followed from the accident scene to the hospital. Vital signs and acuity scoring tools, including the Revised Trauma Score (RTS), Injury Severity Score (ISS), National Early Warning Score (NEWS), Shock Index (SI), Modified Shock Index (MSI) and Trauma and Injury Severity Score (TRISS), were collected both on the scene as well as at the hospital. A logistic regression was performed to ascertain the effects of clinical parameters on the likelihood of survival of patients with TBI regarding 24-h mortality.

RESULTS

A total of 185 patients were included in this study. The mortality rate was 14% (25/185). The logistic regression model was statistically significant at χ²=60.8, p=0.001. A hierarchical forward stepwise logistic regression analysis showed that age, hospital RTS and prehospital NEWS significantly improved mortality predictions. The model explained the 51.2% variance in survival of patients with TBI.

CONCLUSIONS

The NEWS and the RTS may be used to triage TBI patients for prehospital and hospital emergency care, respectively. Therefore, because traditional vital signs criteria may be of limited use for the triage of TBI patients, it is recommended that acuity scoring tools be used in such cases.

A Comparison of the Ability of the Physiologic Components of Medical Emergency Team Criteria and the U.K. National Early Warning Score to Discriminate Patients at Risk of a Range of Adverse Clinical Outcomes

OBJECTIVE

To compare the ability of medical emergency team criteria and the National Early Warning Score to discriminate cardiac arrest, unanticipated ICU admission and death within 24 hours of a vital signs measurement, and to quantify the associated workload.

DESIGN

Retrospective cohort study.

SETTING

A large U.K. National Health Service District General Hospital.

PATIENTS

Adults hospitalized from May 25, 2011, to December 31, 2013.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We applied the National Early Warning Score and 44 sets of medical emergency team criteria to a database of 2,245,778 vital signs sets (103,998 admissions). The National Early Warning Score's performance was assessed using the area under the receiver-operating characteristic curve and compared with sensitivity/specificity for different medical emergency team criteria. Area under the receiver-operating characteristic curve (95% CI) for the National Early Warning Score for the combined outcome (i.e., death, cardiac arrest, or unanticipated ICU admission) was 0.88 (0.88-0.88). A National Early Warning Score value of 7 had sensitivity/specificity values of 44.5% and 97.4%, respectively. For the 44 sets of medical emergency team criteria studied, sensitivity ranged from 19.6% to 71.2% and specificity from 71.5% to 98.5%. For all outcomes, the position of the National Early Warning Score receiver-operating characteristic curve was above and to the left of all medical emergency team criteria points, indicating better discrimination. Similarly, the positions of all medical emergency team criteria points were above and to the left of the National Early Warning Score efficiency curve, indicating higher workloads (trigger rates).

CONCLUSIONS

When medical emergency team systems are compared to a National Early Warning Score value of greater than or equal to 7, some medical emergency team systems have a higher sensitivity than National Early Warning Score values of greater than or equal to 7. However, all of these medical emergency team systems have a lower specificity and would generate greater workloads.

Can the prehospital National Early Warning Score identify patients most at risk from subsequent deterioration?

INTRODUCTION

The National Early Warning Score (NEWS) aids the early recognition of those at risk of becoming critically ill. NEWS has been recommended for use by ambulance services, but very little work has been undertaken to date to determine its suitability. This paper examines whether a prehospital NEWS derived from ambulance service clinical observations is associated with the hospital ED disposition.

METHODS

Prehospital NEWS was retrospectively calculated from the ambulance service clinical records of 287 patients who were treated by the ambulance service and transported to hospital. In this cohort study, derived NEWS scores were compared with ED disposition data and patients were categorised into the following groups depending on their outcome: discharged from ED, admitted to a ward, admitted to intensive therapy unit (ITU) or died.

RESULTS

Prehospital NEWS-based ambulance service clinical observations were significantly associated with discharge disposition groups (p<0.001), with scores escalating in line with increasing severity of outcome. Patients who died or were admitted to ITU had higher scores than those admitted to a ward or discharged from ED (mean NEWS 7.2 and 7.5 vs 2.6 and 1.7, respectively), and in turn those who were admitted to a ward had higher pre-hospital NEWS than those who were discharged (2.6 vs 1.7).

CONCLUSION

Our findings suggest that the NEWS could successfully be used by ambulance services to identify patients most at risk from subsequent deterioration. The implementation of this early warning system has the potential to support ambulance clinician decision making, providing an additional tool to identify and appropriately escalate care for acutely unwell patients.

Preceding national early warnings scores among in-hospital cardiac arrests and their impact on survival

OBJECTIVES

In-hospital cardiac arrests (IHCAs) are often preceded by abnormal vital signs. Preceding abnormal vital signs might lower the physiological reserve capacity and therefore decrease survival after an IHCA.

AIM

To assess the preceding national early warning score (NEWS) and its relation to survival after an IHCA.

MATERIAL AND METHODS

All patients ≥18years suffering an IHCA at Karolinska University Hospital between 1st January 2014 and 31st December 2015 were included. Data regarding the IHCA, patient characteristics, calculated NEWS and 30-day survival were obtained from electronic patient records. Parameters included in NEWSs were assessed up to 12h before the IHCA. Differences in survival were assessed with adjusted logistic regression models and presented as Odds Ratios with 95% Confidence Intervals (OR, 95% CI) between patients with NEWSs of 0-4 points (low) versus those with at least 5 points (moderate) and 7 points (high). Adjustments included hospital site, sex, co-morbidities, first rhythm and location of the IHCA.

RESULTS

In all, 358 patients suffered an IHCA, of whom 109 (30%) survived at least 30days and 296 (83%) had sufficient vital sign documentation to calculate NEWS before the IHCA. The 87 patients with a medium NEWS had a fourfold chance and those 78 with a high NEWS (22%) had an almost tenfold chance of dying after the IHCA compared to those with a low NEWS (Adjusted OR 4.43, 95% CI 1.81-10.83 and OR 9.88 95% C.I. 2.77-35.26, respectively).

CONCLUSION

The NEWS can be a probable proxy for estimating physiological reserve capacity since high NEWS is associated to high change of death in case of an IHCA. This information can be used when discussing prognosis with patients and relatives. But even more importantly, it stresses the need for better preventive strategies in IHCAs. STRENGTHENS AND LIMITATIONS WITH THIS STUDY.

Scoping review: The use of early warning systems for the identification of in-hospital patients at risk of deterioration

INTRODUCTION

Early warning systems (EWS) were developed as a means of alerting medical staff to patient clinical decline. Since 85% of severe adverse events are preceded by abnormal physiological signs, the patient bed-side vital signs observation chart has emerged as an EWS tool to help staff identify and quantify deteriorating patients. There are three broad categories of patient observation chart EWS: single or multiple parameter systems; aggregated weighted scoring systems; or combinations of single or multiple parameter and aggregated weighted scoring systems.

OBJECTIVE

This scoping review is an overview of quantitative studies and systematic reviews examining the efficiency of the adult EWS charts in the recognition of in-hospital patient deterioration.

METHOD

A broad search was undertaken of peer-reviewed publications, official government websites and databases housing research theses, using combinations of keywords and phrases.

DATA SOURCES

CINAHL with full text; MedLine, PsycINFO, MasterFILE Premier, GreenFILE and ScienceDirect. Also, the Cochrane Library database, Department of Health government websites and Ethos, ProQuest and Trove databases were searched.

EXCLUSIONS

Paediatric, obstetric and intensive care studies, studies undertaken at the point of hospital admission or pre-admission, non-English publications and editorials.

RESULTS

Five hundred and sixty five publications, government documents, reports and theses were located of which 91 were considered and 21 were included in the scoping review. Of the 21 publications eight studies compared the efficacy of various EWS and 13 publications validated specific EWS.

CONCLUSIONS

There is low level quantitative evidence that EWS improve patient outcomes and strong anecdotal evidence that they augment the ability of the clinical staff to recognise and respond to patient decline, thus reducing the incidence of severe adverse events. Although aggregated weighted scoring systems are most frequently used, the efficiency of the specific EWS appears to be dependent on the patient cohort, facilities available and staff training and attitude. While the review demonstrates support for EWS, researchers caution that given the contribution of human factors to the EWS decision-making process, patient EWS charts alone cannot replace good clinical judgment.

A single-centre cohort study of National Early Warning Score (NEWS) and near patient testing in acute medical admissions

INTRODUCTION

The utility of an early warning score may be improved when used with near patient testing. However, this has not yet been investigated for National Early Warning Score (NEWS). We hypothesised that the combination of NEWS and blood gas variables (lactate, glucose or base-excess) was more strongly associated with clinical outcome compared to NEWS alone.

METHODS

This was a prospective cohort study of adult medical admissions to a single-centre over 20days. Blood gas results and physiological observations were recorded at admission. NEWS was calculated retrospectively and combined with the biomarkers in multivariable logistic regression models. The primary outcome was a composite of mortality or critical care escalation within 2days of hospital admission. The secondary outcome was hospital length of stay.

RESULTS

After accounting for missing data, 15 patients out of 322 (4.7%) died or were escalated to the critical care unit. The median length of stay was 4 (IQR 7) days. When combined with lactate or base excess, NEWS was associated with the primary outcome (OR 1.18, p=0.01 and OR 1.13, p=0.03). However, NEWS alone was more strongly associated with the primary outcome measure (OR 1.46, p<0.01). The combination of NEWS with glucose was not associated with the primary outcome. Neither NEWS nor any combination of NEWS and a biomarker were associated with hospital length of stay.

CONCLUSION

Admission NEWS is more strongly associated with death or critical care unit admission within 2days of hospital admission, compared to combinations of NEWS and blood-gas derived biomarkers.

The National Early Warning Score (NEWS) for outcome prediction in emergency department patients with community-acquired pneumonia: results from a 6-year prospective cohort study

OBJECTIVE

To investigate the accuracy of the National Early Warning Score (NEWS) to predict mortality and adverse clinical outcomes for patients with community-acquired pneumonia (CAP) compared to standard risk scores such as the pneumonia severity index (PSI) and CURB-65.

DESIGN

Secondary analysis of patients included in a previous randomised-controlled trial with a median follow-up of 6.1 years.

SETTINGS

Patients with CAP included on admission to the emergency departments (ED) of 6 tertiary care hospitals in Switzerland.

PARTICIPANTS

A total of 925 patients with confirmed CAP were included. NEWS, PSI and CURB-65 scores were calculated on admission to the ED based on admission data.

MAIN OUTCOME MEASURE

Our primary outcome was all-cause mortality within 6 years of follow-up. Secondary outcomes were adverse clinical outcome defined as intensive care unit (ICU) admission, empyema and unplanned hospital readmission all occurring within 30 days after admission. We used regression models to study associations of baseline risk scores and outcomes with the area under the receiver operating curve (AUC) as a measure of discrimination.

RESULTS

6-year overall mortality was 45.1% (n=417) with a stepwise increase with higher NEWS categories. For 30 day and 6-year mortality prediction, NEWS showed only low discrimination (AUC 0.65 and 0.60) inferior compared to PSI and CURB-65. For prediction of ICU admission, NEWS showed moderate discrimination (AUC 0.73) and improved the prognostic accuracy of a regression model, including PSI (AUC from 0.66 to 0.74, p=0.001) and CURB-65 (AUC from 0.64 to 0.73, p=0.015). NEWS was also superior to PSI and CURB-65 for prediction of empyema, but did not well predict rehospitalisation.

CONCLUSIONS

NEWS provides additional prognostic information with regard to risk of ICU admission and complications and thereby improves traditional clinical-risk scores in the management of patients with CAP in the ED setting.

TRIAL REGISTRATION NUMBER

ISRCTN95122877; Post-results.

National Early Warning Score (NEWS) as an emergency department predictor of disease severity and 90-day survival in the acutely dyspneic patient - a prospective observational study

BACKGROUND

National Early Warning Score (NEWS) was designed to detect deteriorating patients in hospital wards, specifically those at increased risk of ICU admission, cardiac arrest, or death within 24 h. NEWS is not validated for use in Emergency Departments (ED), but emerging data suggest it may be useful. A criticism of NEWS is that patients with chronic poor oxygenation, e.g. severe chronic obstructive pulmonary disease (COPD), will have elevated NEWS also in the absence of acute deterioration, possibly reducing the predictive power of NEWS in this subgroup. We wanted to prospectively evaluate the usefulness of NEWS in unselected adult patients emergently presenting in a Norwegian ED with respiratory distress as main symptom.

METHODS

In respiratory distressed patients, NEWS was calculated on ED arrival, after 2-4 h, and the next day. Manchester Triage Scale (MTS) category, age, gender, comorbidity (ASA score), ICU-admission, ventilatory support, and discharge diagnoses were noted. Survival status was tracked for >90 days through the Population Registry. Data are medians (25-75th percentiles). Factors predicting 90-day survival were analysed with multiple logistic regression.

RESULTS

We included 246 patients; 71 years old (60-80), 89 % home-dwelling, 74 % ASA 3-4, 72 % MTS 1-2, 88 % admitted to hospital. NEWS on arrival was 5 (3-7). NEWS correlated closely with MTS category and maximum in-hospital level of care (ED, ward, high-dependency unit, ICU). Sixteen patients died in-hospital, 26 died after discharge within 90 days. Controlled for age, ASA score, and COPD, a higher NEWS on ED arrival predicted poorer 90-day survival. Increased NEWS also correlated with decreased 30-day- and in-hospital survival and a decreased probability for home-dwelling patients to be discharged directly home.

DISCUSSION

In respiratory distressed patients, NEWS on ED arrival correlated closely with triage category and need of ICU admission and predicted long-term out-of-hospital survival controlled for age, comorbidity, and COPD.

CONCLUSIONS

NEWS should be explored in the ED setting to determine its role in clinical decision-making and in communication along the acute care chain.

Analysis of Unplanned Postoperative Admissions to the Intensive Care Unit

PURPOSE

To investigate factors associated with unplanned postoperative admissions to the intensive care unit (ICU).

METHODS

Data from the National Anesthesia Clinical Outcomes Registry (NACOR) were analyzed. We performed univariate and multivariate logistic regression to identify patient- and surgery-specific characteristics associated with unplanned postoperative ICU admission. We also recorded the prevalence of Current Procedural Terminology (CPT) and International Classification of Diseases, ninth revision ( ICD-9) billing codes and outcomes for unplanned postoperative ICU admissions.

RESULTS

Of 23 341 130 records in the database, 2 910 738 records met our inclusion criteria. A higher American Society of Anesthesiologists physical status (ASA PS) class, case duration greater than 4 hours, and advanced age were associated with a greater likelihood of unplanned ICU admission. Vascular and thoracic surgery patients were more likely to have an unplanned ICU admission. The most common CPT and ICD-9 codes involved repair of femur/hip fracture, bowel resection, and acute postoperative pain. Large community hospitals were more likely than university hospitals to have unplanned postoperative ICU admissions. Patients in the unplanned postoperative ICU admission group were more likely to have experienced intraoperative cardiac arrest, hemodynamic instability, or respiratory failure and were more likely to die in the immediate perioperative period.

CONCLUSION

Our study is the first diverse analysis of unplanned postoperative ICU admissions in the literature across multiple specialties and practice models. We found an association of advanced age, higher ASA PS class, and duration of procedure with unplanned ICU admission after surgery. Surgical specialties and procedures with the most unplanned ICU admissions could be areas for quality improvement and clinical pathways in the future.