In-hospital mortality and morbidity of elderly medical patients can be predicted at admission by the Modified Early Warning Score: a prospective study

Relationship between inflammatory factors, lactic acid levels, acute skin failure, bad mood, and sleep quality

BACKGROUND

The central link between septic shock and acute skin failure (ASF) is the inflammatory response, which occurs throughout disease progression and can lead to systemic inflammatory response syndrome. Patients often experience bad moods, sleep disorders, and other health issues. Despite recognizing these factors, no studies have examined the correlation between inflammatory factors, lactic acid levels, ASF, mood disturbances, and sleep quality in critically ill patients. We hypothesize that higher levels of inflammatory factors and lactic acid are associated with more severe ASF and poorer mood and sleep quality, which may inform clinical treatment for septic shock and ASF.

AIM

To explore the relationship between inflammatory factors, lactic acid levels, the severity of ASF, bad mood, and sleep quality.

METHODS

The retrospective study included 150 patients with septic shock from the Second Hospital of Dalian Medical University, categorized into ASF (n = 35) or non-ASF groups (n = 115). We compared the peripheral blood inflammatory factors, including tumor necrosis factor-α (TNF-α), C-reactive protein (CRP), interleukin-6 (IL-6), lactic acid levels, skin mottling score (SMS), modified early warning score (MEWS), self-rating depression scale (SDS), self-rating anxiety scale (SAS), and Pittsburgh sleep quality index (PSQI) scores. Pearson correlation analysis assessed relationships among these variables.

RESULTS

The ASF group had significantly higher levels of CRP (19.60 ± 4.10 vs 15.30 ± 2.96 mg/mL), IL-6 (298.65 ± 48.65 vs 268.66 ± 33.66 pg/L), procalcitonin, lactic acid (8.42 ± 2.32 vs 5.70 ± 1.27 mmol/L), SMS [0 (0, 1) vs 3 (2, 3)], MEWS (9.34 ± 1.92 vs 6.48 ± 1.96), SAS (61.63 ± 12.03 vs 53.71 ± 12.48), SDS (60.17 ± 12.64 vs 52.27 ± 12.64), and PSQI scores (14.23 ± 3.94 vs 8.69 ± 2.46) compared with the non-ASF group (all P < 0.001). Pearson correlation analysis revealed that IL-6, CRP, TNF-α, and lactic acid were positively correlated with SMS, MEWS, SAS, SDS, and PSQI scores (P < 0.05).

CONCLUSION

Peripheral blood levels of IL-6, CRP, TNF-α, and lactic acid correlate positively with SMS, MEWS, SAS, SDS, and PSQI in critically ill patients with ASF.

Characteristics and outcomes of patients screened by the rapid response team and transferred to intensive care unit in South Korea

The rapid response system (RRS) is associated with a reduction in in-hospital mortality. This study aimed to determine the characteristics and outcomes of patients transferred to the intensive care unit (ICU) by a rapid response team (RRT). This retrospective, multicenter cohort study included patients from nine hospitals in South Korea. Adult patients who were admitted to the general ward (GW) and required RRS activation were included. Patients with do-not-resuscitate orders and without lactate level or Sequential Organ Failure Assessment score were excluded. A total of 8228 patients were enrolled, 3379 were transferred to the ICU. The most common reasons for RRT activation were respiratory distress, sepsis and septic shock. The number of patients who underwent interventions, the length of hospital stays, 28-day mortality, and in-hospital mortality were higher in the ICU group than in the GW group. Factors that could affect both 28-day and in-hospital mortality included the severity score, low PaO2/FiO2 ratio, higher lactate and C-reactive protein levels, and hospitalization time prior to RRT activation. Patients admitted to the ICU after RRT activation generally face more challenging clinical situations, which may affect their survival outcomes.

Detecting early signs of deterioration and preventing hospitalizations in skilled nursing facilities using remote respiratory monitoring

An increase in respiratory rate (RR) can be an early indicator of clinical deterioration, yet it remains an often-neglected vital sign. The most common way of measuring RR is by manually counting chest-wall movements, a time-consuming and error-prone process. Staffing and funding shortages, particularly in post-acute and long-term care, mean these RR measurements are often infrequent, potentially leading to missed diagnoses and preventable readmissions. Here we present a case series from skilled nursing facilities, highlighting how continuous respiratory monitoring using a contactless remote patient monitoring (RPM) system can support clinicians in initiating timely interventions, potentially reducing preventable hospitalizations, mortality, and associated financial implications.

Comparing Continuous with Periodic Vital Sign Scoring for Clinical Deterioration Using a Patient Data Model

To evaluate a minute-by-minute monitoring algorithm against a periodic early warning score (EWS) in detecting clinical deterioration and workload. Periodic EWSs suffer from large measurement intervals, causing late detection of deterioration. This might be prevented by continuous vital sign monitoring with a real-time algorithm such as the Visensia Safety Index (VSI). This prospective comparative data modeling cohort study (NCT04189653) compares continuous algorithmic alerts against periodic EWS in continuous monitored medical and surgical inpatients. We evaluated sensitivity, frequency, number of warnings needed to evaluate (NNE) and time of initial alert till escalation of care (EOC): Rapid Response Team activation, unplanned ICU admission, emergency surgery, or death. Also, the percentage of VSI alerting minutes was compared between patients with or without EOC. In 1529 admissions continuous VSI warned for 55% of EOC (95% CI: 45-64%) versus 51% (95% CI: 41-61%) by periodic EWS. NNE for VSI was 152 alerts per detected EOC (95% CI: 114-190) compared to 21 (95% CI: 17-28). It generated 0.99 warnings per day per patient compared to 0.13. Time from detection score till escalation was 8.3 hours (IQR: 2.6-24.8) with VSI versus 5.2 (IQR: 2.7-12.3) hours with EWS (P=0.074). The percentage of warning VSI minutes was higher in patients with EOC than in stable patients (2.36% vs 0.81%, P<0.001). Although sensitivity of detection was not significantly improved continuous vital sign monitoring shows potential for earlier alerts for deterioration compared to periodic EWS. A higher percentage of alerting minutes may indicate risk for deterioration.

Data Modeling Using Vital Sign Dynamics for In-hospital Mortality Classification in Patients with Acute Coronary Syndrome

OBJECTIVES

This study compared feature selection by machine learning or expert recommendation in the performance of classification models for in-hospital mortality among patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI).

METHODS

A dataset of 1,123 patients with ACS who underwent PCI was analyzed. After assigning 80% of instances to the training set through random splitting, we performed feature scaling and resampling with the synthetic minority over-sampling technique and Tomek link method. We compared two feature selection.

METHODS

recursive feature elimination with cross-validation (RFECV) and selection by interventional cardiologists. We used five simple models: support vector machine (SVM), random forest, decision tree, logistic regression, and artificial neural network. The performance metrics were accuracy, recall, and the false-negative rate, measured with 10-fold cross-validation in the training set and validated in the test set.

RESULTS

Patients' mean age was 66.22 ± 12.88 years, and 33.63% had ST-elevation ACS. Fifteen of 34 features were selected as important with the RFECV method, while the experts chose 11 features. All models with feature selection by RFECV had higher accuracy than the models with expert-chosen features. In the training set, the random forest model had the highest accuracy (0.96 ± 0.01) and recall (0.97 ± 0.02). After validation in the test set, the SVM model displayed the highest accuracy (0.81) and a recall of 0.61.

CONCLUSIONS

Models with feature selection by RFECV had higher accuracy than those with feature selection by experts in identifying patients with ACS at high risk for in-hospital mortality.

Hospital practices and clinical outcomes associated with behavioral symptoms in persons with dementia

BACKGROUND

Hospitalized persons living with dementia (PLWD) often experience behavioral symptoms that challenge medical care.

OBJECTIVE

This study aimed to identify clinical practices and outcomes associated with behavioral symptoms in hospitalized PLWD.

DESIGN

A retrospective cross-sectional study.

SETTINGS AND PARTICIPANTS

The study included PLWD (65+) admitted to one of severe health system hospitals in 2019.

INTERVENTION

Behavioral symptoms were defined as the presence of (1) a psychoactive medication for behavioral symptoms; (2) an order for physical restraints or constant observation; and/or (3) physician documentation of delirium, encephalopathy, or behavioral symptoms.

MAIN OUTCOME AND MEASURES

Associations between behavioral symptoms and patient characteristics and hospital practices (e.g., bladder catheter) were examined. Multivariable logistic/linear regression was used to evaluate the association between behavioral symptoms and clinical outcomes (e.g., mortality).

RESULTS

Of hospitalized PLWD (N = 8637), the average age was 84.5 years (IQR = 79-90), 61.7% were female, 60.1% were white, and 9.4% (n = 833) were Hispanic. Behavioral symptoms were identified in 40.6% (N = 3606) of individuals. Behavioral symptoms were significantly associated with male gender (40.3% vs. 36.9%, p = .001), white race (62.7% vs. 58.3%, p < .001), and residence in a facility prior to admission (26.6% vs. 23.7%, p < .001). Regarding hospital practices, indwelling bladder catheters (11.2% vs. 6.0%, p < .001) and dietary restriction (41.9% vs. 33.8%, p < .001) were associated with behavioral symptoms. In multivariable models, behavioral symptoms were associated with increased hospital mortality (odds ratio [OR]: 1.90, CI95%: 1.57-2.29), length of stay (parameter estimate: 2.10, p < .001), 30-day readmissions (OR: 1.14, CI95%: 1.014-1.289), and decreased discharge home (OR: 0.59, CI95%: 0.53-0.65, p < .001).

CONCLUSIONS

Given the association between behavioral symptoms and poor clinical outcomes, there is an urgent need to improve the provision of care for hospitalized PLWD.

A Retrospective Cohort Study Evaluating the Use of the Modified Early Warning Score to Improve Outcome Prediction in Neurosurgical Patients

Introduction

The modified early warning score (mEWS) has been used to identify decompensating patients in critical care settings, potentially leading to better outcomes and safer, more cost-effective patient care. We examined whether the admission or maximum mEWS of neurosurgical patients was associated with outcomes and total patient costs across neurosurgical procedures.

Methods

This retrospective cohort study included all patients hospitalized at a quaternary care hospital for neurosurgery procedures during 2019. mEWS were automatically generated during a patient’s hospitalization from data available in the electronic medical record. Primary and secondary outcome measures were the first mEWS at admission, maximum mEWS during hospitalization, length of stay (LOS), discharge disposition, mortality, cost of hospitalization, and patient biomarkers (i.e., white blood cell count, erythrocyte sedimentation rate, C-reactive protein, and procalcitonin).

Results

In 1,408 patients evaluated, a mean first mEWS of 0.5 ± 0.9 (median: 0) and maximum mEWS of 2.6 ± 1.4 (median: 2) were observed. The maximum mEWS was achieved on average one day (median = 0 days) after admission and correlated with other biomarkers (p < 0.0001). Scores correlated with continuous outcomes (i.e., LOS and cost) distinctly based on disease types. Multivariate analysis showed that the maximum mEWS was associated with longer stay (OR = 1.8; 95% CI = 1.6-1.96, p = 0.0001), worse disposition (OR = 0.82, 95% CI = 0.71-0.95, p = 0.0001), higher mortality (OR = 1.7; 95% CI = 1.3-2.1, p = 0.0001), and greater cost (OR = 1.2, 95% CI = 1.1-1.3, p = 0.001). Machine learning algorithms suggested that logistic regression, naïve Bayes, and neural networks were most predictive of outcomes.

Conclusion

mEWS was associated with outcomes in neurosurgical patients and may be clinically useful. The composite score could be integrated with other clinical factors and was associated with LOS, discharge disposition, mortality, and patient cost. mEWS also could be used early during a patient's admission to stratify risk. Increase in mEWS scores correlated with the outcome to a different degree in distinct patient/disease types. These results show the potential of the mEWS to predict outcomes in neurosurgical patients and suggest that it could be incorporated into clinical decision-making and/or monitoring of neurosurgical patients during admission. However, further studies and refinement of mEWS are needed to better integrate it into patient care.

Prognostic value of National Early Warning Score and Modified Early Warning Score on intensive care unit readmission and mortality: A prospective observational study

Background

Modified Early Warning Score (MEWS) and National Early Warning Score (NEWS) are widely used in predicting the mortality and intensive care unit (ICU) admission of critically ill patients. This study was conducted to evaluate and compare the prognostic value of NEWS and MEWS for predicting ICU readmission, mortality, and related outcomes in critically ill patients at the time of ICU discharge.

Methods

This multicenter, prospective, observational study was conducted over a year, from April 2019 to March 2020, in the general ICUs of two university-affiliated hospitals in Northwest Iran. MEWS and NEWS were compared based on the patients’ outcomes (including mortality, ICU readmission, time to readmission, discharge type, mechanical ventilation (MV), MV duration, and multiple organ failure after readmission) using the univariable and multivariable binary logistic regression. The receiver operating characteristic (ROC) curve was used to determine the outcome predictability of MEWS and NEWS.

Results

A total of 410 ICU patients were enrolled in this study. According to multivariable logistic regression analysis, both MEWS and NEWS were predictors of ICU readmission, time to readmission, MV status after readmission, MV duration, and multiple organ failure after readmission. The area under the ROC curve (AUC) for predicting mortality was 0.91 (95% CI = 0.88–0.94, P < 0.0001) for the NEWS and 0.88 (95% CI = 0.84–0.91, P < 0.0001) for the MEWS. There was no significant difference between the AUC of the NEWS and the MEWS for predicting mortality (P = 0.082). However, for ICU readmission (0.84 vs. 0.71), time to readmission (0.82 vs. 0.67), MV after readmission (0.83 vs. 0.72), MV duration (0.81 vs. 0.67), and multiple organ failure (0.833 vs. 0.710), the AUCs of MEWS were significantly greater (P < 0.001).

Conclusion

National Early Warning Score and MEWS values of >4 demonstrated high sensitivity and specificity in identifying the risk of mortality for the patients’ discharge from ICU. However, we found that the MEWS showed superiority over the NEWS score in predicting other outcomes. Eventually, MEWS could be considered an efficient prediction score for morbidity and mortality of critically ill patients.

Geriatrics-focused indicators predict mortality more than age in older adults hospitalized with COVID-19

BACKGROUND

Age has been implicated as the main risk factor for COVID-19-related mortality. Our objective was to utilize administrative data to build an explanatory model accounting for geriatrics-focused indicators to predict mortality in hospitalized older adults with COVID-19.

METHODS

Retrospective cohort study of adults age 65 and older (N = 4783) hospitalized with COVID-19 in the greater New York metropolitan area between 3/1/20-4/20/20. Data included patient demographics and clinical presentation. Stepwise logistic regression with Akaike Information Criterion minimization was used.

RESULTS

The average age was 77.4 (SD = 8.4), 55.9% were male, 20.3% were African American, and 15.0% were Hispanic. In multivariable analysis, male sex (adjusted odds ration (adjOR) = 1.06, 95% CI:1.03-1.09); Asian race (adjOR = 1.08, CI:1.03-1.13); history of chronic kidney disease (adjOR = 1.05, CI:1.01-1.09) and interstitial lung disease (adjOR = 1.35, CI:1.28-1.42); low or normal body mass index (adjOR:1.03, CI:1.00-1.07); higher comorbidity index (adjOR = 1.01, CI:1.01-1.02); admission from a facility (adjOR = 1.14, CI:1.09-1.20); and mechanical ventilation (adjOR = 1.52, CI:1.43-1.62) were associated with mortality. While age was not an independent predictor of mortality, increasing age (centered at 65) interacted with hypertension (adjOR = 1.02, CI:0.98-1.07, reducing by a factor of 0.96 every 10 years); early Do-Not-Resuscitate (DNR, life-sustaining treatment preferences) (adjOR = 1.38, CI:1.22-1.57, reducing by a factor of 0.92 every 10 years); and severe illness on admission (at 65, adjOR = 1.47, CI:1.40-1.54, reducing by a factor of 0.96 every 10 years).

CONCLUSION

Our findings highlight that residence prior to admission, early DNR, and acute illness severity are important predictors of mortality in hospitalized older adults with COVID-19. Readily available administrative geriatrics-focused indicators that go beyond age can be utilized when considering prognosis.

Service evaluation comparing Acute Care at Home for older people service and conventional service within an acute hospital care of elderly ward

AIMS AND OBJECTIVES

This study evaluated the impact of a consultant-led Acute Care at Home service in comparison with conventional hospital admission to a care of elderly ward.

BACKGROUND

Globally, there has been an increased demand for healthcare services caused by population growth and a rise in chronic conditions and an ageing population. Acute Care at Home services offer acute, hospital-level care in a person's own home. Five services have been commissioned across Northern Ireland since 2014 with limited research investigating their feasibility and effectiveness.

DESIGN

Quantitative design, using service evaluation methodology.

METHODS

A 1-year retrospective chart review was undertaken exploring admission demographics and post-discharge clinical outcomes of patients admitted to a Northern Ireland, Care of the Elderly ward (n = 191) and a consultant-led Acute Care at Home Service (n = 314) between April 2018-March 2019. Data were analysed using descriptive and inferential data analysis methods including frequencies, independent t tests and chi-square analysis. Outcome measurements included length of stay, 30-day, 3- and 6-month readmission and mortality rates, functional ability and residence on discharge. STROBE checklist was used in reporting this study.

RESULTS

Acute Care at Home services are associated with higher readmission and mortality rates at 30 days, 3 and 6 months. Fewer patients die while under Acute Care at Home care. Patients admitted to the Acute Care at Home services experience a reduced length of stay and decreased escalation in domiciliary care packages and are less likely to require subacute rehabilitation on discharge. There is no difference in gender, age and early warnings score between the two cohorts.

CONCLUSION

The Acute Care at Home service is a viable alternative to hospital for older patients. It prevents functional decline and the need for domiciliary care or nursing home placement. It is likely that the Acute Care at Home service has higher mortality and readmissions rates due to treating a higher proportion of dependent, frail older adults.

RELEVANCE TO CLINICAL PRACTICE

Acute Care at Home services continue to evolve worldwide. This service evaluation has confirmed that Acute Care at Home services are safe and cost-effective alternatives to traditional older people hospital services. Such services offer patient choice, reduce length of stay and costs and prevent functional decline of older adults. This study accentuates the need to expand Acute Care at Home provision and capacity throughout Northern Ireland.

The effect of COVID-19 epidemic on vital signs in hospitalized patients: a pre-post heat-map study from a large teaching hospital

The Lombardy SARS-CoV-2 outbreak in February 2020 represented the beginning of COVID-19 epidemic in Italy. Hospitals were flooded by thousands of patients with bilateral pneumonia and severe respiratory, and vital sign derangements compared to the standard hospital population. We propose a new visual analysis technique using heat maps to describe the impact of COVID-19 epidemic on vital sign anomalies in hospitalized patients. We conducted an electronic health record study, including all confirmed COVID-19 patients hospitalized from February 21st, 2020 to April 21st, 2020 as cases, and all non-COVID-19 patients hospitalized in the same wards from January 1st, 2018 to December 31st, 2018. All data on temperature, peripheral oxygen saturation, respiratory rate, arterial blood pressure, and heart rate were retrieved. Derangement of vital signs was defined according to predefined thresholds. 470 COVID-19 patients and 9241 controls were included. Cases were older than controls, with a median age of 79 vs 76 years in non survivors (p =  < 0.002). Gender was not associated with mortality. Overall mortality in COVID-19 hospitalized patients was 18%, ranging from 1.4% in patients below 65 years to about 30% in patients over 65 years. Heat maps analysis demonstrated that COVID-19 patients had an increased frequency in episodes of compromised respiratory rate, acute desaturation, and fever. COVID-19 epidemic profoundly affected the incidence of severe derangements in vital signs in a large academic hospital. We validated heat maps as a method to analyze the clinical stability of hospitalized patients. This method may help to improve resource allocation according to patient characteristics.

Performance of universal early warning scores in different patient subgroups and clinical settings: a systematic review

OBJECTIVE

To assess predictive performance of universal early warning scores (EWS) in disease subgroups and clinical settings.

DESIGN

Systematic review.

DATA SOURCES

Medline, CINAHL, Embase and Cochrane database of systematic reviews from 1997 to 2019.

INCLUSION CRITERIA

Randomised trials and observational studies of internal or external validation of EWS to predict deterioration (mortality, intensive care unit (ICU) transfer and cardiac arrest) in disease subgroups or clinical settings.

RESULTS

We identified 770 studies, of which 103 were included. Study designs and methods were inconsistent, with significant risk of bias (high: n=16 and unclear: n=64 and low risk: n=28). There were only two randomised trials. There was a high degree of heterogeneity in all subgroups and in national early warning score (I2=72%-99%). Predictive accuracy (mean area under the curve; 95% CI) was highest in medical (0.74; 0.74 to 0.75) and surgical (0.77; 0.75 to 0.80) settings and respiratory diseases (0.77; 0.75 to 0.80). Few studies evaluated EWS in specific diseases, for example, cardiology (n=1) and respiratory (n=7). Mortality and ICU transfer were most frequently studied outcomes, and cardiac arrest was least examined (n=8). Integration with electronic health records was uncommon (n=9).

CONCLUSION

Methodology and quality of validation studies of EWS are insufficient to recommend their use in all diseases and all clinical settings despite good performance of EWS in some subgroups. There is urgent need for consistency in methods and study design, following consensus guidelines for predictive risk scores. Further research should consider specific diseases and settings, using electronic health record data, prior to large-scale implementation.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42019143141.

Modified early warning score and risk of mortality after acute stroke

OBJECTIVE

An accurate prediction tool may facilitate optimal management of patients with acute stroke from an early stage. We evaluated the association between admission modified early warning score (MEWS) and mortality in patients with acute stroke.

METHOD

Data from the Anglia Stroke Clinical Network Evaluation Study (ASCNES) were analysed. We evaluated the association between admission MEWS and four outcomes; in-patient, 7-day, 30-day and 1-year mortality. Logistic regression models were used to calculate the odds of all mortality timeframes, whereas Cox proportional hazards models were used to calculate mortality at 1 year. Five univariate and multivariate models were constructed, adjusting for confounders. Patients with a moderate (2-3) or high (≥4) scores were compared to patients with a low score (0-1).

RESULTS

The study population consisted of 2006 patients. A total of 1196 patients had low MEWS, 666 had moderate MEWS and 144 had a high MEWS. A high MEWS was associated with increased mortality as an in-patient (OR 4.93, 95 % CI: 2.88-8.42), at 7 days (OR 7.53, 95 % CI: 4.24-13.38), at 30 days (OR 5.74, 95 % CI: 3.38-9.76) and 1-year (HR 2.52, 95 % CI 1.88-3.39). At 1 year, model 5 had a 1.02 OR (95 % CI 0.83-1.24) with moderate MEWS and 2.52 (95 % CI 1.88-3.39) with high MEWS.

CONCLUSION

Elevated MEWS on admission is a potential marker for acute-stroke mortality and may therefore be a useful risk prediction tool, able to guide clinicians attempting to prognosticate outcomes for patients with acute-stroke.

Comparison of within 7 Day All-Cause Mortality among HDU Patients with Modified Early Warning Score of ≥5 with those with Score of <5

Objective

To compare 7-Day All-Cause Mortality among HDU Patients with Modified Early Warning Score of ≥5 with Those with Score of <5.

Methods

All patients of age more than 18 years, of either gender admitted in HDU of Medical Unit-II, CHK between September 2019 to February 2020 were included. MEWS was calculated for each patient at time of admission. Patients with MEWS score of ≥5 were allocated to Group-A and those with score of <5 were allocated to Group-B. Patients were followed for seven days and outcome status of alive, expired or discharged was noted.

Results

Total of 336 patients were selected out of which 168 patients was inducted in Group-A and 168 patients in Group-B. MEWS Score in patients who expired was significantly higher (Mdn=11) than in those who survived (Mdn=4), p <.001. 7-day mortality in Group-A was 62 (39.9%) while in Group-B was 40 (23.8%). ROC was plotted of MEWS Score for mortality, it showed significant area under curve of 68.4% (p <.001, 95% CI = .62 to .75). MEWS Score of 3.5 showed sensitivity of 89.2% and specificity of 65%.

Conclusion

Our results show that MEWS has a positive trend to predict mortality. MEWS score of 3.5 is suggested cut off based on ROC in our study.

Predicting cardiac arrest in the emergency department

In-hospital cardiac arrest remains a leading cause of death: roughly 300,000 in-hospital cardiac arrests occur each year in the United States, ≈10% of which occur in the emergency department. ED-based cardiac arrest may represent a subset of in-hospital cardiac arrest with a higher proportion of reversible etiologies and a higher potential for neurologically intact survival. Patients presenting to the ED have become increasingly complex, have a high burden of critical illness, and face crowded departments with thinly stretched resources. As a result, patients in the ED are vulnerable to unrecognized clinical deterioration that may lead to ED-based cardiac arrest. Efforts to identify patients who may progress to ED-based cardiac arrest have traditionally been approached through identification of critically ill patients at triage and the identification of patients who unexpectedly deteriorate during their stay in the ED. Interventions to facilitate appropriate triage and resource allocation, as well as earlier identification of patients at risk of deterioration in the ED, could potentially allow for both prevention of cardiac arrest and optimization of outcomes from ED-based cardiac arrest. This review will discuss the epidemiology of ED-based cardiac arrest, as well as commonly used approaches to predict ED-based cardiac arrest and highlight areas that require further research to improve outcomes for this population.

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.

Comparison of the National Early Warning Score (NEWS) and the Modified Early Warning Score (MEWS) for predicting admission and in-hospital mortality in elderly patients in the pre-hospital setting and in the emergency department

The aim of this study is to evaluate the usefulness of the pre-hospital National Early Warning Score (pNEWS) and the pre-hospital Modified Early Warning Score (pMEWS) for predicting admission and in-hospital mortality in elderly patients presenting to the emergency department (ED). We also compare the value of the pNEWS with that of the ED NEWS (eNEWS) and ED MEWS (eMEWS) for predicting admission and in-hospital mortality. This retrospective, single-centre observational study was carried out in the ED of Jikei University Kashiwa Hospital, in Chiba, Japan, from 1st April 2017 to 31st March 2018. All patients aged 65 years or older were included in this study. The pNEWS/eNEWS were derived from seven common physiological vital signs: respiratory rate, peripheral oxygen saturation, the presence of inhaled oxygen parameters, body temperature, systolic blood pressure, pulse rate and Alert, responds to Voice, responds to Pain, Unresponsive (AVPU) score, whereas the pMEWS/eMEWS were derived from six common physiological vital signs: respiratory rate, peripheral oxygen saturation, body temperature, systolic blood pressure, pulse rate and AVPU score. Discrimination was assessed by plotting the receiver operating characteristic (ROC) curve and calculating the area under the ROC curve (AUC). The median pNEWS, pMEWS, eNEWS and eMEWS were significantly higher at admission than at discharge (p < 0.001). The median pNEWS, pMEWS, eNEWS and eMEWS of non-survivors were significantly higher than those of the survivors (p < 0.001). The AUC for predicting admission was 0.559 for the pNEWS and 0.547 for the pMEWS. There was no significant difference between the AUCs of the pNEWS and the pMEWS for predicting admission (p = 0.102). The AUCs for predicting in-hospital mortality were 0.678 for the pNEWS and 0.652 for the pMEWS. There was no significant difference between the AUCs of the pNEWS and the pMEWS for predicting in-hospital mortality (p = 0.081). The AUC for predicting admission was 0.628 for the eNEWS and 0.591 for the eMEWS. The AUC of the eNEWS was significantly greater than that of the eMEWS for predicting admission (p < 0.001). The AUC for predicting in-hospital mortality was 0.789 for the eNEWS and 0.720 for the eMEWS. The AUC of the eNEWS was significantly greater than that of the eMEWS for predicting in-hospital mortality (p < 0.001). For admission and in-hospital mortality, the AUC of the eNEWS was significantly greater than that of the pNEWS (p < 0.001, p < 0.001), and the AUC of the eMEWS was significantly greater than that of the pMEWS (p < 0.01, p < 0.05). Our single-centre study has demonstrated the low utility of the pNEWS and the pMEWS as predictors of admission and in-hospital mortality in elderly patients, whereas the eNEWS and the eMEWS predicted admission and in-hospital mortality more accurately. Evidence from multicentre studies is needed before introducing pre-hospital versions of risk-scoring systems.

Characterising variation in composition and activation criteria of rapid response and cardiac arrest teams: a survey of Medicare participating hospitals in five American states

OBJECTIVES

To characterise the variation in composition, leadership, and activation criteria of rapid response and cardiac arrest teams in five north-eastern states of the USA.

DESIGN

Cross-sectional study consisting of a voluntary 46-question survey of acute care hospitals in north-eastern USA.

SETTING

Acute care hospitals in New York, New Jersey, Rhode Island, Vermont, and Pennsylvania.

PARTICIPANTS

Surveys were completed by any member of the rapid response team (RRT) with a working knowledge of team composition and function. Participants were all Medicare-participating acute care hospitals, including teaching and community hospitals as well as hospitals from rural, urban and suburban areas.

RESULTS

Out of 378 hospitals, contacts were identified for 303, and 107 surveys were completed. All but two hospitals had an RRT, 70% of which changed members daily. The most common activation criteria were clinical concern (95%), single vital sign abnormalities (77%) and early warning score (59%). Eighty one per cent of hospitals had a dedicated cardiac arrest team.RRT composition varied widely, with respiratory therapists, critical care nurses, physicians and nurse managers being the most likely to attend (89%, 78%, 64% and 51%, respectively). Consistent presence of critical care physicians was uncommon and both cardiac arrest teams and teams were frequently led by trainee physicians, often without senior supervision.

CONCLUSIONS

As the largest study to date in the USA, we have demonstrated wide heterogeneity, rapid team turnover and a lack of senior supervision of RRT and cardiac arrest teams. These factors likely contribute to the mixed results seen in studies of RRTs.

Sepsis Screening: Combining Early Warning Scores and SIRS Criteria

Providing effective screening tools to nurses is necessary to improve patient outcomes and health care quality. This research examines if the modification of two electronic health record sepsis screening tools using a combined systemic inflammatory response syndrome (SIRS), modified early warning score (MEWS), and national early warning score (NEWS) criteria improves the recognition of sepsis by nurses. Medical-surgical/telemetry units at a medical center in the Midwest were examined using a quasiexperimental design. Modifications of tool 1 captured 18% more correct classifications of sepsis (odds ratio [OR] = .82, 95% CI = [0.68, 0.98]), triggering for 10% fewer patients, t(1033) = 9.31, p < .001. 95% CI = [0.078, 0.119]. Modifications of tool 2 captured 3 times more correct alerts (OR = .29, 95% CI = [0.24, 0.35]), triggering for 46% fewer patients, t(1033) = 24.38, p < .001. 95% CI = [0.420, 0.493]. The updated criteria showed significant improvement toward correctly identifying sepsis and presents the opportunity to develop an effective tool that balances sensitivity with specificity.

Are Early Warning Scores Useful Predictors for Mortality and Morbidity in Hospitalised Acutely Unwell Older Patients? A Systematic Review

BACKGROUND

Early warning scores (EWSs) are used to identify deteriorating patients for appropriate interventions. We performed a systematic review to examine the usefulness of EWSs in predicting inpatient mortality and morbidity (transfer to higher-level care and length of hospital stay) in older people admitted to acute medical units with sepsis, acute cardiovascular events, or pneumonia.

METHODS

A systematic review of published and unpublished databases was conducted. Cochrane's tool for assessing Risk of Bias in Non-Randomised Studies-of Interventions (ROBINS-I) was used to appraise the evidence. A narrative synthesis was performed due to substantial heterogeneity.

RESULTS

Five studies (n = 12,057) were eligible from 1033 citations. There was an overall "moderate" risk of bias for all studies. The predictive ability of EWSs regarding mortality was reported in one study (n = 274), suggesting EWSs were better at predicting survival, (negative predictive value >90% for all scores). Three studies (n = 1819) demonstrated a significant association between increasing modified EWSs (MEWSs) and increased risk of mortality. Hazards ratios for a composite death/intensive care (ICU) admission with MEWSs ≥5 were significant in one study (p = 0.003). Two studies (n = 1421) demonstrated that a MEWS ≥6 was associated with 21 times higher probability of mortality (95% Confidence Interval (CI): 2.71⁻170.57) compared with a MEWS ≤1. A MEWS of ≥5 was associated with 22 times higher probability of mortality (95% CI: 10.45⁻49.16).

CONCLUSION

Increasing EWSs are strongly associated with mortality and ICU admission in older acutely unwell patients. Future research should be targeted at better understanding the usefulness of high and increasing EWSs for specific acute illnesses in older adults.

Barriers and facilitators related to the implementation of a physiological track and trigger system: A systematic review of the qualitative evidence

Purpose

To identify the barriers to, and facilitators of, the implementation of physiological track and trigger systems (PTTSs), perceived by healthcare workers, through a systematic review of the extant qualitative literature.

Data sources

Searches were performed in PUBMED, CINAHL, PsycInfo, Embase and Web of Science. The reference lists of included studies were also screened.

Study selection

The electronic searches yielded 2727 papers. After removing duplicates, and further screening, a total of 10 papers were determined to meet the inclusion criteria and were reviewed.

Data extraction

A deductive content analysis approach was taken to organizing and analysing the data. A framework consisting of two overarching dimensions ('User-related changes required to implement PTTSs effectively' and 'Factors that affect user-related changes'), 5 themes (staff perceptions of PTTSs and patient safety, workflow adjustment, PTTS, implementation process and local context) and 14 sub themes was used to classify the barriers and facilitators to the implementation of PTTSs.

Results of data synthesis

Successful implementation of a PTTS must address the social context in which it is to be implemented by ensuring that the users believe that the system is effective and benefits patient care. The users must feel invested in the PTTS and its use must be supported by training to ensure that all healthcare workers, senior and junior, understand their role in using the system.

Conclusion

PTTSs can improve patient safety and quality of care. However, there is a need for a robust implementation strategy or the benefits of PTTSs will not be realized.

Using modified early warning score to predict need of lifesaving intervention in adult non-trauma patients in a tertiary state hospital

Background:

Modified early warning score has been validated in many uses in the emergency department. We propose that the modified early warning score performs well in predicting the need of lifesaving interventions in the emergency department, as a predictor of patients who are critically ill.

Objective:

The study aims to evaluate the use of modified early warning score in sorting out critically ill patients in the emergency department.

Methods:

The patients’ demographic data and first vital signs (blood pressure, heart rate, temperature, respiratory rate, and level of consciousness) were collected prospectively. Individual modified early warning score was calculated. The outcome was a patient received one or more lifesaving interventions toward the end of stay in emergency department. Multivariate logistic regression analysis was utilized to assess the association between modified early warning score and other potential predictors with outcome.

Results:

There are a total of 259 patients enrolled into the study. The optimal modified early warning score in predicting lifesaving intervention was ≥4 with a sensitivity of 95% and specificity of 81%. Modified early warning score ≥4 (odds ratio = 96.97, 95% confidence interval = 11.82–795.23, p < 0.001) was found to significantly increase the risk of receiving lifesaving intervention in the emergency department.

Conclusion:

Modified early warning score is found to be a good predictor for patients in need of lifesaving intervention in the emergency department.

Hospital at Home care for older patients with cognitive impairment: a protocol for a randomised controlled feasibility trial

INTRODUCTION

An acute hospital admission is a stressful life event for older people, particularly for those with cognitive impairment. The hospitalisation is often complicated by hospital-associated geriatric syndromes, including delirium and functional loss, leading to functional decline and nursing home admission. Hospital at Home care aims to avoid hospitalisation-associated adverse outcomes in older patients with cognitive impairment by providing hospital care in the patient's own environment.

METHODS AND ANALYSIS

This randomised, non-blinded feasibility trial aims to assess the feasibility of conducting a randomised controlled trial in terms of the recruitment, use and acceptability of Hospital at Home care for older patients with cognitive impairment. The quality of care will be evaluated and the advantages and disadvantages of the Hospital at Home care programme compared with usual hospital care. Eligible patients will be randomised either to Hospital at Home care in their own environment or usual hospital care. The intervention consists of hospital level care provided at patients' homes, including visits from healthcare professionals, diagnostics (laboratory tests, blood cultures) and treatment. The control group will receive usual hospital care. Measurements will be conducted at baseline, during admission, at discharge and at 3 and 6 months after the baseline assessment.

ETHICS AND DISSEMINATION

Institutional ethics approval has been granted. The findings will be disseminated through public lectures, professional and scientific conferences, as well as peer-reviewed journal articles. The study findings will contribute to knowledge on the implementation of Hospital at Home care for older patients with cognitive disorders. The results will be used to inform and support strategies to deliver eligible care to older patients with cognitive impairment.

TRIAL REGISTRATION NUMBER

e020313; Pre-results.

Norton scale score on admission and mortality of patients hospitalised in Internal Medicine departments

OBJECTIVE

To determine the association between the Norton scale score (which assesses the risk of pressure ulcers) and mortality in the short, medium and long term in patients hospitalised in Internal Medicine departments.

PATIENTS AND METHODS

A prospective, single-centre cohort study was conducted on patients hospitalised in the months of October 2010 and January, May and October 2011. Data was collected on age, sex, Barthel index, Norton scale, presence of pressure ulcers, major diagnostic category, hospital stay and weight of the diagnosis-related group. The patients were divided according to the risk categories of the Norton scale. The follow-up was 3 years.

RESULTS

The study included 624 patients with a median age (interquartile range) of 79 (17) years and a median Norton scale score of 16 (7). During hospitalisation, 74 (11.9%) patients died, 176 (28.2%) died at 6 months, 212 (34.0%) died at 1 year, and 296 (47.4%) died at 3 years. Mortality was greater in the higher risk categories of the Norton scale. The Norton score was independently associated with mortality at 6 months (p<.001), at 1 year (p=.005), and at 3 years (p=.002). The areas under the curve of the Norton scale were 0.746 (95% CI 0.686-0.806), 0.735 (95% CI 0.691-0.780) and 0.751 (95% CI 0.713-0.789), respectively (p<.001).

CONCLUSIONS

The Norton scale is useful for predicting the prognosis in the short, medium and long term in patients hospitalized in internal medicine departments.

Examination of Patients in the Intensive Care Unit

•

Careful examination of the intensive care unit (ICU) patient remains essential because it is the only way (among many examples) to detect the purulence around intravenous lines, the warmth of an infected joint, the purpuric skin lesions of septic emboli, the wheezing of bronchospasm, the neck stiffness of meningitis, or the absent doll’s-eyes of cerebellar stroke.

•

The modified early warning score accurately identifies a patient’s risk of hospital mortality.

•

In patients with shock, several findings have diagnostic value. For example, the absence of warm hands decreases the probability of septic shock, the presence of elevated venous pressure and crackles increases the probability of cardiogenic shock, and the presence of a pulse pressure increment after passive leg elevation increases the probability of hypovolemic shock.

•

The findings of cool limbs, prolonged capillary refill times, and mottling of the limbs (i.e., blotchy or lacelike pattern of dusky discoloration) all increase the probability of reduced cardiac output and a worse prognosis.

The most commonly used disease severity scores are inappropriate for risk stratification of older emergency department sepsis patients: an observational multi-centre study

Background

Sepsis recognition in older emergency department (ED) patients is difficult due to atypical symptom presentation. We therefore investigated whether the prognostic and discriminative performance of the five most commonly used disease severity scores were appropriate for risk stratification of older ED sepsis patients (≥70 years) compared to a younger control group (<70 years).

Methods

This was an observational multi-centre study using an existing database in which ED patients who were hospitalized with a suspected infection were prospectively included. Patients were stratified by age < 70 and ≥70 years. We assessed the association with in-hospital mortality (primary outcome) and the area under the curve (AUC) with receiver operator characteristics of the Predisposition, Infection, Response, Organ dysfunction (PIRO), quick Sequential Organ Failure Assessment (qSOFA), Mortality in ED Sepsis (MEDS), and the Modified and National Early Warning (MEWS and NEWS) scores.

Results

In-hospital mortality was 9.5% ((95%-CI); 7.4–11.5) in the 783 included older patients, and 4.6% (3.6–5.7) in the 1497 included younger patients. In contrast to younger patients, disease severity scores in older patients associated poorly with mortality. The AUCs of all disease severity scores were poor and ranged from 0.56 to 0.64 in older patients, significantly lower than the good AUC range from 0.72 to 0.86 in younger patients. The MEDS had the best AUC (0.64 (0.57–0.71)) in older patients. In older and younger patients, the newly proposed qSOFA score (Sepsis 3.0) had a lower AUC than the PIRO score (sepsis 2.0).

Conclusion

The prognostic and discriminative performance of the five most commonly used disease severity scores was poor and less useful for risk stratification of older ED sepsis patients.

Electronic supplementary material

The online version of this article (10.1186/s13049-017-0436-3) contains supplementary material, which is available to authorized users.

Early prediction of hospital admission for emergency department patients: a comparison between patients younger or older than 70 years

OBJECTIVE

The aim of this study was to develop models that predict hospital admission to ED of patients younger and older than 70 and compare their performance.

METHODS

Prediction models were derived in a retrospective observational study of all patients≥18 years old visiting the ED of a university hospital during the first 6 months of 2012. Patients were stratified into two age groups (<70 years old and ≥70 years old). Multivariable logistic regression analysis was used to identify predictors of hospital admission among factors available immediately after patient arrival to the ED. Validation of the prediction models was performed on patients presenting to the ED during the second half of the year 2012.

RESULTS

10 807 patients were included in the derivation and 10 480 in the validation cohorts. The strongest independent predictors of hospital admission among the 8728 patients <70 years old were age, sex, triage category, mode of arrival, performance of blood tests, chief complaint, ED revisit, type of specialist, phlebotomised blood sample and all vital signs. The area under the curve (AUC) of the validation cohort for those <70 years old was 0.86 (95% CI 0.85 to 0.87). Among the 2079 patients ≥70 years, the same factors were predictive, except for gender, type of specialist and heart rate; the AUC was 0.77 (95% CI 0.75 to 0.79). The prediction models could identify a group of 10% of patients with the highest risk in whom hospital admission was predicted at ED triage, with a positive predictive value (PPV) of 71% (95% CI 68% to 74%) in younger patients and PPV of 87% (95% CI 81% to 92%) in older patients.

CONCLUSION

Demographic and clinical factors readily available early in the ED visit can be useful in identifying patients who are likely to be admitted to the hospital. While the model for the younger patients had a higher AUC, the model for older patients had a higher PPV in identifying the patients at highest risk for admission. Of note, heart rate was not a useful predictor in the older patients.

Deaths among the elderly with ICU infections

Objective

to evaluate the clinical outcome of elderly patients admitted to intensive care units who had nosocomial infection, correlating the findings with sociodemographic and clinical variables.

Method

descriptive research, performed with 308 elderly patients. The collection was made from medical records and covers the years 2012 to 2015. Uni-/bivariate analyses were performed.

Results

a statistical association was found between the clinical outcome types and the variables age, length of stay, presence of previous comorbidities, main diagnosis, respiratory and urinary tract infections, use of central venous and indwelling urinary catheters, mechanical ventilation, and tracheostomy. The survival curve showed higher mortality among the elderly from the age of 80 on.

Conclusion

the clinical outcome of the elderly who acquire infection in the intensive care unit is influenced by sociodemographic and clinical variables that increase mortality rates.

A combination of clinical parameters and blood-gas analysis identifies patients at risk of transfer to intensive care upon arrival to the Emergency Department

OBJECTIVES

Identifying patients at risk of transfer to the ICU upon arrival to the Emergency Department (ED) might direct early therapy and optimize transfers. However, among the many ED patients, it is difficult to pinpoint the few who insidiously deteriorate to an ICU-requiring level. The aim of this study was to identify predictors in background information, vital values and blood-gas analysis for transfer to ICU 3-36 h after arrival among nontrauma ED patients.

METHODS

A case-control study of 10 007 acute adult patients admitted to ED within 1 year was carried out. The case group consisted of all ICU transfers 3-36 h after arrival who underwent blood-gas analysis and a similar control group not transferred to the ICU. Blood pressure, respiratory frequency, pulse rate, peripheral oxygen saturation and temperature, triage, height, weight, Glasgow Coma Score, drugs, alcohol, tobacco, age, sex, Charlson score and blood-gas results were analysed.

RESULTS

A total of 49 medical and 33 surgical patients were transferred to the ICU. For medical cases, 2.3 and surgical cases 3.7 controls were included. For medical patients, low systolic blood pressure [odds ratio (OR) 14.4], elevated heart rate (OR 3.9), severe acidosis (OR 5.1) and hypercapnia (OR 8.4) and for surgical patients age 60-79 years (OR 6.3), low diastolic blood pressure (OR 2.7) and severe acidosis (OR 15.3) were associated significantly with later transfer to the ICU.

CONCLUSION

The predictors identified could be used as part of ED triage to identify high-risk patients for ICU. These findings should be examined in a well-designed prospective cohort study.

Modified Early Warning Score and VitalPac Early Warning Score in geriatric patients admitted to emergency department

OBJECTIVE

The aim of this study was to evaluate the value of the Modified Early Warning Score (MEWS) and the VitalPac Early Warning Score (VIEWS) in predicting hospitalization and in-hospital mortality in geriatric emergency department (ED) patients.

PATIENTS AND METHODS

This prospective, single-centered observational study was carried out over 1 month at the ED of a university hospital in patients 65 years of age and older presenting to the ED. The vital parameters of the patients measured on admission to ED were recorded. The MEWS and VIEWS were calculated using the recorded physiological parameters of the patients. Hospitalization and in-hospital mortality were used as the primary outcomes.

RESULTS

A total of 671 patients included in the study. The median age of the patients was 75 (11) years, and 375 (55.9%) were men. The MEWS is effective for discriminating patient groups that have been discharged from ED, admitted to a ward and admitted to ICU [1 (2) vs. 1 (1) vs. 3 (3), respectively, P<0.001]. The VIEWS is also effective for discriminating patient groups that have been discharged from ED, admitted to a ward, and admitted to ICU [2 (3) vs. 5 (5) vs. 8 (8), respectively, P<0.001]. The AUCs of the MEWS and VIEWS were 0.727 [95% confidence interval (CI) 0.689-0.765] and 0.756 (95% CI 0.720-0.792) in predicting hospitalization, respectively. The AUCs of the MEWS and VIEWS were 0.891 (95% CI 0.844-0.937) and 0.900 (95% CI 0.860-0.941) in predicting in-hospital mortality, respectively.

CONCLUSION

The MEWS and VIEWS are powerful scoring systems that are easy-to-use for predicting the hospitalization and in-hospital mortality of geriatric ED patients.

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.

Application of the National Early Warning Score (NEWS) as a stratification tool on admission in an Italian acute medical ward: A perspective study

AIM

We aimed to assess the performance of the National Early Warning Score (NEWS) as tool for patient risk stratification at admission in an acute Internal Medicine ward and to ensure patient placement in ward areas with the required and most appropriate intensity of care. As secondary objective, we considered NEWS performance in two subgroups of patients: sudden cardiac events (acute coronary syndromes and arrhythmic events), and chronic respiratory insufficiency.

METHODS

We conducted a perspective cohort single centre study on 2,677 unselected patients consecutively admitted from July 2013 to March 2015 in the Internal Medicine ward of the hospital of Trento, Italy. The NEWS was mandatory collected on ward admission. We defined three risk categories for clinical deterioration: low score (NEWS 0-4), medium score (NEWS 5-6), and high score (NEWS≥7). Following adverse outcomes were considered: total and early (<72 hours) in-hospital mortality, urgent transfers to a higher intensity of care. A logistic regression model quantified the association between outcomes and NEWS.

RESULTS

For patients with NEWS >4 vs patients with NEWS <4, the risk of early death increased from 12 to 36 times, total mortality from 3.5 to 9, and urgent transfers from 3.5 to 7. In patients with sudden cardiac events, lower scores were significantly associated with higher risk of transfer to a higher intensity of care. In patients affected by chronic hypoxaemia, adverse outcomes occurred less in medium and high score categories of NEWS.

CONCLUSIONS

National Early Warning Score assessed on ward admission may enable risk stratification of clinical deterioration and can be a good predictor of in-hospital serious adverse outcomes, although sudden cardiac events and chronic hypoxaemia could constitute some limits.

Quick SOFA Scores Predict Mortality in Adult Emergency Department Patients With and Without Suspected Infection

STUDY OBJECTIVE

The Quick Sequential Organ Failure Assessment (qSOFA) score (composed of respiratory rate ≥22 breaths/min, systolic blood pressure ≤100 mm Hg, and altered mental status) may identify patients with infection who are at risk of complications. We determined the association between qSOFA scores and outcomes in adult emergency department (ED) patients with and without suspected infection.

METHODS

We performed a single-site, retrospective review of adult ED patients between January 2014 and March 2015. Patients triaged to fast-track, dentistry, psychiatry, and labor and delivery were excluded. qSOFA scores were calculated with simultaneous vital signs and Modified Early Warning System scores. Patients receiving intravenous antibiotics were presumed to have suspected infection. Univariate and multivariate analyses were performed to explore the association between qSOFA scores and inpatient mortality, admission, and length of stay. Receiver operating characteristics curve analysis and c statistics were also calculated for ICU admission and mortality.

RESULTS

We included 22,530 patients. Mean age was 54 years (SD 21 years), 53% were women, 45% were admitted, and mortality rate was 1.6%. qSOFA scores were associated with mortality (0 [0.6%], 1 [2.8%], 2 [12.8%], and 3 [25.0%]), ICU admission (0 [5.1%], 1 [10.5%], 2 [20.8%], and 3 [27.4%]), and hospital length of stay (0 [123 hours], 1 [163 hours], 2 [225 hours], and 3 [237 hours]). Adjusted rates were also associated with qSOFA. The c statistics for mortality in patients with and without suspected infection were similarly high (0.75 [95% confidence interval 0.71 to 0.78) and 0.70 (95% confidence interval 0.65 to 0.74), respectively.

CONCLUSION

qSOFA scores were associated with inpatient mortality, admission, ICU admission, and hospital length of stay in adult ED patients likely to be admitted both with and without suspected infection and may be useful in predicting outcomes.

Respiratory rates measured by a standardised clinical approach, ward staff, and a wireless device

BACKGROUND

Respiratory rate is among the first vital signs to change in deteriorating patients. The aim was to investigate the agreement between respiratory rate measurements by three different methods.

METHODS

This prospective observational study included acutely admitted adult patients in a medical ward. Respiratory rate was measured by three methods: a standardised approach over 60 s while patients lay still and refrained from talking, by ward staff and by a wireless electronic patch (SensiumVitals). The Bland-Altman method was used to compare measurements and three breaths per minute (BPM) was considered a clinically relevant difference.

RESULTS

We included 50 patients. The mean difference between the standardised approach and the electronic measurement was 0.3 (95% CI: -1.4 to 2.0) BPM; 95% limits of agreement were -11.5 (95% CI: -14.5 to -8.6) and 12.1 (95% CI: 9.2 to 15.1) BPM. Removal of three outliers with huge differences lead to a mean difference of -0.1 (95% CI: -0.7 to 0.5) BPM and 95% limits of agreement of -4.2 (95% CI: -5.3 to -3.2) BPM and 4.0 (95% CI: 2.9 to 5.0) BPM. The mean difference between staff and electronic measurements was 1.7 (95% CI: -0.5 to 3.9) BPM; 95% limits of agreement were -13.3 (95% CI: -17.2 to -9.5) BPM and 16.8 (95% CI: 13.0 to 20.6) BPM.

CONCLUSION

A concerning lack of agreement was found between a wireless monitoring system and a standardised clinical approach. Ward staff's measurements also seemed to be inaccurate.

Can a Patient's In-Hospital Length of Stay and Mortality Be Explained by Early-Risk Assessments?

Objective

To assess whether a patient’s in-hospital length of stay (LOS) and mortality can be explained by early objective and/or physicians’ subjective-risk assessments.

Data Sources/Study Setting

Analysis of a detailed dataset of 1,021 patients admitted to a large U.S. hospital between January and September 2014.

Study Design

We empirically test the explanatory power of objective and subjective early-risk assessments using various linear and logistic regression models.

Principal Findings

The objective measures of early warning can only weakly explain LOS and mortality. When controlled for various vital signs and demographics, objective signs lose their explanatory power. LOS and death are more associated with physicians’ early subjective risk assessments than the objective measures.

Conclusions

Explaining LOS and mortality require variables beyond patients’ initial medical risk measures. LOS and in-hospital mortality are more associated with the way in which the human element of healthcare service (e.g., physicians) perceives and reacts to the risks.

Clinical study of a new Modified Early Warning System scoring system for rapidly evaluating shock in adults

OBJECTIVE

Shock, the most common severe emergency syndrome, has a complicated etiopathogenesis, is difficult to identify, progresses quickly, and is dangerous. Early identification and intervention play determining roles in the final outcomes of shock patients, but no specific scoring system for shock has been established to date.

METHODS

We collected 292 shock patients and analyzed the correlation between 28-day prognosis and the Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II), Modified Early Warning System (MEWS), and Sequential Organ Failure Assessment scoring systems. According to the previous result, we established a new MEWS scoring system based on the conventional MEWS, which also included age and transcutaneous oxygen saturation. Some of the items with a strong correlation with the 28-day prognosis were selected to establish the new MEWS scoring system. We then evaluated the predictive efficacy of the new MEWS scoring system on 28-day prognosis and the correlation with other scoring systems.

RESULTS

Some indexes, including age, transcutaneous oxygen saturation, arterial blood pH and blood lactic acid, serum sodium, serum potassium, HCO₃, and red blood cells deposited, differed significantly between the nonsurviving and surviving groups (P<.05). The area under the curve (AUC) of the APACHE II, MEWS, shock index, and Sequential Organ Failure Assessment scoring systems for 28-day prognosis indicated a critical predictive efficacy. Receiver operating characteristic curves indicated that the MEWS AUC was 0.614, new MEWS AUC was 0.696, and APACHE II AUC was 0.785, suggesting superiority of the new MEWS to the conventional MEWS but inferiority to the APACHE II. Interestingly, the correlation efficient of the traditional MEWS and the new MEWS was 0.81. The correlation efficient of these scoring systems with other indexes, including lactic acid and hemoglobin, was less than 0.3.

CONCLUSIONS

The new MEWS scoring system could be an independent indicator to reflect shock severity. It has higher predictive efficacy in septic shock, especially for 28-day prognosis.

Identifying High-Risk Children in the Emergency Department

PURPOSE

Early warning scores (EWS) identify high-risk hospitalized patients prior to clinical deterioration; however, their ability to identify high-risk pediatric patients in the emergency department (ED) has not been adequately evaluated. We sought to determine the association between modified pediatric EWS (MPEWS) in the ED and inpatient ward-to-pediatric intensive care unit (PICU) transfer within 24 hours of admission.

METHODS

This is a case-control study of 597 pediatric ED patients admitted to the inpatient ward at Seattle Children's Hospital between July 1, 2010, and December 31, 2011. Cases were children subsequently transferred to the PICU within 24 hours, whereas controls remained hospitalized on the inpatient ward. The association between MPEWS in the ED and ward-to-PICU transfer was determined by chi-square analysis.

RESULTS

Fifty children experienced ward-to-PICU transfer within 24 hours of admission. The area under the receiver-operator characteristic curve was 0.691. Children with MPEWS > 7 in the ED were more likely to experience ward-to-PICU transfer (odds ratio 8.36, 95% confidence interval 2.98-22.08); however, the sensitivity was only 18.0% with a specificity of 97.4%. Using MPEWS >7 for direct PICU admission would have led to 167 unnecessary PICU admissions and identified only 9 of 50 patients who required PICU care.

CONCLUSIONS

Elevated MPEWS in the ED is associated with increased risk of ward-to-PICU transfer within 24 hours of admission; however, an MPEWS threshold of 7 is not sufficient to identify more than a small proportion of ward-admitted children with subsequent clinical deterioration.

Predicting mortality in acutely hospitalized older patients: a retrospective cohort study

Acutely hospitalized older patients have an increased risk of mortality, but at the moment of presentation this risk is difficult to assess. Early identification of patients at high risk might increase the awareness of the physician, and enable tailored decision-making. Existing screening instruments mainly use either geriatric factors or severity of disease for prognostication. Predictive performance of these instruments is moderate, which hampers successive interventions. We conducted a retrospective cohort study among all patients aged 70 years and over who were acutely hospitalized in the Acute Medical Unit of the Leiden University Medical Center, the Netherlands in 2012. We developed a prediction model for 90-day mortality that combines vital signs and laboratory test results reflecting severity of disease with geriatric factors, represented by comorbidities and number of medications. Among 517 patients, 94 patients (18.2 %) died within 90 days after admission. Six predictors of mortality were included in a model for mortality: oxygen saturation, Charlson comorbidity index, thrombocytes, urea, C-reactive protein and non-fasting glucose. The prediction model performs satisfactorily with an 0.738 (0.667-0.798). Using this model, 53 % of the patients in the highest risk decile (N = 51) were deceased within 90 days. In conclusion, we are able to predict 90-day mortality in acutely hospitalized older patients using a model with directly available clinical data describing disease severity and geriatric factors. After further validation, such a model might be used in clinical decision making in older patients.

Emergency department Modified Early Warning Score association with admission, admission disposition, mortality, and length of stay

BACKGROUND

Geisinger Health System implemented the Modified Early Warning Score (MEWS) in 2011 and is fully integrated to the Electronic Medical Record (EMR). Our objective was to assess whether the emergency department (ED) MEWS (auto-calculated by EMR) is associated with admission to the hospital, admission disposition, inpatient mortality, and length of stay (LOS) 4 years after its implementation.

METHODS

A random sample of 3,000 patients' first encounter in the ED was extracted in the study period (between January 1, 2014 and May 31, 2015). Logistic regression was done to analyze whether mean, maximum, and median ED MEWS is associated with admission disposition, mortality, and LOS.

RESULTS

Mean, maximum, and median ED MEWS is associated with admission to the hospital, admission disposition, and mortality. It correlates weakly with LOS.

CONCLUSION

MEWS can be integrated to the EMR, and the score automatically generated still helps predict catastrophic events. MEWS can be used as a triage tool when deciding whether and where patients should be admitted.

Early warning score predicts acute mortality in stroke patients

OBJECTIVES

Clinical deterioration and death among patients with acute stroke are often preceded by detrimental changes in physiological parameters. Systematic and effective tools to identify patients at risk of deterioration early enough to intervene are therefore needed. The aim of the study was to investigate whether the aggregate weighted track and trigger system early warning score (EWS) can be used as a simple observational tool to identify patients at risk and predict mortality in a population of patients with acute stroke.

MATERIALS AND METHODS

Patients admitted with acute stroke at the Copenhagen University Hospital, Nordsjaellands Hospital, Denmark, from May to September 2012 were enrolled in a retrospective cohort study (n = 274). Vital signs were measured immediately after admission and consistently during the hospitalization period. Based on the vital signs, a single composite EWS was calculated. Death within 30 days was used as outcome. Area under the receiver operating characteristics curve (AUROC) and a Kaplan-Meier curve were computed to examine the prognostic validity of EWS.

RESULTS

A total of 24 patients (8.8%) died within 30 days. The prognostic performance was high for both the EWS at admission (AUROC 0.856; 95% CI 0.760-0.951; P-value < 0.001) and the maximal EWS measured (AUROC 0.949; 95% CI 0.919-0.980; P-value < 0.001). Mortality rates were lowest for admission EWS 0-1 (2%) and highest for admission EWS ≥ 5 (63%).

CONCLUSIONS

Early warning score is a simple and valid tool for identifying patients at risk of dying after acute stroke. Readily available physiological parameters are converted to a single score, which can guide both nurses and physicians in clinical decision making and resource allocation.

Can prehospital Modified Early Warning Score identify non-trauma patients requiring life-saving intervention in the emergency department?

OBJECTIVE

We aim to investigate whether prehospital Modified Early Warning Score (MEWS) can identify non-trauma patients requiring life-saving intervention (LSI) within 4 h of presentation to the ED.

METHODS

It was a prospective study of non-trauma ED patients by ambulance who were 16 years or older from 1 to 27 November 2013. Prehospital MEWS was calculated according to vital signs measured by the ambulance crew. Data on patients' demographics, triage category, LSI within 4 h of ED presentation and 24 h mortality were retrieved. LSI was defined as emergency interventions to airway, breathing and circulation, emergency procedures and medications administered. The performance of prehospital MEWS was analysed with sensitivity, specificity, predictive values (PV), likelihood ratios (LR) and the receiver operating characteristic curve.

RESULTS

Recruited during the study period were 1493 patients. The median age was 78 years. Of the patients, 49.9% belonged to critical, emergent or urgent triage categories. LSI was required in 321 patients (21.5%). Thirteen died within 24 h of ED presentation. The area under the receiver operating characteristic curve of prehospital MEWS relating to LSI was 0.72 (95% confidence interval 0.69 to 0.75). The sensitivity, specificity, positive PV, negative PV, positive LR and negative LR were 0.57, 0.76, 0.40, 0.87, 2.43 and 0.56, respectively, when prehospital MEWS  ≥3 was chosen as the cut-off value.

CONCLUSIONS

Prehospital MEWS is useful in identifying non-trauma patients requiring LSI within 4 h of ED presentation. This may in turn enhance the triage accuracy in the ED in addition to clinical assessment.

The Effect of an Impaired Arousal on Short- and Long-Term Mortality of Elderly Patients Admitted to an Acute Geriatric Unit

OBJECTIVE

Impaired arousal is associated with negative outcomes in intensive care units, but studies in acute medical wards are scanty. The study aim was to evaluate the association between impaired arousal, as measured using an ultrabrief screen, and risk of both 1- and 6-month mortality and discharge to nursing home (NH) or hospice.

DESIGN

Prospective cohort study with 6-month follow-up.

SETTING

An acute geriatric unit (AGU) of a university-based hospital in Northern Italy.

PARTICIPANTS

All patients aged 65 years or older, admitted to the AGU between September 2012 and February 2015.

MEASUREMENTS

The modified Richmond Agitation Sedation Scale (m-RASS) was used to assess patients' arousal; a score of 0 denotes normal arousal, scores ranging from +1 to +4 denote increased arousal, and scores ranging from -1 to -5 denote decreased levels. The association of m-RASS scores with 6-month mortality was assessed by a Kaplan-Meier analysis. The impact of impaired arousal, defined by the m-RASS as anything other than "awake and alert," was determined using Cox proportional hazard regression for 1- and 6-month mortality after admission and logistic regressions were used for discharge to NH or hospice. The models were adjusted for age, sex, dementia, Sequential Organ Failure Assessment score, and disability.

RESULTS

Patients (n = 2477) had a mean age of 84 years, and were predominantly women (59.8%). Impaired arousal on admission was present in 644 (25.9%) patients: 33 (1.3%) were comatose (m-RASS = -5), 56 (2.3%) awakened to pain only (m-RASS = -4), 43 (1.7%) were very drowsy (m-RASS = -3), 93 (3.8%) drowsy (m-RASS = -2), and 212 (8.6%) were slightly drowsy (m-RASS = -1), but there were also 110 (4.4%) patients with restlessness, 75 (3.0%) with agitation, 17 (0.7%) with severe agitation, and 3 (0.1%) with combative behavior. Globally, 337 patients died within 1 month and 689 patients within 6 months. After adjustment for covariates, patients with impaired arousal had a significantly higher chance of having died at 1-month (adjusted hazard ratio [HR] 1.56, 95% confidence interval [CI] 1.22-2.03) and 6-month follow-up (adjusted HR 1.31, 95% CI 1.10-1.57). Those with impaired arousal were more likely to be discharged to a new NH (odds ratio [OR] 1.75, 95% CI 1.19-2.57) or to hospice (OR 1.96, 95% CI 1.18-3.23) than those without impaired arousal.

CONCLUSIONS

An abnormal arousal level is an independent predictor of increased risk of 1- and 6-month mortality and of discharge to a new NH or hospice. The assessment of arousal with m-RASS should be routinely performed on all older patients on admission to acute hospital wards to screen potentially critical conditions.

An Early Warning Score Predicts Risk of Death after In-hospital Cardiopulmonary Arrest in Surgical Patients

In-hospital cardiopulmonary arrest can contribute significantly to publicly reported mortality rates. Systems to improve mortality are being implemented across all specialties. A review was conducted for all surgical patients >18 years of age who experienced a “Code Blue” event between January 1, 2013 and March 9, 2014 at a university hospital. A previously validated Modified Early Warning Score (MEWS) using routine vital signs and neurologic status was calculated at regular intervals preceding the event. In 62 patients, the most common causes of arrest included respiratory failure, arrhythmia, sepsis, hemorrhage, and airway obstruction, but remained unknown in 27 per cent of cases. A total of 56.5 per cent of patients died before hospital discharge. In-hospital death was associated with American Society of Anesthesiologists status ( P = 0.039) and acute versus elective admission ( P = 0.003). Increasing MEWS on admission, 24 hours before the event, the event-day, and a maximum MEWS score on the day of the event increased the odds of death. Max MEWS remained associated with death after multivariate analysis (odds ratio 1.39, P = 0.025). Simple and easy to implement warning scores such as MEWS can identify surgical patients at risk of death after arrest. Such recognition may provide an opportunity for clinical intervention resulting in improved patient outcomes and hospital mortality rates.

Modified early warning scoring (MEWS): evaluating the evidence for tool inclusion of sepsis screening criteria and impact on mortality and failure to rescue

AIMS AND OBJECTIVES

To evaluate current research evidence reporting outcomes from modified early warning scoring system tools utilisation to prevent failure to rescue in hospitalised adult medical-surgical/telemetry patients.

BACKGROUND

Early sepsis detection exhibits clinical significance to practitioners and patients. Thorough and timely clinical observations, along with a willingness of nurses to call for help, are pivotal to survival of hospitalised patients. This project examined effects of modified early warning scoring system tool usage on patient mortality and failure to rescue events in hospitalised adult medical-surgical/telemetry patients as reported in the literature.

DESIGN

A comprehensive review and evaluation of published peer-reviewed literature was conducted.

METHODS

Electronic databases searched included PubMed, MEDLINE, CINAHL, Cochrane Library of systematic reviews and Agency for Healthcare Research and Quality through 2014.

RESULTS

Eighteen articles were identified for review. Evidence ratings included 6% (1) Level I, 44% (8) Level IV, 6% (1) Level V, 33% (6) Level VI and 11% (2) Level VII. Six reported mortality predictive value and/or reduction, three measured impact on emergency calls, and four reported impact on mortality and rapid response team utilisation.

CONCLUSION

While modified early warning scoring system tools have been widely adopted and are recommended for utility in detection of inpatients at-risk for clinical deterioration, limited high-level data and no clinical trials linking use of modified early warning scoring system tool usage to robust outcomes were found. Established criteria for validating modified early warning scoring system criteria, organisational-specific reliability testing and multi-site trials are recommended.

RELEVANCE TO CLINICAL PRACTICE

Development of all-cause illness screening tools, including sepsis, is imperative. The clinical picture may be quantified with scoring tools to assist nurses' clinical decision-making, thus leading to improved outcomes and decreased incidence of failure to rescue. Clinical outcomes of interest should be measured and reported in peer-reviewed literature to disseminate the impact on clinical outcomes.