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Bergbrant S, Sundell N, Andersson LM, Lindh M, Gustavsson L, Westin J. Syndromic testing for respiratory pathogens but not National Early Warning Score can be used to identify viral cause in hospitalised adults with lower respiratory tract infections. Infect Dis (Lond) 2024; 56:554-563. [PMID: 38564409 DOI: 10.1080/23744235.2024.2333973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/18/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Community-acquired lower respiratory tract infection (LRTI) is a common reason for hospitalisation. Antibiotics are frequently used while diagnostic microbiological methods are underutilised in the acute setting. OBJECTIVES We aimed to investigate the relative proportion of viral and bacterial infections in this patient group and explore methods for proper targeting of antimicrobial therapy. METHODS We collected nasopharyngeal samples prospectively from adults hospitalised with LRTIs during three consecutive winter seasons (2016-2019). Syndromic nasopharyngeal testing was performed using a multiplex PCR panel including 16 viruses and four bacteria. Medical records were reviewed for clinical data. RESULTS Out of 220 included patients, a viral pathogen was detected in 74 (34%), a bacterial pathogen in 63 (39%), both viral and bacterial pathogens in 49 (22%), while the aetiology remained unknown in 34 (15%) cases. The proportion of infections with an identified pathogen increased from 38% to 85% when syndromic testing was added to standard-of-care testing. Viral infections were associated with a low CRP level and absence of pulmonary infiltrates. A high National Early Warning Score did not predict bacterial infections. CONCLUSIONS Syndromic testing by a multiplex PCR panel identified a viral infection or viral/bacterial coinfection in a majority of hospitalised adult patients with community-acquired LRTIs.
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Affiliation(s)
- Susanna Bergbrant
- Department of Medicine Geriatrics and Emergency Medicine, Östra Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Nicklas Sundell
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
- Department of Infectious Diseases, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars-Magnus Andersson
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
- Department of Infectious Diseases, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Lindh
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
- Department of Infectious Diseases, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Gustavsson
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
- Department of Infectious Diseases, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Westin
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
- Department of Infectious Diseases, Sahlgrenska University Hospital, Gothenburg, Sweden
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Briggs J, Kostakis I, Meredith P, Dall'ora C, Darbyshire J, Gerry S, Griffiths P, Hope J, Jones J, Kovacs C, Lawrence R, Prytherch D, Watkinson P, Redfern O. Safer and more efficient vital signs monitoring protocols to identify the deteriorating patients in the general hospital ward: an observational study. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-143. [PMID: 38551079 DOI: 10.3310/hytr4612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
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.
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Affiliation(s)
- Jim Briggs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Ina Kostakis
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Paul Meredith
- Research Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | | | - Julie Darbyshire
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Stephen Gerry
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | | | - Jo Hope
- Health Sciences, University of Southampton, Southampton, UK
| | - Jeremy Jones
- Health Sciences, University of Southampton, Southampton, UK
| | - Caroline Kovacs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | | | - David Prytherch
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Peter Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Oliver Redfern
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Prim BTA, Kalla IS, Zamparini J, Mohamed F. COVID-19: An evaluation of predictive scoring systems in South Africa. Heliyon 2023; 9:e21733. [PMID: 38027857 PMCID: PMC10665741 DOI: 10.1016/j.heliyon.2023.e21733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
Background | The Coronavirus Disease 2019 (COVID-19) pandemic, caused by SARS-CoV-2, has resulted in more than 700 million cases worldwide. Sepsis and pneumonia severity scores assist in risk assessment of critical outcomes in patients with COVID-19. This allows healthcare workers to triage patients, by using clinical parameters and limited special investigations, thus offering the most appropriate level of care. Methods | A retrospective cohort study of 605 adult patients hospitalised with moderate to severe COVID-19, at a tertiary state hospital in South Africa. Evaluating the utility of the CURB65, NEWS2 and ISARIC-4C Mortality Score, in predicting critical outcomes, using clinical characteristics on admission. Outcomes included in-hospital mortality, invasive mechanical ventilation, and intensive care unit admission (ICU). Performance of severity scores and risk factors was assessed by area under the receiver operator characteristics (AUROC) analysis and logistic regression. Findings | A total of 605 records were used, 129 (21 %) non-survivors, 101 (17 %) ICU admissions and 77 (13 %) requiring invasive ventilation. Greater odds of mortality was associated with moderate and severe risk groups of the CURB65, ISARIC-4C and NEWS2 score. Mortality AUROC curve analysis for the CURB65 score was 0·76 (95 % CI: 0·71-0·8), 0·77 (95 % CI: 0·73-0·81) for the ISARIC-4C and 0·77 (95 % CI: 0·73-0·82) for the NEWS2 score. The CURB65 score had a sensitivity of 86 % with 12·8 % mortality, ISARIC-4C score a sensitivity of 87·6 % with 8 % mortality and NEWS2 score a sensitivity of 92·2 % with 8·6 % mortality. Interpretation | In 605 hospitalised patients with moderate to severe COVID-19, predominantly infected by the ancestral strain, good performance of the NEWS2 and ISARIC-4C score in predicting in-hospital mortality was noted. The CURB65 score had a high mortality rate in its low-risk group suggesting unexplained risk factors, not accounted for in the score, thus limiting its utility in the South African setting.
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Affiliation(s)
| | - Ismail Sikander Kalla
- Department of Internal Medicine, Division of Pulmonology, University of Witwatersrand, Johannesburg, 2193, South Africa
| | - Jarrod Zamparini
- Department of Internal Medicine, University of Witwatersrand, Johannesburg, 2193, South Africa
| | - Farzahna Mohamed
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of Witwatersrand, Johannesburg, 2193, South Africa
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Anam AM, Shareef A, Shumy F, Gerardus King MR. Preventing unrecognized deterioration & improving outcomes of critically ill patients using the National Early Warning Score 2 in a high dependency unit in Bangladesh: A quality improvement project. Trop Doct 2023; 53:419-427. [PMID: 37309167 DOI: 10.1177/00494755231178124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
This Quality Improvement Project (QIP) aimed to assess the acceptability and utility of the National Early Warning Score 2 (NEWS2) in a Bangladeshi level-2 care setting. All nurses and physicians were trained on NEWS2 scores and a proper response before starting the QIP. Utilization of NEWS2 and patient outcome were documented and analyzed. Acceptability was acknowledged by increase in utilization, and utility by reduction in unrecognized deterioration of patients. The modified NEWS2 was well adopted and utilized by the nursing staff. There was a statistically significant reduction in unrecognized deterioration leading to cardiac arrest and the need for transfer to the Intensive Care Unit after implementation of NEWS2. With adequate training, motivation and appropriate modification, NEWS2 can become a well-accepted, widely adopted and realistic bedside monitoring tool in resource-limited settings like Bangladesh.
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Affiliation(s)
- Ahmad Mursel Anam
- Associate Consultant, Critical Care & Internal Medicine, Square Hospitals Ltd, Dhaka, Bangladesh
| | - Adnan Shareef
- Senior House Officer, HDU, Square Hospitals Ltd, Dhaka, Bangladesh
| | - Farzana Shumy
- Associate Consultant, Rheumatology & Internal Medicine, Square Hospitals Ltd, Dhaka, Bangladesh
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Kakehi E, Uehira R, Ohara N, Akamatsu Y, Osaka T, Sakurai S, Hirotani A, Nozaki T, Shoji K, Adachi S, Kotani K. Utility of the New Early Warning Score (NEWS) in combination with the neutrophil-lymphocyte ratio for the prediction of prognosis in older patients with pneumonia. Fam Med Community Health 2023; 11:e002239. [PMID: 37344123 DOI: 10.1136/fmch-2023-002239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023] Open
Abstract
OBJECTIVE Predictors of prognosis are necessary for use in routine clinical practice for older patients with pneumonia, given the ageing of the population. Recently, the National Early Warning Score (NEWS), a comprehensive predictor of severity that consists solely of physiological indicators, has been proposed to predict the prognosis of pneumonia. The neutrophil/lymphocyte ratio (NLR) is a simple index of inflammation that may also be predictive of pneumonia. In the present study, we aimed to determine whether NEWS or a combination of NEWS and NLR predicts mortality in older patients with pneumonia. DESIGN A retrospective cohort study. SETTING A general hospital in Japan. PARTICIPANTS We collected data from patients aged ≥65 years with pneumonia who were admitted between 2018 and 2020 (n=282; age=85.3 (7.9)). Data regarding vital signs, demographics and the length of hospital stay, in addition to the NEWS and NLR, were extracted from the participants' electronic medical records. INTERVENTION The utility of the combination of NEWS and NLR was assessed using NEWS×NLR and NEWS+NLR. MAIN OUTCOME MEASURES Their predictive ability for 30-day mortality as the primary outcome was assessed using receiver operating characteristic (ROC) curve analysis. RESULTS According to the NEWS classification, 80 (28.3%), 64 (22.7%) and 138 (48.9%) of the participants were at low, medium and high risk of mortality, respectively. The 30-day mortality for the entire cohort was 9.2% (n=26), and the mortality rate increased with the NEWS classification: low, 1.3%; medium, 7.8%; and high, 14.5%. The NLRs were 6.0 (4.2-9.8), 6.8 (4.8-10.4) and 14.6 (9.4-22.2), respectively (p<0.001). The areas under the ROC curves for 30-day mortality were 0.73 for the NEWS score, 0.84 for NEWS×NLR and 0.83 for NEWS+NLR, indicating that the combinations represent superior predictors of mortality to the NEWS alone. NEWS×NLR and NEWS+NLR tended to have better sensitivity, accuracy, positive predictive value and negative predictive value than NEWS alone (p=0.06). CONCLUSIONS A combination of the NEWS and NLR (NEWS×NLR or NEWS+NLR) may be superior to the NEWS alone for the prediction of 30-day mortality in older patients with pneumonia. However, further validation of these combinations for use in the prediction of prognosis is required.
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Affiliation(s)
- Eiichi Kakehi
- Department of General Medicine, Tottori Municipal Hospital, Tottori, Japan
| | - Ryo Uehira
- Department of General Medicine, Tottori Municipal Hospital, Tottori, Japan
| | - Nobuaki Ohara
- Department of General Medicine, Tottori Municipal Hospital, Tottori, Japan
| | - Yukinobu Akamatsu
- Department of General Medicine, Tottori Municipal Hospital, Tottori, Japan
| | - Taeko Osaka
- Department of General Medicine, Tottori Municipal Hospital, Tottori, Japan
| | - Shigehisa Sakurai
- Department of General Medicine, Tottori Municipal Hospital, Tottori, Japan
| | - Akane Hirotani
- Department of General Medicine, Tottori Municipal Hospital, Tottori, Japan
| | - Takafumi Nozaki
- Department of General Medicine, Tottori Municipal Hospital, Tottori, Japan
| | - Keisuke Shoji
- Department of General Medicine, Tottori Municipal Hospital, Tottori, Japan
| | - Seiji Adachi
- Department of General Medicine, Tottori Municipal Hospital, Tottori, Japan
| | - Kazuhiko Kotani
- Division of Community and Family Medicine, Jichi Medical University, Shimotsuke, Japan
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Comparison of the Performance of the CURB-65, A-DROP, and NEWS Scores for the Prediction of Clinical Outcomes in Pneumonia. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2023. [DOI: 10.1097/ipc.0000000000001240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
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Predictive Ability of the National Early Warning Score in Mortality Prediction of Acute Pulmonary Embolism in the Southeast Asian Population. J Cardiovasc Dev Dis 2023; 10:jcdd10020060. [PMID: 36826556 PMCID: PMC9960332 DOI: 10.3390/jcdd10020060] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/26/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The National Early Warning Scores (NEWS) easily and objectively measures acute clinical deterioration. However, the performance of NEWS to predict mortality in patients with acute pulmonary embolism (APE) is still required. Therefore, the objective of this study was to evaluate the performance of the NEWS in predicting the mortality of patients with APE. METHODS NEWS and Pulmonary Embolism Severity Index (PESI) at diagnosis time were calculated. Risk regression analysis was performed to identify the NEWS and PESI risk classification as a predictor for 30 days all-cause mortality and PE-related mortality. RESULTS NEWS was significantly higher in non-survivors compared to survivors (median (IQR) was 10 (7, 11) vs. 7 (2, 9), respectively, p < 0.001). The best cut-off point of NEWS in discriminating APE patients who non-survived from those who survived at 30 days was ≥9, with a sensitivity and specificity of 66.9% and 66.3%, respectively. The adjusted risk ratio of 30-day all-cause mortality in patients with initial NEWS ≥ 9 was 2.96 (95% CI; 2.13, 4.12, p < 0.001). CONCLUSIONS The NEWS can be used for mortality prediction in patients with APE. APE patients with NEWS ≥ 9 are associated with a high risk of mortality and should be closely monitored.
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The National Early Warning Score 2(NEWS2) to Predict Early Progression to Severe Community-Acquired Pneumonia. Trop Med Infect Dis 2023; 8:tropicalmed8020068. [PMID: 36828485 PMCID: PMC9962139 DOI: 10.3390/tropicalmed8020068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023] Open
Abstract
This study aimed to assess the predictive performance of the National Early Warning Score 2 (NEWS2) to identify the early progression to severe disease in patients with community-acquired pneumonia (CAP). A prospective-cohort study was conducted among patients with CAP admitted to a university hospital between October 2020 and December 2021. The endpoint of interest was the progression to severe CAP, defined as the requirement for a mechanical ventilator, a vasopressor, or death within 72 h after hospital admission. Among 260 patients, 53 (25.6%) had early progression to severe CAP. The median NEWS2 of the early progression group was higher than that of the non-progression group [8 (6-9) vs. 7 (5-8), p = 0.015, respectively]. The AUROC of NEWS2 to predict early progression to severe CAP was 0.61 (95% CI: 0.52-0.70), while IDSA/ATS minor criteria ≥ 3 had AUROC 0.56 (95% CI 0.48-0.65). The combination of NEWS2 ≥ 8, albumin level < 3 g/dL and BUN ≥ 30 mg/dL improved AUROC from 0.61 to 0.71 (p = 0.015). NEWS2 and IDSA/ATS minor criteria showed fair predictive-accuracy in predicting progression to severe CAP. The NEWS2 cut-off ≥ 8 in combination with low albumin and uremia improved predictive-accuracy, and could be easily used in general practice.
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Bavalia R, Stals MAM, Mulder FI, Bistervels IM, Coppens M, Faber LM, Hendriks SV, Hofstee HMA, Huisman MV, van der Hulle T, Mairuhu ATA, Kruip MJHA, Middeldorp S, Klok FA, Hutten BA, Holleman F. Use of the National Early Warning Score for predicting deterioration of patients with acute pulmonary embolism: a post-hoc analysis of the YEARS Study. J Accid Emerg Med 2023; 40:61-66. [PMID: 36344240 DOI: 10.1136/emermed-2021-211506] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 10/13/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The Pulmonary Embolism Severity Index (PESI) and the simplified PESI (sPESI) are validated scores for mortality prediction in patients with pulmonary embolism (PE). National Early Warning Score (NEWS) is a general prognostic risk score for multiple clinical settings. We investigated whether the NEWS had a comparable performance with the PESI and sPESI, for predicting intensive care unit (ICU) admission and death in patients with acute PE. METHODS In haemodynamically stable patients with confirmed PE from the YEARS Study (2013-2015), we evaluated the performance of the NEWS, PESI and sPESI for predicting 7-day ICU admission and 30-day mortality. Receiver operating characteristic curves were plotted and the area under the curve (AUC) was calculated. RESULTS Of 352 patients, 12 (3.4%) were admitted to the ICU and 5 (1.4%) died. The AUC of the NEWS for ICU admission was 0.80 (95% CI 0.66 to 0.94) and 0.92 (95% CI 0.82 to 1.00) for 30-day mortality. At a threshold of 3 points, NEWS yielded a sensitivity and specificity of 92% and 53% for ICU admission and 100% and 52% for 30-day mortality. The AUC of the PESI was 0.64 (95% CI 0.48 to 0.79) for ICU admission and 0.94 (95% CI 0.87 to 1.00) for mortality. At a threshold of 66 points, PESI yielded a sensitivity of 75% and a specificity of 38% for ICU admission. For mortality, these were 100% and 37%, respectively. The performance of the sPESI was similar to that of PESI. CONCLUSION In comparison with PESI and sPESI, NEWS adequately predicted 7-day ICU admission as well as 30-day mortality, supporting its potential relevance for clinical practice.
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Affiliation(s)
- Roisin Bavalia
- Vascular Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | | | - Frits I Mulder
- Vascular Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Ingrid M Bistervels
- Vascular Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands.,Internal Medicine, Flevo Hospital, Almere, The Netherlands
| | - Michiel Coppens
- Vascular Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Laura M Faber
- Internal Medicine, Red Cross Hospital, Beverwijk, The Netherlands
| | - Stephan V Hendriks
- Thrombosis and Hemostasis, LUMC, Leiden, The Netherlands.,Internal Medicine, Haga Hospital, Den Haag, The Netherlands
| | | | | | | | | | | | - Saskia Middeldorp
- Vascular Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands.,Internal Medicine & Radboud Institute of Health Sciences, Radboud University Nijmegen Faculty of Medical Sciences, Nijmegen, The Netherlands
| | | | - Barbara A Hutten
- Epidemiology and Data Science, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Frits Holleman
- Internal Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
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Garber B. Pneumonia Update for Emergency Clinicians. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2022; 10:36-44. [PMID: 35874176 PMCID: PMC9296333 DOI: 10.1007/s40138-022-00246-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 11/28/2022]
Abstract
Purpose of Review
Many new concepts in diagnosis, management, and risk stratification of patients with pneumonia have been described recently. The COVID pandemic made importance of viruses as dangerous pathogens of pneumonia quite clear while several non-invasive measures for patients with respiratory failure gained a more wide-spread usage. Recent Findings Studies continue to examine feasibility of bedside ultrasound as a tool in accurate diagnosis of pneumonia in the emergency department, and several new antibiotics have been approved for treatment while others are in late-stage clinical trials. Additionally, the Infectious Diseases Society, American Thoracic Society, and their European counterparts published updated guidelines in recent years. For differences important to emergency medicine clinicians and new emphasis as compared to the prior guidelines, please see Table 1. Several new antibiotics have been approved recently but remain relatively unknown to emergency clinicians as their use is frequently restricted to infectious disease specialists.Differences important to emergency medicine clinicians and new emphasis [8, 16, 18, 19••, 30, 34] New recommendations | Difference with prior guidelines if any | Comment |
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Blood and sputum cultures recommended in severe disease and in inpatients treated for MRSA or P. aeruginosa | Similar from the ED perspective | Clinical gestalt performs as well as various decision instruments in deciding who needs blood cultures [13] | Obtaining procalcitonin level not recommended to guide antibacterial therapy | Was not covered in prior guidelines | | Recommend using validated risk factors to determine the need for P. aeruginosa or MRSA coverage instead of using hospital-acquired and ventilator-associated guidelines | Emphasized healthcare-associated pneumonia category | MDRO prevalence varies widely between communities challenging study interpretation [8] | Macrolide monotherapy conditional for outpatients based on local resistance patterns | Was strongly recommended | S. pneumonia is increasingly resistant to macrolides | Amoxicillin or doxycycline monotherapy for outpatients with no comorbidities or risk factors for MDRO. Amoxicillin/clavulanate or cephalosporin (cefuroxime or cefpodoxime) combined with a macrolide or doxycycline or monotherapy with a respiratory fluoroquinolone such as moxifloxacin for patients with comorbidities | Amoxicillin, amoxicillin/clavulanate, and doxycycline were not considered prominently in treatment regimens | The recommendation for including doxycycline in the treatment protocols is conditional and is based on weak evidence and is only recommended in patients with contraindications to both macrolides and fluoroquinolones. M. pneumonia is increasingly resistant to macrolides, and tetracyclines and respiratory fluoroquinolones are viable alternatives if a patient with a known M. pneumonia infection does not respond to a macrolide. In admitted patients, the addition of a macrolide to a b-lactam consistently lowers mortality [18]. Amoxicillin does not cover the atypicals | Do not give corticosteroids to pneumonia patients except in possibly decompensated refractory septic shock or known adrenal insufficiency | Was not considered | Note that in certain special forms of pneumonia (not considered CAP), such as Pneumocystis jirovecii pneumonia, corticosteroid therapy may still be necessary. Corticosteroids increase mortality in patients with influenza infection who develop pneumonia | When treating a patient with severe CAP b-lactam/macrolide combination preferred over b-lactam/fluoroquinolone combination, the use of anti-influenza therapy is recommended if influenza viral test is positive (expert recommendation) | B-lactam/macrolide combination OR b-lactam/fluoroquinolone combination; use of anti-influenza therapy was not considered | Influenza therapy in hospitalized patients has not been validated in a randomized controlled trial | Limiting the length of antibiotic therapy to 7–10 days including in ventilator-associated pneumonia | Recommended 14–21 days of therapy | In one study, CAP patients who received a single dose of intravenous ceftriaxone did just as well as patients who got it daily for 7 days [18]. Since that study compared ceftriaxone to daptomycin (that was later found to be inactivated by surfactant), this can be hypothesis generation only | Follow-up chest imaging after symptoms of pneumonia improve recommended only as necessary for lung cancer screening | Follow-up chest imaging was not addressed | |
Summary As the emergency physicians gain new tools to rapidly diagnose, treat, and appropriately disposition pneumonia cases that appear to become more complex as people unfortunately accumulate more comorbidities, we hope to offer better care and improve outcomes for our patients while allowing staff to enjoy coming to work.
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Affiliation(s)
- Boris Garber
- Metro Health Medical Center, Cleveland, USA
- CWRU School of Medicine, Cleveland, USA
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Desenlaces clínicos en pacientes con diagnóstico de neumonía relacionada con SARS-CoV-2 manejados con cánula de alto flujo, una experiencia clínica. (Estudio CANALF). ACTA COLOMBIANA DE CUIDADO INTENSIVO 2022. [PMCID: PMC9050654 DOI: 10.1016/j.acci.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Mohammadian Erdi A, Yousefian M, Isazadehfar K, Badamchi F. Evaluating the Efficacy of the National Early Warning Score in Predicting the Mortality of Stroke Patients Admitted to Intensive Care Units. Anesth Pain Med 2022; 12:e116358. [PMID: 35991775 PMCID: PMC9375957 DOI: 10.5812/aapm-116358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/09/2022] [Accepted: 03/11/2022] [Indexed: 12/03/2022] Open
Abstract
Background National Early Warning Score (NEWS) is a tool used to identify patients at risk. Scores are based on initial clinical observations, including heart rate, respiration rate, systolic blood pressure, oxygen saturation, level of consciousness, body temperature, and oxygen support. To date, few studies have been conducted on NEWS evaluation worldwide, and no study has been conducted in Iran. Objectives This study aims to evaluate the efficacy of the NEWS in predicting the mortality of stroke patients admitted to intensive care units (ICU). Methods The present cross-sectional study included 90 patients with a definitive diagnosis of cerebrovascular accident (CVA) based on symptoms and para-clinical evidence. At the beginning of admission to the ICU and up to first 24 hours of admission, all NEWS parameters were measured and evaluated. Results There was a significant relationship between systolic blood pressure, respiratory support, heart rate, and level of consciousness with patients’ discharge status. Also, there was no significant relationship between age, sex, respiratory rate, SPO2, and fever with discharge status. In addition, there was a significant relationship between clinical risk based on NEWS scoring system and patients’ status. Conclusions Our results showed a significant relationship between clinical risk based on NEWS scoring and patients’ discharge status so that there was a significant increase in mortality in patients with higher NEWS.
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Affiliation(s)
- Ali Mohammadian Erdi
- Department of Anesthesiology, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Mahzad Yousefian
- Department of Anesthesiology, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
- Corresponding Author: Department of Anesthesiology, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran.
| | - Khatereh Isazadehfar
- Social Determinants of Health Research Center (SDH), Ardabil University of Medical Sciences, Ardabil, Iran
| | - Fatemeh Badamchi
- School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
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13
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Abstract
ABSTRACT The coronavirus disease 2019 (COVID-19) pandemic has led to not only increase in substance misuse, substance use disorder, and risk of overdose but also lack of access to treatment services. Due to lack of knowledge of the course and impact of COVID-19 and outcomes of it's interactions with existing treatments, the Substance Misuse Service Team initiated a safety improvement project to review the safety of opioid substitution treatment, particularly the safety of methadone. This preliminary retrospective cross-sectional audit of safety improvement intiative underscores the importance of providing treatment services to those with opioid use disorders and that methadone is safe among this population with a high burden of comorbidity, most of which leads to negative outcomes from COVID-19. The outcomes show that patients who have COVID-19 should continue with opioid substitution treatment with methadone. Although treatment with methadone is safe, symptomatic patients should be monitored. In addition, patients who take methadone at home should be educated on the risk of overdose due to, and adverse outcomes from, COVID-19 infection. Patients should monitor themselves using pulse oximeter for any signs of hypoxia.
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14
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Saberian P, Abdollahi A, Hasani-Sharamin P, Modaber M, Karimialavijeh E. Comparing the prehospital NEWS with in-hospital ESI in predicting 30-day severe outcomes in emergency patients. BMC Emerg Med 2022; 22:42. [PMID: 35287593 PMCID: PMC8922925 DOI: 10.1186/s12873-022-00598-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/03/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Peyman Saberian
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Anesthesiology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Atefeh Abdollahi
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Anesthesiology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | - Ehsan Karimialavijeh
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran. .,Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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15
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Davidson LT, Gauffin E, Henanger P, Wajda M, Wilhelms D, Ekman B, Arnqvist HJ, Schilling M, Chisalita SI. Admission of patients with chest pain and/or breathlessness from the emergency department in relation to risk assessment and copeptin levels - an observational study. Ups J Med Sci 2022; 127:8941. [PMID: 36590754 PMCID: PMC9793763 DOI: 10.48101/ujms.127.8941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND One of the most critical decisions that emergency department (ED) physicians make is the discharge versus admission of patients. We aimed to study the association of the decision in the ED to admit patients with chest pain and/or breathlessness to a ward with risk assessment using the Rapid Emergency Triage and Treatment System (RETTS), the National Early Warning Score (NEWS), and plasma levels of the biomarkers copeptin, midregional proadrenomedulin (MR-proADM), and midregional proatrial natriuretic peptide (MR-proANP). METHODS Patients presenting at the ED with chest pain and/or breathlessness with less than one week onset were enrolled. Patients were triaged according to RETTS. NEWS was calculated from the vital signs retrospectively. RESULTS Three hundred and thirty-four patients (167 males), mean age 63.8 ± 16.8 years, were included. Of which, 210 (62.8%) patients complained of chest pain, 65 (19.5%) of breathlessness, and 59 (17.7%) of both. Of these, 176 (52.7%) patients were admitted to a ward, and 158 (47.3%) patients were discharged from the ED. In binary logistic models, age, gender, vital signs (O2 saturation and heart rate), NEWS class, and copeptin were associated with admission to a ward from the ED. In receiver-operating-characteristics (ROC) analysis, copeptin had an incremental predictive value compared to NEWS alone (P = 0.002). CONCLUSIONS Emergency physicians' decisions to admit patients with chest pain and/or breathlessness from the ED to a ward are related to age, O2 saturation, heart rate, NEWS category, and copeptin. As an independent predictive marker for admission, early analysis of copeptin might be beneficial when improving patient pathways at the ED.
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Affiliation(s)
- Lee Ti Davidson
- Department of Emergency Medicine in Linköping, Local Health Care Services in Central Östergötland, Region Östergötland & Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Emilia Gauffin
- Department of Endocrinology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Preben Henanger
- Department of Endocrinology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Maciej Wajda
- Department of Emergency Medicine in Linköping, Local Health Care Services in Central Östergötland, Region Östergötland & Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Daniel Wilhelms
- Department of Emergency Medicine in Linköping, Local Health Care Services in Central Östergötland, Region Östergötland & Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Bertil Ekman
- Department of Endocrinology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Hans J. Arnqvist
- Department of Endocrinology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Martin Schilling
- Clinicum and Innovations Centrum, Department of Emergency Medicine and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Simona I. Chisalita
- Department of Endocrinology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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16
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Lv C, Chen Y, Shi W, Pan T, Deng J, Xu J. Comparison of Different Scoring Systems for Prediction of Mortality and ICU Admission in Elderly CAP Population. Clin Interv Aging 2021; 16:1917-1929. [PMID: 34737556 PMCID: PMC8560064 DOI: 10.2147/cia.s335315] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/21/2021] [Indexed: 01/22/2023] Open
Abstract
Background The incidence and mortality rate of community-acquired pneumonia (CAP) in elderly patients were higher than the younger population. Different scoring systems, including The quick Sequential Organ Function Assessment (qSOFA), Combination of Confusion, Urea, Respiratory Rate, Blood Pressure, and Age ≥65 (CURB-65), Modified Early Warning Score (MEWS) and National Early Warning Score (NEWS), were used widely for predicting mortality and ICU admission of patients with community-acquired pneumonia (CAP). This study aimed to identify the most suitable score system for better hospitalization. Methods We retrospectively analyzed elderly patients with CAP in Minhang Hospital, Fudan University from 1 January 2018 to 1 January 2020. We recorded information of the patients including age, gender, underlying disease, consciousness state, vital signs, physiological and laboratory variables and further calculated the qSOFA, CURB-65, MEWS, and NEWS scores. Receiver operating characteristic (ROC) curves were used to predict the mortality risk and ICU admission. Kaplan–Meier survival curves were used in survival rate. Results In total, 1044 patients were selected for analysis and divided into two groups, namely survivor groups (902 cases) and non-survivor groups (142 cases). Depending on ICU admission enrolled patients were classified into ICU admission (n = 102) and non-ICU admission (n = 942) groups. Mortality expressed as AUC values were 0.844 (p < 0.001), 0.868 (p < 0.001), 0.927 (p < 0.001) and 0.892 (p < 0.001) for qSOFA, CURB 65, MEWS and NEWS, respectively. There were clear differences in MEWS vs CURB-65 (p < 0.0001), MEWS vs NEWS (p < 0.001), MEWS vs qSOFA (p < 0.0001). For ICU-admission, the AUC values of qSOFA, CURB-65, MEWS and NEWS scores were 0.866 (p < 0.001), 0.854 (p < 0.001), 0.922 (p < 0.001), 0.976 (p < 0.001), respectively. There were significant differences in NEWS vs CURB-65 (p < 0.0001), NEWS vs MEWS (p < 0.001), NEWS vs qSOFA (p < 0.0001). Conclusion We explored the outcome prediction values of CURB65, qSOFA, MEWS and NEWS for patients aged 65-years and older with community-acquired pneumonia. We found that MEWS showed superiority over the other severity scores in predicting hospital mortality, and NEWS showed superiority over the other scores in predicting ICU admission.
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Affiliation(s)
- Chunxin Lv
- Oncology Department, Punan Hospital of Pudong New District, Shanghai, People's Republic of China
| | - Yue Chen
- Centre for Cancer Genomics and Computational Biology, Barts Cancer Institute, London, EC1M 6BE, UK
| | - Wen Shi
- Department of Dermatology, Punan Hospital of Pudong New District, Shanghai, People's Republic of China
| | - Teng Pan
- Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, People's Republic of China
| | - Jinhai Deng
- Key Laboratory of Medical Immunology, Department of Immunology, Peking University Center for Human Disease Genomics, Ministry of Health, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, People's Republic of China
| | - Jiayi Xu
- Geriatric Department, Fudan University, Minhang Hospital, Shanghai, 201100, People's Republic of China
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17
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Sharma DN, Guleria R, Wig N, Mohan A, Rath G, Subramani V, Bhatnagar S, Mallick S, Sharma A, Patil P, Madan K, Soneja M, Thulkar S, Singh A, Singh S. Low-dose radiation therapy for COVID-19 pneumonia: a pilot study. Br J Radiol 2021; 94:20210187. [PMID: 34545760 PMCID: PMC9328067 DOI: 10.1259/bjr.20210187] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Objectives: The World Health Organization (WHO) has declared coronavirus disease 2019 (COVID-19) as pandemic in March 2020. Currently there is no specific effective treatment for COVID-19. The major cause of death in COVID-19 is severe pneumonia leading to respiratory failure. Radiation in low doses (<100 cGy) has been known for its anti-inflammatory effect and therefore, low dose radiation therapy (LDRT) to lungs can potentially mitigate the severity of pneumonia and reduce mortality. We conducted a pilot trial to study the feasibility and clinical efficacy of LDRT to lungs in the management of patients with COVID-19. Methods: From June to Aug 2020, we enrolled 10 patients with COVID-19 having moderate to severe risk disease [National Early Warning Score (NEWS) of ≥5]. Patients were treated as per the standard COVID-19 management guidelines along with LDRT to both lungs with a dose of 70cGy in single fraction. Response assessment was done based on the clinical parameters using the NEWS. Results: All patients completed the prescribed treatment. Nine patients had complete clinical recovery mostly within a period ranging from 3 to 7 days. One patient, who was a known hypertensive, showed clinical deterioration and died 24 days after LDRT. No patients showed the signs of acute radiation toxicity. Conclusion: The results of our pilot study suggest that LDRT is feasible in COVID-19 patients having moderate to severe disease. Its clinical efficacy may be tested by conducting randomized controlled trials. Advances in knowledge: LDRT has shown promising results in COVID-19 pneumonia and should be researched further through randomized controlled trials.
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Affiliation(s)
- Daya Nand Sharma
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Randeep Guleria
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Naveet Wig
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Anant Mohan
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Goura Rath
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Vellaiyan Subramani
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Bhatnagar
- Department of Onco-anesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Supriya Mallick
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Aman Sharma
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Pritee Patil
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Karan Madan
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Manish Soneja
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Thulkar
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Angel Singh
- Department of Hospital Administration, All India Institute of Medical Sciences, New Delhi, India
| | - Sheetal Singh
- Department of Hospital Administration, All India Institute of Medical Sciences, New Delhi, India
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18
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Pokeerbux MR, Yelnik CM, Faure E, Drumez E, Bruandet A, Labreuche J, Assaf A, Goffard A, Garabedian C, Poissy J, Desbordes J, Garrigue D, Scherpereel A, Faure K, Lambert M. National early warning score to predict intensive care unit transfer and mortality in COVID-19 in a French cohort. Int J Clin Pract 2021; 75:e14121. [PMID: 33650136 PMCID: PMC7995084 DOI: 10.1111/ijcp.14121] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 02/26/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND No risk stratification tool has been validated in hospitalised patients with coronavirus disease 2019 (COVID-19), despite a high rate of intensive care requirement and in-hospital mortality. We aimed to determine whether the National Early Warning Score (NEWS) at admission can accurately predict in-hospital mortality and ICU transfer. METHODS This was a retrospective cohort study from January 24 to April 16, 2020, at Lille University Hospital. All consecutive adult patients with laboratory-confirmed COVID-19 who were initially admitted to non-ICU wards were included. The primary outcome was a composite criterion consisting of ICU transfer or in-hospital mortality. We evaluated the prognostic performance of NEWS by calculating the area under (AUC) the receiver operating characteristic curve, the optimal threshold value of NEWS, and its association with the primary outcome. RESULTS Of the 202 COVID-19 patients, the median age was 65 (interquartile range 52-78), 38.6% were women and 136 had at least one comorbidity. The median NEWS was 4 (2-6). A total of 65 patients were transferred to the ICU or died in the hospital. Compared with patients with favourable outcome, these patients were significantly older, had more comorbidities and higher NEWS. The AUC for NEWS was 0.68 (0.60-0.77) and the best cutoff value was 6. Adjusted odds ratio for NEWS ≥ 6 as an independent predictor was 3.78 (1.94-7.09). CONCLUSIONS In hospitalised COVID-19 patients, NEWS was an independent predictor of ICU transfer and in-hospital death. In daily practice, NEWS ≥ 6 at admission may help to identify patients who are at risk to deteriorate.
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Affiliation(s)
| | - Cécile M. Yelnik
- Internal Medicine DepartmentUniv. LilleINSERM U1167CHU LilleLilleFrance
| | - Emmanuel Faure
- Infectious Disease DepartmentUniv. LilleINSERM U1019CHU LilleCNRS UMR9017LilleFrance
| | - Elodie Drumez
- Department of BiostatisticsUniv. LilleULR 2694 ‐ METRICS : Évaluation des technologies de santé et des pratiques médicalesCHU LilleLilleFrance
| | | | - Julien Labreuche
- Department of BiostatisticsUniv. LilleULR 2694 ‐ METRICS : Évaluation des technologies de santé et des pratiques médicalesCHU LilleLilleFrance
| | - Ady Assaf
- Infectious Disease DepartmentUniv. LilleINSERM U1019CHU LilleCNRS UMR9017LilleFrance
| | - Anne Goffard
- Virology DepartmentUniv. LilleINSERM U1019CHU LilleCNRS UMR 9017LilleFrance
| | | | - Julien Poissy
- Univ. LilleINSERM U1285CHU LilleIntensive Care UnitCNRSUMR 8576UGSF ‐ Unité de Glycobiologie Structurale et FonctionnelleLilleFrance
| | | | | | - Arnaud Scherpereel
- Department of Pulmonary and Thoracic OncologyUniv. LilleCHU LilleLilleFrance
| | - Karine Faure
- Infectious Disease DepartmentUniv. LilleINSERM U1019CHU LilleCNRS UMR9017LilleFrance
| | - Marc Lambert
- Internal Medicine DepartmentUniv. LilleINSERM U1167CHU LilleLilleFrance
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19
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Alhmoud B, Bonnici T, Patel R, Melley D, Williams B, Banerjee A. Performance of universal early warning scores in different patient subgroups and clinical settings: a systematic review. BMJ Open 2021; 11:e045849. [PMID: 36044371 PMCID: PMC8039269 DOI: 10.1136/bmjopen-2020-045849] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/01/2021] [Accepted: 03/04/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To assess predictive performance of universal early warning scores (EWS) in disease subgroups and clinical settings. DESIGN Systematic review. DATA SOURCES Medline, CINAHL, Embase and Cochrane database of systematic reviews from 1997 to 2019. INCLUSION CRITERIA Randomised trials and observational studies of internal or external validation of EWS to predict deterioration (mortality, intensive care unit (ICU) transfer and cardiac arrest) in disease subgroups or clinical settings. RESULTS We identified 770 studies, of which 103 were included. Study designs and methods were inconsistent, with significant risk of bias (high: n=16 and unclear: n=64 and low risk: n=28). There were only two randomised trials. There was a high degree of heterogeneity in all subgroups and in national early warning score (I2=72%-99%). Predictive accuracy (mean area under the curve; 95% CI) was highest in medical (0.74; 0.74 to 0.75) and surgical (0.77; 0.75 to 0.80) settings and respiratory diseases (0.77; 0.75 to 0.80). Few studies evaluated EWS in specific diseases, for example, cardiology (n=1) and respiratory (n=7). Mortality and ICU transfer were most frequently studied outcomes, and cardiac arrest was least examined (n=8). Integration with electronic health records was uncommon (n=9). CONCLUSION Methodology and quality of validation studies of EWS are insufficient to recommend their use in all diseases and all clinical settings despite good performance of EWS in some subgroups. There is urgent need for consistency in methods and study design, following consensus guidelines for predictive risk scores. Further research should consider specific diseases and settings, using electronic health record data, prior to large-scale implementation. PROSPERO REGISTRATION NUMBER PROSPERO CRD42019143141.
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Affiliation(s)
- Baneen Alhmoud
- Institute of Health Informatics, University College London, London, UK
| | - Timothy Bonnici
- Institute of Health Informatics, University College London, London, UK
- University College London Hospitals NHS Trust, London, UK
| | - Riyaz Patel
- University College London Hospitals NHS Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
- Barts Health NHS Trust, London, UK
| | | | - Bryan Williams
- University College London Hospitals NHS Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK
- University College London Hospitals NHS Trust, London, UK
- Barts Health NHS Trust, London, UK
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20
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Nikitin IG, Melekhov AV, Sayfullin MA, Agafonov SS, Bedritskiy SA, Vishninskiy AA, Gultiaeva NA, Guseynov ER, Ermakov NA, Zorin EA, Koroleva IV, Kudryavtsev DV, Manevskiy AP, Negovskiy AA, Petrovichev VS, Rudakov BE, Ruleva AI, Serebryakov AB, Sitnikov AR, Fedosova NF, Khammad EV, Avramov AA, Agaeva AI, Golubykh KY. [Organizing the medical care for the COVID-19 patients in non-infectious Moscow hospital: reassignment experience]. TERAPEVT ARKH 2020; 92:31-37. [PMID: 33720601 DOI: 10.26442/00403660.2020.11.000838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 12/25/2020] [Indexed: 01/10/2023]
Abstract
AIM To present the results of work of National Medical Research Center of Treatment and Rehabilitation, reassigned for COVID-19 patients treatment during pandemic. Run-up methodology, procedures and working process organization are detailed. MATERIALS AND METHODS 354 COVID-19 patients were treated from 13.04.2020 to 10.06.2020 [age 59 (470) years, 56% women, body mass index 28.5 (24.932.2) kg/m2]. Patients were admitted at 8 (611) day of sickness. In-hospital stay was 16 (1420) days. RESULTS NEWS scale at the day of admittance was 2 (14); 2 (13) in patients discharged alive and 6 (47) in died patients, p=0.0001. So prognostic accuracy of NEWS scale was confirmed as very well (area under ROC-curve = 0.819). 69 patients (19.5%) were treated at intensive care department for 7 (413) days. 13 patients died, 11 of them had COVID-19 as direct or indirect cause of death. Total in-hospital mortality was 3.67%, in-hospital mortality of COVID-19 patients 3.1%. 17 healthcare workers (HCW), contacted with COVID-19 patients were infected (2.67%). 4 HCW, who had no direct contact with patients were also infected and 7 HCW were infected before the first patient was admitted. No one of them died. CONCLUSION Complex tasks of healthcare organization during COVID-19 pandemic can be solved quickly with acceptable quality, characterized by low levels of patients; mortality and HCW infection.
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Affiliation(s)
- I G Nikitin
- National Medical Research Center of Treatment and Rehabilitation.,Pirogov Russian National Research Medical University
| | - A V Melekhov
- National Medical Research Center of Treatment and Rehabilitation.,Pirogov Russian National Research Medical University
| | - M A Sayfullin
- National Medical Research Center of Treatment and Rehabilitation.,Pirogov Russian National Research Medical University
| | - S S Agafonov
- National Medical Research Center of Treatment and Rehabilitation
| | - S A Bedritskiy
- National Medical Research Center of Treatment and Rehabilitation
| | - A A Vishninskiy
- National Medical Research Center of Treatment and Rehabilitation
| | - N A Gultiaeva
- National Medical Research Center of Treatment and Rehabilitation
| | - E R Guseynov
- National Medical Research Center of Treatment and Rehabilitation
| | - N A Ermakov
- National Medical Research Center of Treatment and Rehabilitation
| | - E A Zorin
- National Medical Research Center of Treatment and Rehabilitation
| | - I V Koroleva
- National Medical Research Center of Treatment and Rehabilitation
| | - D V Kudryavtsev
- National Medical Research Center of Treatment and Rehabilitation
| | - A P Manevskiy
- National Medical Research Center of Treatment and Rehabilitation
| | - A A Negovskiy
- National Medical Research Center of Treatment and Rehabilitation
| | - V S Petrovichev
- National Medical Research Center of Treatment and Rehabilitation
| | - B E Rudakov
- National Medical Research Center of Treatment and Rehabilitation
| | - A I Ruleva
- National Medical Research Center of Treatment and Rehabilitation
| | - A B Serebryakov
- National Medical Research Center of Treatment and Rehabilitation
| | - A R Sitnikov
- National Medical Research Center of Treatment and Rehabilitation
| | - N F Fedosova
- National Medical Research Center of Treatment and Rehabilitation
| | - E V Khammad
- National Medical Research Center of Treatment and Rehabilitation
| | - A A Avramov
- National Medical Research Center of Treatment and Rehabilitation
| | - A I Agaeva
- Pirogov Russian National Research Medical University
| | - K Y Golubykh
- Pirogov Russian National Research Medical University
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21
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Engebretsen S, Bogstrand ST, Jacobsen D, Rimstad R. Characteristics, management and outcome of critically ill general medical patients in the Emergency Department: An observational study. Int Emerg Nurs 2020; 54:100939. [PMID: 33302239 DOI: 10.1016/j.ienj.2020.100939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/23/2020] [Accepted: 10/01/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Critically ill general medical patients are an increasing group in the Emergency Department (ED). This register-based cohort study aimed to examine these patients' characteristics, ED management and outcome, and investigate factors associated with ICU admission. METHODS The study comprised all adult medical triage 1 patients treated by a specialized multidisciplinary team in 2015 and 2016. Univariate and multivariate analysis were used. RESULTS 1294 patients were included. Mean age was 59 years, 56% (n = 725) were male, mean National Early Warning Score 2 (NEWS2) was 7, intensive care unit (ICU) admission was 56.8% (n = 735) and mortality rate was 16.8% (n = 217). Median ED length of stay (LOS) was 1.6 h, 1.2 h if admitted to ICU. The most frequent discharge diagnosis was acute poisoning (24.0%, n = 308). Younger age, male gender, arriving at nighttime weekdays, higher NEWS2 at arrival, critical care interventions or medications in the ED was associated with ICU admission. CONCLUSION More than half of the patients were admitted to ICU, and the mortality rate was 16.8%. A large proportion was diagnosed with acute poisoning. Younger age, higher NEWS and critical care in ED were associated with ICU admission. The short ED LOS suggests that management by a multidisciplinary team is beneficial.
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Affiliation(s)
- Stine Engebretsen
- Emergency Department, Division of Emergencies and Critical Care, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Postboks 1171 Blindern, 0318 Oslo, Norway.
| | - Stig Tore Bogstrand
- Department of Forensic Sciences, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway; Institute of Health and Society, University of Oslo, Postboks 1130 Blindern, 0318 Oslo, Norway.
| | - Dag Jacobsen
- Institute of Clinical Medicine, University of Oslo, Postboks 1171 Blindern, 0318 Oslo, Norway; Department of Acute Medicine, Division of Medicine, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway.
| | - Rune Rimstad
- Medicine, Health, Patient Safety and Integration, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway.
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22
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Zhou HJ, Lan TF, Guo SB. Outcome prediction value of National Early Warning Score in septic patients with community-acquired pneumonia in emergency department: A single-center retrospective cohort study. World J Emerg Med 2020; 11:206-215. [PMID: 33014216 DOI: 10.5847/wjem.j.1920-8642.2020.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Hai-Jiang Zhou
- Emergency Medicine Clinical Research Center, Beijing Chao-yang Hospital, Capital Medical University & Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
| | - Tian-Fei Lan
- Department of Allergy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Shu-Bin Guo
- Emergency Medicine Clinical Research Center, Beijing Chao-yang Hospital, Capital Medical University & Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
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Engebretsen S, Bogstrand ST, Jacobsen D, Vitelli V, Rimstad R. NEWS2 versus a single-parameter system to identify critically ill medical patients in the emergency department. Resusc Plus 2020; 3:100020. [PMID: 34223303 PMCID: PMC8244393 DOI: 10.1016/j.resplu.2020.100020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/18/2020] [Accepted: 07/21/2020] [Indexed: 01/01/2023] Open
Abstract
AIM To test National Early Warning Score 2 (NEWS2) versus a single-parameter system to identify critically ill general medical patients in the emergency department (ED), by 1) testing NEWS2s prediction of and association with primary outcome 'mortality' (hospital or 30 day) and secondary outcomes 'intensive care unit (ICU) admission' and 'critical care in ED' and 2) comparing this for different NEWS2 cut-offs and the single-parameter system in use. METHODS Register-data on adult triage 1 and 2 patients with complete NEWS2 from 2015 and 2016 were retrieved. Prediction was assessed using area under the receiver-operating characteristic curve. Associations were analyzed using multiple logistic regression. RESULTS 1586 patients were included. NEWS2 showed poor prediction of 'mortality' (AUC 0.686, CI 0.633-0.739) and adequate prediction of 'ICU admission' (AUC 0.716, CI 0.690-0.742) and 'critical care in ED' (AUC 0.756, CI 0.732-0.780). It was strongly associated with all outcomes (all p<0.001). All NEWS2 cut-offs and the single-parameter system showed poor prediction of all outcomes (all AUCs <0.7). The single-parameter system had the strongest association with 'mortality' (OR 1.688, CI 1.052-2.708, p<0.05) and 'critical care in ED' (OR 3.267, CI 2.490-4.286, p<0.001). NEWS2 > 4 had the strongest association with 'ICU admission' (OR 2.339, CI 1.742-3.141, p<0.001). CONCLUSION For identification in order to trigger a response in the ED, outcomes closest in time seem most clinically relevant. As such, the single-parameter system had acceptable performance. NEWS2 > 4 should be considered as an additional trigger due to its association with ICU admission.
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Affiliation(s)
- Stine Engebretsen
- Emergency Department, Division of Emergencies and Critical Care, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Postboks 1171 Blindern, 0318, Oslo, Norway
| | - Stig Tore Bogstrand
- Department of Forensic Sciences, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway
- Institute of Health and Society, University of Oslo, Postboks 1130 Blindern, 0318, Oslo, Norway
| | - Dag Jacobsen
- Institute of Clinical Medicine, University of Oslo, Postboks 1171 Blindern, 0318, Oslo, Norway
- Department of Acute Medicine, Division of Medicine, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway
| | - Valeria Vitelli
- Oslo Center for Biostatistics and Epidemiology, Department of Biostatistics, University of Oslo, Postboks 1122 Blindern, 0317, Oslo, Norway
| | - Rune Rimstad
- Medicine, Health, Patient Safety and Integration, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway
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Patient-Related Complexity of Care in Healthcare Organizations: A Management and Evaluation Model. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17103463. [PMID: 32429208 PMCID: PMC7277885 DOI: 10.3390/ijerph17103463] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/05/2020] [Accepted: 05/13/2020] [Indexed: 01/08/2023]
Abstract
In times of economic stringency, the prerequisite for the provision of healthcare services differentiated by complexity is identified in the right patients’ allocation. Since access to high-intensity care units is restricted, it is necessary both to promptly diagnose patients who are at risk of rapid clinical deterioration or death and to define criteria to identify the correct allocation of patients based on clinical-care needs. Although the so-called “early warning scores” were used by healthcare professionals to alert medical staff, nowadays, they can also be used as decision rules for managing patient admissions, increasing their effective usefulness. The procedure for assessing the complexity of care profiles needs to be based on a multidisciplinary approach. The primary objective of scientific research was to determine the intensity of care (clinical instability and care dependence) of the patients allocated in different settings of the medical area. To correctly frame the phenomenon, the main methods and strategies developed for different care models were discussed. In the Italian healthcare organization, the indicators, methodologies and tools to evaluate the clinical-care complexity were identified and subsequently applied. In conclusion, the findings and proposals for improvement actions are shown.
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Martín-Rodríguez F, López-Izquierdo R, Del Pozo Vegas C, Sánchez-Soberón I, Delgado-Benito JF, Martín-Conty JL, Castro-Villamor MA. Can the prehospital National Early Warning Score 2 identify patients at risk of in-hospital early mortality? A prospective, multicenter cohort study. Heart Lung 2020; 49:585-591. [PMID: 32169257 DOI: 10.1016/j.hrtlng.2020.02.047] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 02/17/2020] [Accepted: 02/27/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Francisco Martín-Rodríguez
- Advanced Clinical Simulation Center, Faculty of Medicine, Universidad de Valladolid, Avda. Ramón y Cajal, 7, 47005 Valladolid, Spain; Advanced Medical Life Support, Emergency Medical Services (SACYL), P° Hospital Militar, 24, 47007 Valladolid, Spain.
| | - Raúl López-Izquierdo
- Advanced Clinical Simulation Center, Faculty of Medicine, Universidad de Valladolid, Avda. Ramón y Cajal, 7, 47005 Valladolid, Spain; Emergency Department, Hospital Universitario Rio Hortega, C/ Dulzaina 2, 47012 Valladolid, Spain
| | - Carlos Del Pozo Vegas
- Emergency Department, Hospital Clínico Universitario, Avda. Ramón y Cajal, 3, 47003 Valladolid, Spain
| | - Irene Sánchez-Soberón
- Advanced Medical Life Support, Emergency Medical Services (SACYL), P° Hospital Militar, 24, 47007 Valladolid, Spain
| | - Juan F Delgado-Benito
- Advanced Medical Life Support, Emergency Medical Services (SACYL), P° Hospital Militar, 24, 47007 Valladolid, Spain
| | - José Luis Martín-Conty
- Faculty of Health Sciences, Castilla la Mancha University, Avda. Real Fábrica de Seda, s/n, 45600 Talavera de la Reina, Toledo, Spain
| | - Miguel A Castro-Villamor
- Advanced Clinical Simulation Center, Faculty of Medicine, Universidad de Valladolid, Avda. Ramón y Cajal, 7, 47005 Valladolid, Spain
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Community-Acquired Pneumonia. Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) Guidelines. 2020 Update. Arch Bronconeumol 2020. [PMID: 32139236 DOI: 10.1016/j.arbres.2020.01.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The guidelines for community-acquired pneumonia, last published in 2010, have been updated to provide recommendations based on a critical summary of the latest literature to help health professionals make the best decisions in the care of immunocompetent adult patients. The methodology was based on 6 PICO questions (on etiological studies, assessment of severity and decision to hospitalize, antibiotic treatment and duration, and pneumococcal conjugate vaccination), agreed by consensus among a working group of pulmonologists and an expert in documentation science and methodology. A comprehensive review of the literature was performed for each PICO question, and these were evaluated in in-person meetings. The American Thoracic Society guidelines were published during the preparation of this paper, so the recommendations of this association were also evaluated. We concluded that the etiological source of the infection should be investigated in hospitalized patients who have suspected resistance or who fail to respond to treatment. Prognostic scales, such as PSI, CURB 65, and CRB65, are useful for assessing severity and the decision to hospitalize. Different antibiotic regimens are indicated, depending on the treatment setting - outpatient, hospital, or intensive care unit - and the resistance of PES microorganisms should be calculated. The minimum duration of antibiotic treatment should be 5 days, based on criteria of clinical stability. Finally, we reviewed the indication of the 13-valent conjugate vaccine in immunocompetent patients with risk factors and comorbidity.
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Development of the National Early Warning Score-Calcium Model for Predicting Adverse Outcomes in Patients With Acute Pancreatitis. J Emerg Nurs 2019; 46:171-179. [PMID: 31866070 DOI: 10.1016/j.jen.2019.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 11/03/2019] [Accepted: 11/04/2019] [Indexed: 02/08/2023]
Abstract
INTRODUCTION This study aimed to develop a new model on the basis of the National Early Warning Score to predict intensive care unit admission and the mortality of patients with acute pancreatitis. METHODS Patients diagnosed with acute pancreatitis in the emergency department were enrolled. The values of the National Early Warning Score, Modified Early Warning Score, and Bedside Index of Severity in Acute Pancreatitis in predicting intensive care unit admission and mortality of patients with acute pancreatitis were evaluated. RESULTS A total of 379 patients with acute pancreatitis were enrolled; 77 patients (20.3%) were admitted to the intensive care unit and 14 (3.7%) died. The National Early Warning Score and calcium level were identified as independent risk factors of intensive care unit admission. Serum calcium exhibited a moderate correlation with National Early Warning Score (r = -0.46; P < 0.001), Modified Early Warning Score (r = -0.37; P < 0.001), and Bedside Index of Severity in Acute Pancreatitis (r = -0.39; P < 0.001). A new model called National Early Warning Score-calcium was developed by combining National Early Warning Score and calcium blood test result, which had larger areas under the curve for predicting intensive care unit admission and mortality than the other 3 scoring systems. DISCUSSION A new model developed by combining National Early Warning Score and calcium exhibited better value in predicting the prognosis of acute pancreatitis than the models involving National Early Warning Score, Modified Early Warning Score, and Bedside Index of Severity in Acute Pancreatitis alone.
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Tirkkonen J, Karlsson S, Skrifvars MB. National early warning score (NEWS) and the new alternative SpO 2 scale during rapid response team reviews: a prospective observational study. Scand J Trauma Resusc Emerg Med 2019; 27:111. [PMID: 31842961 PMCID: PMC6915867 DOI: 10.1186/s13049-019-0691-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/26/2019] [Indexed: 01/30/2023] Open
Abstract
Background The national early warning score (NEWS) enables early detection of in-hospital patient deterioration and timely activation of hospital’s rapid response team (RRT). NEWS was updated in 2017 to include a separate SpO2 scale for those patients with type II respiratory failure (T2RF). In this study we investigated whether NEWS with and without the new SpO2 scale for the T2RF patients is associated with immediate and in-hospital patient outcomes among the patients actually attended by the RRT. Methods We conducted a two-year prospective observational study including all adult RRT patients without limitations of medical treatment (LOMT) in a large Finnish university associated tertiary level hospital. According to the first vital signs measured by the RRT, we calculated NEWSs for the RRT patients and further utilized the new SpO2 scale for the patients with confirmed T2RF. We used multivariate logistic regression and area under the receiver operating characteristic analyses to test NEWS’s accuracy to predict two distinct outcomes: RRT patient’s I) immediate need for intensive care and/or new LOMT and 2) in-hospital death or discharge with cerebral performance category >2 and/or LOMT. Results The final cohort consisted of 886 RRT patients attended for the first time during their hospitalization. Most common reasons for RRT activation were respiratory (343, 39%) and circulatory (226, 26%) problems. Cohort’s median (Q1, Q3) NEWS at RRT arrival was 8 (5, 10) and remained unchanged if the new SpO2 scale was applied for the 104 patients with confirmed T2RF. Higher NEWS was independently associated with both immediate (OR 1.28; 95% CI 1.22–1.35) and in-hospital (1.15; 1.10–1.21) adverse outcomes. Further, NEWS had fair discrimination for both the immediate (AUROC 0.73; 0.69–0.77) and in-hospital (0.68; 0.64–0.72) outcomes. Utilizing the new SpO2 scale for the patients with confirmed T2RF did not improve the discrimination capability (0.73; 0.69–0.76 and 0.68; 0.64–0.71) for these outcomes, respectively. Conclusions We found that in patients attended by a RRT, the NEWS predicts patient’s hospital outcome with moderate accuracy. We did not find any improvement using the new SpO2 scale in T2RF patients.
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Affiliation(s)
- Joonas Tirkkonen
- Department of Intensive Care Medicine and Department of Emergency, Anaesthesia and Pain Medicine, Tampere University Hospital, PO Box 2000, FI-33521, Tampere, Finland. .,Faculty of Medicine, University of Tampere, PO Box 2000, FI-33521, Tampere, Finland.
| | - Sari Karlsson
- Department of Intensive Care Medicine, Tampere University Hospital, PO Box 2000, FI-33521, Tampere, Finland
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Minimal Impact of Implemented Early Warning Score and Best Practice Alert for Patient Deterioration. Crit Care Med 2019; 47:49-55. [PMID: 30247239 DOI: 10.1097/ccm.0000000000003439] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Kovach CP, Fletcher GS, Rudd KE, Grant RM, Carlbom DJ. Comparative prognostic accuracy of sepsis scores for hospital mortality in adults with suspected infection in non-ICU and ICU at an academic public hospital. PLoS One 2019; 14:e0222563. [PMID: 31525224 PMCID: PMC6746500 DOI: 10.1371/journal.pone.0222563] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 09/03/2019] [Indexed: 12/20/2022] Open
Abstract
Background Sepsis is a global healthcare challenge and reliable tools are needed to identify patients and stratify their risk. Here we compare the prognostic accuracy of the sepsis-related organ failure assessment (SOFA), quick SOFA (qSOFA), systemic inflammatory response syndrome (SIRS), and national early warning system (NEWS) scores for hospital mortality and other outcomes amongst patients with suspected infection at an academic public hospital. Measurements and main results 10,981 adult patients with suspected infection hospitalized at a U.S. academic public hospital between 2011–2017 were retrospectively identified. Primary exposures were the maximum SIRS, qSOFA, SOFA, and NEWS scores upon inclusion. Comparative prognostic accuracy for the primary outcome of hospital mortality was assessed using the area under the receiver operating characteristic curve (AUROC). Secondary outcomes included mortality in ICU versus non-ICU settings, ICU transfer, ICU length of stay (LOS) >3 days, and hospital LOS >7 days. Adjusted analyses were performed using a model of baseline risk for hospital mortality. 774 patients (7.1%) died in hospital. Discrimination for hospital mortality was highest for SOFA (AUROC 0.90 [95% CI, 0.89–0.91]), followed by NEWS (AUROC 0.85 [95% CI, 0.84–0.86]), qSOFA (AUROC 0.84 [95% CI, 0.83–0.85]), and SIRS (AUROC 0.79 [95% CI, 0.78–0.81]; p<0.001 for all comparisons). NEWS (AUROC 0.94 [95% CI, 0.93–0.95]) outperformed other scores in predicting ICU transfer (qSOFA AUROC 0.89 [95% CI, 0.87–0.91]; SOFA AUROC, 0.84 [95% CI, 0.82–0.87]; SIRS AUROC 0.81 [95% CI, 0.79–0.83]; p<0.001 for all comparisons). NEWS (AUROC 0.86 [95% CI, 0.85–0.86]) was also superior to other scores in predicting ICU LOS >3 days (SOFA AUROC 0.84 [95% CI, 0.83–0.85; qSOFA AUROC, 0.83 [95% CI, 0.83–0.84]; SIRS AUROC, 0.75 [95% CI, 0.74–0.76]; p<0.002 for all comparisons). Conclusions Multivariate prediction scores, such as SOFA and NEWS, had greater prognostic accuracy than qSOFA or SIRS for hospital mortality, ICU transfer, and ICU length of stay. Complex sepsis scores may offer enhanced prognostic performance as compared to simple sepsis scores in inpatient hospital settings where more complex scores can be readily calculated.
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Affiliation(s)
- Christopher P. Kovach
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| | - Grant S. Fletcher
- Division of Hospital Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Kristina E. Rudd
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Rosemary M. Grant
- Professional Development and Nursing Excellence, Harborview Medical Center, Seattle, Washington, United States of America
| | - David J. Carlbom
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
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Mitsunaga T, Hasegawa I, Uzura M, Okuno K, Otani K, Ohtaki Y, Sekine A, Takeda S. 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. PeerJ 2019; 7:e6947. [PMID: 31143553 PMCID: PMC6526008 DOI: 10.7717/peerj.6947] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 04/09/2019] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Toshiya Mitsunaga
- Department of Emergency Medicine, Jikei University School of Medicine, Tokyo, Japan.,Centre for Preventive Medical Sciences, Chiba University, Chiba, Japan
| | - Izumu Hasegawa
- Department of Emergency Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Masahiko Uzura
- Department of Emergency Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Kenji Okuno
- Department of Emergency Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Kei Otani
- Department of Emergency Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Yuhei Ohtaki
- Department of Emergency Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Akihiro Sekine
- Centre for Preventive Medical Sciences, Chiba University, Chiba, Japan
| | - Satoshi Takeda
- Department of Emergency Medicine, Jikei University School of Medicine, Tokyo, Japan
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Lee SB, Kim DH, Kim T, Kang C, Lee SH, Jeong JH, Kim SC, Park YJ, Lim D. Emergency Department Triage Early Warning Score (TREWS) predicts in-hospital mortality in the emergency department. Am J Emerg Med 2019; 38:203-210. [PMID: 30795946 DOI: 10.1016/j.ajem.2019.02.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/30/2019] [Accepted: 02/05/2019] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Sang Bong Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Dong Hoon Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea.
| | - Taeyun Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Changwoo Kang
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Soo Hoon Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Jin Hee Jeong
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Seong Chun Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Yong Joo Park
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Daesung Lim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
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Abstract
PURPOSE OF REVIEW To describe the current understanding and clinical applicability of severity scoring systems in pneumonia management. RECENT FINDINGS Severity scores in community-acquired pneumonia are strong markers of mortality, but are not necessarily clinical decision-aid tools. The use of severity scores to support outpatient care in low-risk patients has moderate-to-strong evidence available in the literature, mainly for the pneumonia severity index, and must be applied together with clinical judgment. It is not clear that severity scores are helpful to guide empiric antibiotic treatment. The inclusion of biomarkers and performance status might improve the predictive performance of the well known severity scores in community-acquired pneumonia. We should improve our methods for score evaluation and move toward the development of decision-aid tools. SUMMARY The application of the available evidence favors the use of severity scoring systems to improve the delivery of care for pneumonia patients. The incorporation of new methodologies and the formulation of different questions other than mortality prediction might help the further development of severity scoring systems, and enhance their support to the clinical decision-making process for the pneumonia-management cascade.
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Brink A, Alsma J, Verdonschot RJCG, Rood PPM, Zietse R, Lingsma HF, Schuit SCE. Predicting mortality in patients with suspected sepsis at the Emergency Department; A retrospective cohort study comparing qSOFA, SIRS and National Early Warning Score. PLoS One 2019; 14:e0211133. [PMID: 30682104 PMCID: PMC6347138 DOI: 10.1371/journal.pone.0211133] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 01/08/2019] [Indexed: 12/31/2022] Open
Abstract
Objective In hospitalized patients, the risk of sepsis-related mortality can be assessed using the quick Sepsis-related Organ Failure Assessment (qSOFA). Currently, different tools that predict deterioration such as the National Early Warning Score (NEWS) have been introduced in clinical practice in Emergency Departments (ED) worldwide. It remains ambiguous which screening tool for mortality at the ED is best. The objective of this study was to evaluate the predictive performance for mortality of two sepsis-based scores (i.e. qSOFA and Systemic Inflammatory Response Syndrome (SIRS)-criteria) compared to the more general NEWS score, in patients with suspected infection directly at presentation to the ED. Methods We performed a retrospective cohort study. Patients who presented to the ED between June 2012 and May 2016 with suspected sepsis in a large tertiary care center were included. Suspected sepsis was defined as initiation of intravenous antibiotics and/or collection of any culture in the ED. Outcome was defined as 10-day and 30-day mortality after ED presentation. Predictive performance was expressed as discrimination (AUC) and calibration using Hosmer-Lemeshow goodness-of-fit test. Subsequently, sensitivity, and specificity were calculated. Results In total 8,204 patients were included of whom 286 (3.5%) died within ten days and 490 (6.0%) within 30 days after presentation. NEWS had the best performance, followed by qSOFA and SIRS (10-day AUC: 0.837, 0.744, 0.646, 30-day AUC: 0.779, 0.697, 0.631). qSOFA (≥2) lacked a high sensitivity versus SIRS (≥2) and NEWS (≥7) (28.5%, 77.2%, 68.0%), whilst entailing highest specificity versus NEWS and SIRS (93.7%, 66.5%, 37.6%). Conclusions NEWS is more accurate in predicting 10- and 30-day mortality than qSOFA and SIRS in patients presenting to the ED with suspected sepsis.
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Affiliation(s)
- Anniek Brink
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
- * E-mail:
| | - Jelmer Alsma
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | - Robert Zietse
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Hester Floor Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Stephanie Catherine Elisabeth Schuit
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
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Eckart A, Hauser SI, Kutz A, Haubitz S, Hausfater P, Amin D, Amin A, Huber A, Mueller B, Schuetz P. Combination of the National Early Warning Score (NEWS) and inflammatory biomarkers for early risk stratification in emergency department patients: results of a multinational, observational study. BMJ Open 2019; 9:e024636. [PMID: 30782737 PMCID: PMC6340461 DOI: 10.1136/bmjopen-2018-024636] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES The National Early Warning Score (NEWS) helps to estimate mortality risk in emergency department (ED) patients. This study aimed to investigate whether the prognostic value of the NEWS at ED admission could be further improved by adding inflammatory blood markers (ie, white cell count (WCC), procalcitonin (PCT) and midregional-proadrenomedullin (MR-proADM). DESIGN Secondary analysis of a multinational, observational study (TRIAGE study, March 2013-October 2014). SETTING Three tertiary care centres in France, Switzerland and the USA. PARTICIPANTS A total of 1303 adult medical patients with complete NEWS data seeking ED care were included in the final analysis. NEWS was calculated retrospectively based on admission data. MAIN OUTCOME MEASURES The primary outcome was all-cause 30-day mortality. Secondary outcome was intensive care unit (ICU) admission. We used multivariate regression analyses to investigate associations of NEWS and blood markers with outcomes and area under the receiver operating curve (AUC) as a measure of discrimination. RESULTS Of the 1303 included patients, 54 (4.1%) died within 30 days. The NEWS alone showed fair prognostic accuracy for all-cause 30-day mortality (AUC 0.73), with a multivariate adjusted OR of 1.26 (95% CI 1.13 to 1.40, p<0.001). The AUCs for the prediction of mortality using the inflammatory markers WCC, PCT and MR-proADM were 0.64, 0.71 and 0.78, respectively. Combining NEWS with all three blood markers or only with MR-proADM clearly improved discrimination with an AUC of 0.82 (p=0.002). Combining the three inflammatory markers with NEWS improved prediction of ICU admission (AUC 0.70vs0.65 when using NEWS alone, p=0.006). CONCLUSION NEWS is helpful in risk stratification of ED patients and can be further improved by the addition of inflammatory blood markers. Future studies should investigate whether risk stratification by NEWS in addition to biomarkers improve site-of-care decision in this patient population. TRIAL REGISTRATION NUMBER NCT01768494; Post-results.
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Affiliation(s)
- Andreas Eckart
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Stephanie Isabelle Hauser
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Alexander Kutz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Sebastian Haubitz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Division of Infectious Diseases, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Pierre Hausfater
- Emergency Departement, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
- Sorbonne Universités UPMC-Univ Paris 06, UMRS INSERM 1166, IHUC ICAN, Paris, France
| | | | - Adina Amin
- Morton Plant Hospital, Clearwater, Florida, USA
| | - Andreas Huber
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Beat Mueller
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
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Jeong JH, Kim DH, Kim TY, Kang C, Lee SH, Lee SB, Kim SC, Park YJ. Harmful effects of early hyperoxaemia in patients admitted to general wards: an observational cohort study in South Korea. BMJ Open 2018; 8:e021758. [PMID: 30366913 PMCID: PMC6224716 DOI: 10.1136/bmjopen-2018-021758] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES We evaluated the association between hyperoxaemia induced by a non-invasive oxygen supply for 3 days after emergency department (ED) arrival and the clinical outcomes at day 5 after ED arrival. DESIGN Observational cohort study. SETTING AND PATIENTS Consecutive ED patients ≥16 years of age with available arterial blood gas analysis results who were admitted to our hospital were enrolled from January 2010 to December 2016. INTERVENTIONS The highest (PaO2MAX), average (PaO2AVG) and median (PaO2MED) PaO2 (arterial oxygen pressure) values within 72 hours and the area under the curve divided by the time elapsed between ED admittance and the last PaO2 result (AUC72) were used to assess hyperoxaemia. The AUC72 values were calculated using the trapezoid rule. OUTCOMES The primary outcome was the 90-day in-hospital mortality rate. The secondary outcomes were intensive care unit (ICU) transfer and respiratory failure at day 5 after ED arrival, as well as new-onset cardiovascular, coagulation, hepatic and renal dysfunction at day 5 after ED arrival. RESULTS Among the 10 141 patients, the mortality rate was 5.8%. The adjusted ORs of in-hospital mortality for PaO2MAX, PaO2AVG, PaO2MED and AUC72 were 0.79 (95% CI 0.61 to 1.02; p=0.0715), 0.92 (95% CI 0.69 to 1.24; p=0.5863), 0.82 (95% CI 0.61 to 1.11; p=0.2005) and 1.53 (95% CI 1.25 to 1.88; p<0.0001). All of the hyperoxaemia variables showed significant positive correlations with ICU transfer at day 5 after ED arrival (p<0.05). AUC72 was positively correlated with respiratory failure, as well as cardiovascular, hepatic and renal dysfunction (p<0.05). PaO2MAX was positively correlated with cardiovascular dysfunction. PaO2MAX and AUC72 were negatively correlated with coagulation dysfunction (p<0.05). CONCLUSIONS Hyperoxaemia during the first 3 days in patients outside the ICU is associated with in-hospital mortality and ICU transfer at day 5 after arrival at the ED.
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Affiliation(s)
- Jin Hee Jeong
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Republic of Korea
- Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju-si, Republic of Korea
| | - Dong Hoon Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Republic of Korea
- Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju-si, Republic of Korea
| | - Tae Yun Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Republic of Korea
| | - Changwoo Kang
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Republic of Korea
- Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju-si, Republic of Korea
| | - Soo Hoon Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Republic of Korea
| | - Sang Bong Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Republic of Korea
| | - Seong Chun Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Yong Joo Park
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
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Smart L, Bosio E, Macdonald SP, Dull R, Fatovich DM, Neil C, Arendts G. Glycocalyx biomarker syndecan-1 is a stronger predictor of respiratory failure in patients with sepsis due to pneumonia, compared to endocan. J Crit Care 2018; 47:93-98. [DOI: 10.1016/j.jcrc.2018.06.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/22/2018] [Accepted: 06/14/2018] [Indexed: 12/20/2022]
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The feasibility, acceptability and preliminary testing of a novel, low-tech intervention to improve pre-hospital data recording for pre-alert and handover to the Emergency Department. BMC Emerg Med 2018; 18:16. [PMID: 29940885 PMCID: PMC6019792 DOI: 10.1186/s12873-018-0168-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 06/11/2018] [Indexed: 11/25/2022] Open
Abstract
Background Poor communication during patient handover is recognised internationally as a root cause of a significant proportion of preventable deaths. Data used in handover is not always easily recorded using ambulance based tablets, particularly in time-critical cases. Paramedics have therefore developed pragmatic workarounds (writing on gloves or scrap paper) to record these data. However, such practices can conflict with policy, data recorded can be variable, easily lost and negatively impact on handover quality. Methods This study aimed to measure the feasibility and acceptability of a novel, low tech intervention, designed to support clinical information recording and delivery during pre-alert and handover within the pre-hospital and ED setting. A simple pre and post-test design was used with a historical control. Eligible participants included all ambulance clinicians based at one large city Ambulance Station (n = 69) and all nursing and physician staff (n = 99) based in a city Emergency Department. Results Twenty five (36%) ambulance clinicians responded to the follow-up survey. Most felt both the pre-alert and handover components of the card were either ‘useful-very useful’ (n = 23 (92%); and n = 18 (72%) respectively. Nineteen (76%) used the card to record clinical information and almost all (n = 23 (92%) felt it ‘useful’ to ‘very useful’ in supporting pre-alert. Similarly, 65% (n = 16) stated they ‘often’ or ‘always’ used the card to support handover. For pre-alert information there were improvements in the provision of 8/11 (72.7%) clinical variables. Results from the post-test survey measuring ED staff (n = 37) perceptions of handover demonstrated small (p < 0.05) improvements in handover in 3/5 domains measured. Conclusion This novel low-tech intervention was highly acceptable to ambulance clinician participants, improving their data recording and information exchange processes. However, further well conducted studies are required to test the impact of this intervention on information exchange during pre-alert and handover. Electronic supplementary material The online version of this article (10.1186/s12873-018-0168-3) contains supplementary material, which is available to authorized users.
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Fitzpatrick D, McKenna M, Duncan EAS, Laird C, Lyon R, Corfield A. Critcomms: a national cross-sectional questionnaire based study to investigate prehospital handover practices between ambulance clinicians and specialist prehospital teams in Scotland. Scand J Trauma Resusc Emerg Med 2018; 26:45. [PMID: 29859121 PMCID: PMC5984735 DOI: 10.1186/s13049-018-0512-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/14/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Poor communication during patient handover is recognised internationally as a root cause of a significant proportion of preventable deaths. Improving the accuracy and quality of handover may reduce associated mortality and morbidity. Although the practice of handover between Ambulance and Emergency Department clinicians has received some attention over recent years there is little evidence to support handover best practice within the prehospital domain. Further research is therefore urgently required to understand the most appropriate way to deliver clinical information exchange in the pre-hospital environment. We aimed to investigate current clinical information exchange practices, perceived challenges and the preferred handover mnemonic for use during transfer of high acuity patients between ambulance clinicians and specialist prehospital teams. METHODS A national, cross-sectional questionnaire study. Participants were road based ambulance clinicians (RBAC) or active members of specialist prehospital teams (SPHT) based in Scotland. RESULTS Over a three month study period there were 247 prehospital incidents involving specialist teams. One hundred ninety individuals completed the questionnaire; 61% [n = 116] RBAC and 39% [n = 74] SPHT. Median length of prehospital experience was 10 years (IQR 5-18). Overall current prehospital handover practices were perceived as being effective (Mdn 4.00; IQR 3-4 [1 = very ineffective - 5 = very effective]) although SPHT clinicians rated handover effectiveness slightly lower than RBAC's (Mdn 3.00 vs 4.00, U = 1842.5, p = .03). 'ATMIST' (Age, Time of onset, Medical complaint/injury, Investigation, Signs and Treatment) was deemed the mnemonic of choice. The clinical variables perceived as essential for handover are not explicitly identified within the SBAR mnemonic. The most frequently reported method of recording and transferring information during handover was via memory (n = 112 and n = 120 respectively) and 'interruptions' were perceived as the most significant barrier to effective handover. CONCLUSION While, overall, current prehospital handover practice is perceived as effective this study has identified a number of areas for improvement. These include the development of a shared mental model through system standardisation, innovations to support information recording and delivery, and the clear identification at incidents of a handover lead. Mnemonics must be carefully selected to ensure they explicitly contain the perceived essential clinical variables required for prehospital handover; the mnemonic ATMIST meets these requirements. New theoretically informed, evidence-based interventions, must be developed and tested within existing systems of care to minimise information loss and risk to patients.
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Affiliation(s)
- David Fitzpatrick
- Faculty of Health Sciences and Sport, University of Stirling, FK9 4LA Stirling, Scotland
| | - Michael McKenna
- Scottish Ambulance Service, Glebe Cottage, Strath, Gairloch, Ross-shire IV212BT Scotland
| | - Edward A. S. Duncan
- Nursing, Midwifery & Allied Health Professions Research Unit, University of Stirling, FK9 4NF Scion House, Scotland, UK
| | - Colville Laird
- Basics Scotland, Aberuthven Enterpise Park, Sandpiper House, Aberuthven, Auchterarder Scotland
| | - Richard Lyon
- Pre-Hospital Emergency Care, School of Health Sciences, University of Surrey, Guildford, UK
| | - Alasdair Corfield
- Emergency Medical Retrieval Service, School of Medicine, Dentistry and Nursing, University of Glasgow, Wolfson Medical School Building, G12 8QQ Glasgow, Scotland
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Kivipuro M, Tirkkonen J, Kontula T, Solin J, Kalliomäki J, Pauniaho SL, Huhtala H, Yli-Hankala A, Hoppu S. National early warning score (NEWS) in a Finnish multidisciplinary emergency department and direct vs. late admission to intensive care. Resuscitation 2018; 128:164-169. [PMID: 29775642 DOI: 10.1016/j.resuscitation.2018.05.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 04/21/2018] [Accepted: 05/14/2018] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Mikko Kivipuro
- Medical School, University of Tampere and Department of Anaesthesia, Tampere University Hospital, PO Box 2000, FI-33521 Tampere, Finland.
| | - Joonas Tirkkonen
- Department of Intensive Care Medicine and Department of Emergency, Anaesthesia and Pain Medicine, Tampere University Hospital, PO Box 2000, FI-33521 Tampere, Finland.
| | - Timo Kontula
- Department of Emergency Medicine, Jyväskylä Central Hospital, Keskussairaalantie 19, FI-40620 Jyväskylä, Finland.
| | - Juuso Solin
- Medical School, University of Tampere and Department of Anaesthesia, Tampere University Hospital, PO Box 2000, FI-33521 Tampere, Finland.
| | - Jari Kalliomäki
- Department of Intensive Care Medicine, Tampere University Hospital, PO Box 2000, FI-33521 Tampere, Finland.
| | - Satu-Liisa Pauniaho
- Department of Emergency Medicine, Tampere University Hospital, PO Box 2000, FI-33521 Tampere, Finland.
| | - Heini Huhtala
- Biostatistics, Faculty of Social Sciences, University of Tampere, FI-33014, Finland.
| | - Arvi Yli-Hankala
- Department of Emergency, Anaesthesia and Pain Medicine, Tampere University Hospital, PO Box 2000, FI-33521, Finland; Faculty of Medicine and Life Sciences, University of Tampere, FI-33014 Tampereen yliopisto, Tampere, Finland.
| | - Sanna Hoppu
- Department of Intensive Care Medicine and Department of Emergency, Anaesthesia and Pain Medicine, Tampere University Hospital, PO Box 2000, FI-33521 Tampere, Finland.
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Brabrand M, Henriksen DP. CURB-65 Score is Equal to NEWS for Identifying Mortality Risk of Pneumonia Patients: An Observational Study. Lung 2018. [PMID: 29541854 DOI: 10.1007/s00408-018-0105-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
IMPORTANCE The CURB-65 score is widely implemented as a prediction tool for identifying patients with community-acquired pneumonia (cap) at increased risk of 30-day mortality. However, since most ingredients of CURB-65 are used as general prediction tools, it is likely that other prediction tools, e.g. the British National Early Warning Score (NEWS), could be as good as CURB-65 at predicting the fate of CAP patients. OBJECTIVE To determine whether NEWS is better than CURB-65 at predicting 30-day mortality of CAP patients. DESIGN This was a single-centre, 6-month observational study using patients' vital signs and demographic information registered upon admission, survival status extracted from the Danish Civil Registration System after discharge and blood test results extracted from a local database. SETTING The study was conducted in the medical admission unit (MAU) at the Hospital of South West Jutland, a regional teaching hospital in Denmark. PARTICIPANTS The participants consisted of 570 CAP patients, 291 female and 279 male, median age 74 (20-102) years. RESULTS The CURB-65 score had a discriminatory power of 0.728 (0.667-0.789) and NEWS 0.710 (0.645-0.775), both with good calibration and no statistical significant difference. CONCLUSION CURB-65 was not demonstrated to be significantly statistically better than NEWS at identifying CAP patients at risk of 30-day mortality.
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Affiliation(s)
- Mikkel Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Finsensgade 35, 6700, Esbjerg, Denmark. .,Department of Emergency Medicine, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark. .,Institute of Regional Health Research, University of Southern Denmark, Finsensgade 35, 6700, Esbjerg, Denmark.
| | - Daniel Pilsgaard Henriksen
- Department of Clinical Chemistry and Pharmacology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark
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Ferrari R, Viale P, Muratori P, Giostra F, Agostinelli D, Lazzari R, Voza R, Cavazza M. Rebounds after discharge from the emergency department for community-acquired pneumonia: focus on the usefulness of severity scoring systems. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 88:519-528. [PMID: 29350672 PMCID: PMC6166183 DOI: 10.23750/abm.v88i4.6685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 09/26/2017] [Accepted: 09/26/2017] [Indexed: 11/23/2022]
Abstract
Background: Community-acquired pneumonia (CAP) is common cause of hospital admission and leading cause of morbidity and mortality. Severity scoring systems are used to predict risk profile, outcome and mortality, and to help decisions about management strategies. Aim of the work and Methods: To critically analyze pneumonia “rebound” cases, once discharged from the emergency department (ED) and afterwards admitted. We conducted an observational clinical study in the acute setting of a university teaching hospital, prospectively analyzing, in a 1 year period, demographic, medical, clinical and laboratory data, and the outcome. Results: 249 patients were discharged home with diagnosis of CAP; 80 cases (32.1%) resulted in the high-intermediate risk class according to CURB-65 or CRB-65. Twelve patients (4.8%) presented to the ED twice and were then admitted. At their first visit 5 were in the high-intermediate risk group; just 4 of them were in the non-low risk group at the time of their admission. The rebound cohort showed some peculiar abnormalities in laboratory parameters (coagulation and renal function) and severe chest X-rays characteristics. None died in 30 days. Conclusions: The power of CURB-65 to correctly predict mortality for CAP patients discharged home from the ED is not confirmed by our results; careful clinical judgement seems to be irreplaceable in the management process. Many patients with a high-intermediate risk according to CURB-65 can be safely treated as outpatients, according to adequate welfare conditions; we identified a subgroup of cases that should worth a special attention and, therefore, a brief observation period in the ED before the final decision to safely discharge or admit. (www.actabiomedica.it)
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Affiliation(s)
- Rodolfo Ferrari
- Policlinico Sant'Orsola - Malpighi. Azienda Ospedaliero - Universitaria di Bologna..
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Waterer G. Severity Scores and Community-acquired Pneumonia. Time to Move Forward. Am J Respir Crit Care Med 2017; 196:1236-1238. [DOI: 10.1164/rccm.201706-1285ed] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Grant Waterer
- University of Western AustraliaPerth, Australiaand
- Northwestern UniversityChicago, Illinois
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Nannan Panday RS, Minderhoud TC, Alam N, Nanayakkara PWB. Prognostic value of early warning scores in the emergency department (ED) and acute medical unit (AMU): A narrative review. Eur J Intern Med 2017; 45:20-31. [PMID: 28993097 DOI: 10.1016/j.ejim.2017.09.027] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 09/18/2017] [Accepted: 09/23/2017] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- R S Nannan Panday
- Section Acute Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - T C Minderhoud
- Section Acute Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - N Alam
- Section Acute Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - P W B Nanayakkara
- Section Acute Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands.
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