Identifying the Sickest During Triage: Using Point-of-Care Severity Scores to Predict Prognosis in Emergency Department Patients With Suspected Sepsis

Early warning scores for sepsis identification and prediction of in-hospital mortality in adults with sepsis: A systematic review and meta-analysis

AIM

The early warning scores (EWS), quick Sequential Organ Failure Assessment (qSOFA) and systemic inflammatory response syndrome (SIRS) criteria have been proposed as sepsis screening tools. This review aims to summarise and compare the performance of EWS with the qSOFA and SIRS criteria for predicting sepsis diagnosis and in-hospital mortality in patients with sepsis.

DESIGN

A systematic review with meta-analysis.

REVIEW METHODS

Seven databases were searched from January 1, 2016 until March 10, 2022. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Sensitivity, specificity, likelihood ratios and diagnostic odd ratios were pooled by using the bivariate random effects model. Overall performance was summarised by using the hierarchical summary receiver-operating characteristics curve. This paper adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines.

RESULTS

Ten studies involving 52,474 subjects were included in the review. For predicting sepsis diagnosis, the pooled sensitivity of EWS (65%, 95% CI: 55, 75) was similar to SIRS ≥2 (70%, 95% CI: 49, 85) and higher than qSOFA ≥2 (37%, 95% CI: 20, 59). The pooled specificity of EWS (77%, 95% CI: 64, 86) was higher than SIRS ≥2 (62%, 95% CI: 41, 80) but lower than qSOFA ≥2 (94%, 95% CI: 86, 98). Results were similar for the secondary outcome of in-hospital mortality.

CONCLUSIONS

Although no one scoring system had both high sensitivity and specificity, the EWS had at least equivalent values in most measures of diagnostic accuracy compared with SIRS or qSOFA.

IMPLICATIONS FOR THE PROFESSION

Healthcare systems in which EWS is already in place should consider whether there is any clinical benefit in adopting qSOFA or SIRS.

NO PATIENT OR PUBLIC CONTRIBUTION

This systematic review did not directly involve patient or public contribution to the manuscript.

Comparing 11 early warning scores and three shock indices in early sepsis prediction in the emergency department

BACKGROUND

This study aimed to evaluate the discriminatory performance of 11 vital sign-based early warning scores (EWSs) and three shock indices in early sepsis prediction in the emergency department (ED).

METHODS

We performed a retrospective study on consecutive adult patients with an infection over 3 months in a public ED in Hong Kong. The primary outcome was sepsis (Sepsis-3 definition) within 48 h of ED presentation. Using c-statistics and the DeLong test, we compared 11 EWSs, including the National Early Warning Score 2 (NEWS2), Modified Early Warning Score, and Worthing Physiological Scoring System (WPS), etc., and three shock indices (the shock index [SI], modified shock index [MSI], and diastolic shock index [DSI]), with Systemic Inflammatory Response Syndrome (SIRS) and quick Sequential Organ Failure Assessment (qSOFA) in predicting the primary outcome, intensive care unit admission, and mortality at different time points.

RESULTS

We analyzed 601 patients, of whom 166 (27.6%) developed sepsis. NEWS2 had the highest point estimate (area under the receiver operating characteristic curve [AUROC] 0.75, 95%CI 0.70-0.79) and was significantly better than SIRS, qSOFA, other EWSs and shock indices, except WPS, at predicting the primary outcome. However, the pooled sensitivity and specificity of NEWS2 ≥ 5 for the prediction of sepsis were 0.45 (95%CI 0.37-0.52) and 0.88 (95%CI 0.85-0.91), respectively. The discriminatory performance of all EWSs and shock indices declined when used to predict mortality at a more remote time point.

CONCLUSION

NEWS2 compared favorably with other EWSs and shock indices in early sepsis prediction but its low sensitivity at the usual cut-off point requires further modification for sepsis screening.

Performance of point-of-care severity scores to predict prognosis in patients admitted through the emergency department with COVID-19

BACKGROUND

Identifying COVID-19 patients at the highest risk of poor outcomes is critical in emergency department (ED) presentation. Sepsis risk stratification scores can be calculated quickly for COVID-19 patients but have not been evaluated in a large cohort.

OBJECTIVE

To determine whether well-known risk scores can predict poor outcomes among hospitalized COVID-19 patients.

DESIGNS, SETTINGS, AND PARTICIPANTS

A retrospective cohort study of adults presenting with COVID-19 to 156 Hospital Corporation of America (HCA) Healthcare EDs, March 2, 2020, to February 11, 2021.

INTERVENTION

Quick Sequential Organ Failure Assessment (qSOFA), Shock Index, National Early Warning System-2 (NEWS2), and quick COVID-19 Severity Index (qCSI) at presentation.

MAIN OUTCOME AND MEASURES

The primary outcome was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) admission, mechanical ventilation, and vasopressors receipt. Patients scored positive with qSOFA ≥ 2, Shock Index > 0.7, NEWS2 ≥ 5, and qCSI ≥ 4. Test characteristics and area under the receiver operating characteristics curves (AUROCs) were calculated.

RESULTS

We identified 90,376 patients with community-acquired COVID-19 (mean age 64.3 years, 46.8% female). 17.2% of patients died in-hospital, 28.6% went to the ICU, 13.7% received mechanical ventilation, and 13.6% received vasopressors. There were 3.8% qSOFA-positive, 45.1% Shock Index-positive, 49.8% NEWS2-positive, and 37.6% qCSI-positive at ED-triage. NEWS2 exhibited the highest AUROC for in-hospital mortality (0.593, confidence interval [CI]: 0.588-0.597), ICU admission (0.602, CI: 0.599-0.606), mechanical ventilation (0.614, CI: 0.610-0.619), and vasopressor receipt (0.600, CI: 0.595-0.604).

CONCLUSIONS

Sepsis severity scores at presentation have low discriminative power to predict outcomes in COVID-19 patients and are not reliable for clinical use. Severity scores should be developed using features that accurately predict poor outcomes among COVID-19 patients to develop more effective risk-based triage.

The accuracy of the National Early Warning Score 2 in predicting early death in prehospital and emergency department settings: a systematic review and meta-analysis

Background

Many studies have explored the accuracy of the National Early Warning Score 2 (NEWS2) in predicting mortality in prehospital and emergency settings, but their findings are inconsistent. Whether NEWS2 is reliable for the pre-examination and triage of patients in prehospital settings and emergency departments remains debatable. Hence, this study aimed to evaluate the accuracy of NEWS2 in predicting mortality in prehospital settings and emergency departments.

Methods

We searched PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wan Fang Data, Vip Database and SinoMed from the inception of each database to January 2023. The inclusion criteria: (I) patients in the prehospital settings or emergency departments; (II) the NEWS2 for predicting 2-day mortality, 30-day mortality, and in-hospital mortality; (III) sufficient data, such as sensitivity, specificity, overall survival, and deaths, were provided for the study; (IV) the type of study was accuracy prediction study. Two authors independently extracted data, including authors, year of publication, country of origin, study design, sample size, threshold cutoff values of NEWS2, and mortality. The PROBAST was used to assess the risk of bias in the included studies.

Results

Thirty studies with 185,835 participants were included. Among the 30 included studies, 13 have a high risk of bias, and 17 have a low risk of bias. The pooled sensitivity, specificity and AUC of 2-day mortality (early mortality), 30-day mortality and in-hospital mortality were 0.81 vs. 0.76 vs. 0.72 (95% CI: 0.61, 0.80), 0.81 vs. 0.69 vs. 0.78 (95% CI: 0.49, 0.93) and 0.88 vs. 0.80 vs. 0.78 (95% CI: 0.74, 0.82), respectively.

Conclusions

NEWS2 has excellent sensitivity and specificity in predicting early mortality in patients in the prehospitals setting and emergency departments. Nonetheless, it has poor performance in predicting in-hospital mortality and 30-day mortality. Our findings underpin the use of NEWS2 as a pre-examination and triage tool to predict early death in the prehospital settings and emergency departments. To improve the predictive accuracy, it should be used to monitor patients continuously rather than at a single point-in-time.

Eine Querschnittsuntersuchung zur Qualität der Sauerstofftherapie in drei deutschen Krankenhäusern

Einleitung Sauerstoff (O2) ist eines der am häufigsten angewendeten Arzneimittel in deutschen Krankenhäusern und im Rettungswesen. Sowohl eine Hypoxämie als auch eine Hyperoxämie sind mit Komplikationen vergesellschaftet. In Deutschland fehlen bislang belastbare Daten zur Anwendung, Dokumentation und Überwachung der O2-Therapie.

Methoden Eine Querschnittsstudie zur Sauerstoff-Anwendung wurde in 3 Krankenhäusern der maximalen bzw. supramaximalen Versorgung in Hannover im Herbst 2020 durchgeführt.

Ergebnisse Von 343 erfassten Patienten erhielten 20 % eine O2-Therapie. Bei 29 % der Patienten mit O2-Therapie bestand ein Hyperkapnie-Risiko. Lediglich bei 68 % Patienten mit einer O2-Therapie lag eine SOP zur O2-Anwendung auf den jeweiligen Stationen vor und nur bei 22 % entsprach die gegebene O2-Therapie dem tatsächlichen Bedarf des Patienten. Nur bei 30 % des Gesamtkollektivs und 41 % der Patienten mit O2-Therapie erfolgte eine vollständige Dokumentation der Vitalparameter. Eine Überwachung der O2-Therapie mittels arterieller oder kapillärer Blutgasanalyse (BGA) erfolgte bei 76 % der O2-Patienten. Hier zeigte sich bei 64 % der Patienten eine Normoxämie, bei 17 % eine Hyperoxämie und bei 19 % eine Hypoxämie. Der einzige identifizierbare Prediktor für eine adäquate O2-Therapie war eine vorangegangene Beatmungstherapie.

Diskussion Insgesamt zeigt sich eine suboptimale Indikationsstellung, Anwendung und Kontrolle der Sauerstofftherapie. Schulungen des pflegerischen und ärztlichen Personals zur Verbesserung der Anwendung der O2-Therapie und resultierend auch der Patientensicherheit sind dringend notwendig.

[A cross-sectional study in three German hospitals regarding oxygen therapy characteristics]

Einleitung  Sauerstoff (O2) ist eines der am häufigsten angewendeten Arzneimittel in deutschen Krankenhäusern und im Rettungswesen. Sowohl eine Hypoxämie als auch eine Hyperoxämie sind mit Komplikationen vergesellschaftet. In Deutschland fehlen bislang belastbare Daten zur Anwendung, Dokumentation und Überwachung der O2-Therapie.

Methoden  Eine Querschnittsstudie zur Sauerstoff-Anwendung wurde in 3 Krankenhäusern der maximalen bzw. supramaximalen Versorgung in Hannover im Herbst 2020 durchgeführt.

Ergebnisse  Von 343 erfassten Patienten erhielten 20 % eine O2-Therapie. Bei 29 % der Patienten mit O2-Therapie bestand ein Hyperkapnie-Risiko. Lediglich bei 68 % Patienten mit einer O2-Therapie lag eine SOP zur O2-Anwendung auf den jeweiligen Stationen vor und nur bei 22 % entsprach die gegebene O2-Therapie dem tatsächlichen Bedarf des Patienten. Nur bei 30 % des Gesamtkollektivs und 41 % der Patienten mit O2-Therapie erfolgte eine vollständige Dokumentation der Vitalparameter. Eine Überwachung der O2-Therapie mittels arterieller oder kapillärer Blutgasanalyse (BGA) erfolgte bei 76 % der O2-Patienten. Hier zeigte sich bei 64 % der Patienten eine Normoxämie, bei 17 % eine Hyperoxämie und bei 19 % eine Hypoxämie. Der einzige identifizierbare Prediktor für eine adäquate O2-Therapie war eine vorangegangene Beatmungstherapie.

Diskussion  Insgesamt zeigt sich eine suboptimale Indikationsstellung, Anwendung und Kontrolle der Sauerstofftherapie. Schulungen des pflegerischen und ärztlichen Personals zur Verbesserung der Anwendung der O2-Therapie und resultierend auch der Patientensicherheit sind dringend notwendig.

A comparison of qSOFA, SIRS and NEWS in predicting the accuracy of mortality in patients with suspected sepsis: A meta-analysis

Objective

To identify and compare prognostic accuracy of quick Sequential Organ Failure Assessment (qSOFA) score, Systemic Inflammatory Response Syndrome (SIRS) criteria, and National Early Warning Score (NEWS) to predict mortality in patients with suspected sepsis.

Methods

This meta-analysis followed accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We searched PubMed, EMBASE, Web of Science, and the Cochrane Library databases from establishment of the database to November 29, 2021. The pooled sensitivity and specificity with 95% CIs were calculated using a bivariate random-effects model (BRM). Hierarchical summary receiver operating characteristic (HSROC) curves were generated to assess the overall prognostic accuracy.

Results

Data of 62338 patients from 26 studies were included in this meta-analysis. qSOFA had the highest specificity and the lowest sensitivity with a specificity of 0.82 (95% CI: 0.76–0.86) and a sensitivity of 0.46 (95% CI: 0.39–0.53). SIRS had the highest sensitivity and the lowest specificity with a sensitivity of 0.82 (95% CI: 0.78–0.85) and a specificity 0.24 (95% CI: 0.19–0.29). NEWS had both an intermediate sensitivity and specificity with a sensitivity of 0.73 (95% CI: 0.63–0.81) and a specificity 0.52 (95% CI: 0.39–0.65). qSOFA showed higher overall prognostic accuracy than SIRS and NEWS by comparing HSROC curves.

Conclusions

Among qSOFA, SIRS and NEWS, qSOFA showed higher overall prognostic accuracy than SIRS and NEWS. However, no scoring system has both high sensitivity and specificity for predicting the accuracy of mortality in patients with suspected sepsis.