“NEWS2” as an Objective Assessment of Hospitalised COPD Exacerbation Severity

Prognostic value of early warning scores in patients presenting to the emergency department with exacerbation of COPD

OBJECTIVE

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a condition that frequently presents to the emergency department (ED) and its prognosis is not very well understood. Risk tools that can be used rapidly in the ED are needed to predict the prognosis of these patients.

METHODS

This study comprised a retrospective cohort of AECOPD patients presenting to a single center between 2015 and 2022. The prognostic accuracy of several clinical early warning scoring systems, Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), NEWS‑2, Systemic Inflammatory Response Syndrome (SIRS) and the quick Sepsis-related Organ Failure Assessment (qSOFA), were compared. The outcome variable was determined as one-month mortality.

RESULTS

Of the 598 patients, 63 (10.5%) had died within 1 month after presenting to the ED. Patients who died had more often congestive heart failure, altered mental status, and admission to intensive care, and they were older. Although the MEWS, NEWS, NEWS‑2, and qSOFA scores of those who died were higher than those who survived, there was no difference between the SIRS scores of these two groups. The score with the highest positive likelihood ratio for mortality estimation was qSOFA (8.5, 95% confidence interval [CI] 3.7-19.6). The negative likelihood ratios of the scores were similar, the NEWS score had a negative likelihood ratio of 0.4 (95% CI 0.2-0.8) with the highest negative predictive value of 96.0%.

CONCLUSION

In AECOPD patients, most of the early warning scores that are frequently used in the ED were found to have a moderate ability to exclude mortality and a low ability to predict mortality.

Performance of risk scores in patients with acute exacerbations of COPD

OBJECTIVE

Acute exacerbations of COPD (AECOPD) are common causes of hospitalization. Various scoring systems have been proposed to classify the risk of clinical deterioration or mortality in hospitalized patients with AECOPD. We sought to investigate whether clinical deterioration and mortality scores at admission can predict adverse events occurring during hospitalization and after discharge of patients with AECOPD.

METHODS

We performed a retrospective study of patients admitted with AECOPD. The National Early Warning Score 2 (NEWS2), the NEWS288-92%, the Dyspnea, Eosinopenia, Consolidation, Acidemia, and atrial Fibrillation (DECAF) score, and the modified DECAF (mDECAF) score were calculated at admission. We assessed the sensitivity, specificity, and overall performance of the scores for the following outcomes: in-hospital mortality; need for invasive mechanical ventilation or noninvasive ventilation (NIV); long hospital stays; hospital readmissions; and future AECOPD.

RESULTS

We included 119 patients admitted with AECOPD. The median age was 75 years, and 87.9% were male. The NEWS288-92% was associated with an 8.9% reduction in the number of individuals classified as requiring close, continuous observation, without an increased risk of death in the group of individuals classified as being low-risk patients. The NEWS288-92% and NEWS2 scores were found to be adequate in predicting the need for acute NIV and longer hospital stays. The DECAF and mDECAF scores were found to be better at predicting in-hospital mortality than the NEWS2 and NEWS288-92%.

CONCLUSIONS

The NEWS288-92% safely reduces the need for clinical monitoring in patients with AECOPD when compared with the NEWS2. The NEWS2 and NEWS288-92% appear to be good predictors of the length of hospital stay and need for NIV, but they do not replace the DECAF and mDECAF scores as predictors of mortality.

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.

NEWS2, patient safety and hypercapnic respiratory failure

The National Early Warning Score (NEWS) has been widely adopted for use in clinical practice in the UK since its introduction in 2012. It is designed to improve patient safety. The original score was adapted in 2017 to improve patient safety further by introducing a separate score for oxygen saturation to be used in selected patients with respiratory diseases. In this article, evidence for the effectiveness of the improved score is reviewed.

The predictive value of modified risk scores in patients with acute exacerbation of COPD: a retrospective cohort study

This study aims to evaluate the performance of CREWS (Chronic Respiratory Early Warning Score), S-NEWS (Salford-National Early Warning Score), qNEWS (Quick National Early Warning Score), NEWS (National Early Warning Score), and qSOFA (Quick Sequential Organ Failure Assessment) scores in predicting mortality, intensive care unit (ICU) admission and the need for mechanical ventilation (MV) of patients presented with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). This retrospective cohort study was conducted in the emergency department of a tertiary hospital between January 1 and December 31, 2019. The patients with AECOPD and aged ≥ 18 were included. Patients who were transferred from another center and whose data could not be reached were excluded. Demographic information, comorbid diseases, variables of the scores, laboratory results, and outcomes were recorded. A total of 575 consecutive patients were included. The 30-day mortality, ICU admission, and MV need rate were 5.7% (n = 33), 9.6% (n = 55), and 13.7% (n = 79), respectively. Each score had moderate-to-excellent performance in predicting MV need and ICU admission, while their performance in predicting mortality was poor. CREWS is the most successful score in predicting 30-day mortality (AUC 0.695), ICU admission (AUC 0.841), and MV need (AUC 0.924). ICU admission, age, and creatinine levels were associated with mortality (p < 0.05). All scores have better performance in predicting ICU admission and MV need than mortality. ICU admission, age, and creatinine levels may be the predictors of mortality among AECOPD patients.