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Chua WL, Rusli KDB, Aitken LM. Early warning scores for sepsis identification and prediction of in-hospital mortality in adults with sepsis: A systematic review and meta-analysis. J Clin Nurs 2024; 33:2005-2018. [PMID: 38379353 DOI: 10.1111/jocn.17061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 01/04/2024] [Accepted: 01/23/2024] [Indexed: 02/22/2024]
Abstract
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.
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Affiliation(s)
- Wei Ling Chua
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Khairul Dzakirin Bin Rusli
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Leanne M Aitken
- School of Health & Psychological Sciences, City University of London, London, UK
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Woolfe Loftus N, Navales V, Bowden T. Using the NEWS2 and ABCDE assessment to identify early signs of clinical deterioration. Nurs Stand 2024; 39:40-45. [PMID: 38523526 DOI: 10.7748/ns.2024.e12188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 03/26/2024]
Abstract
Nurses may encounter deteriorating patients in their clinical practice, so they require an understanding of the early physiological signs of deterioration and a structured approach to patient assessment. This enables appropriate management and a timely response to the most life-threatening issues identified, such as a compromised airway. This article describes how nurses can use early warning scores and a structured patient assessment, using the ABCDE (airway, breathing, circulation, disability, exposure) framework, to identify early signs of deterioration and facilitate the timely escalation of patient care where necessary.
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Affiliation(s)
- Nicholas Woolfe Loftus
- Adult Critical Care Unit, St Bartholomew's Hospital, London, and NIHR predoctoral clinical academic fellow, City, University of London, London, England
| | - Vanna Navales
- Adult Critical Care Unit, St Bartholomew's Hospital, London, England
| | - Tracey Bowden
- School of Health and Psychosocial Sciences, City, University of London, London, England
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Commotio S, Leister N, Menzel C, Ulrichs C, Wetsch WA, Emmel M, Trieschmann U. Evaluation of a modified paediatric early warning score for children with congenital heart disease. Cardiol Young 2024; 34:637-642. [PMID: 37694525 DOI: 10.1017/s1047951123003189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
BACKGROUND Paediatric early warning score systems are used for early detection of clinical deterioration of patients in paediatric wards. Several paediatric early warning scores have been developed, but most of them are not suitable for children with cyanotic CHD who are adapted to lower arterial oxygen saturation. AIM The present study compared the original paediatric early warning system of the Royal College of Physicians of Ireland with a modification for children with cyanotic CHD. DESIGN Retrospective single-centre study in a paediatric cardiology intermediate care unit at a German university hospital. RESULTS The distribution of recorded values showed a significant shift towards higher score values in patients with cyanotic CHD (p < 0.001) using the original score, but not with the modification. An analysis of sensitivity and specificity for the factor "requirement of action" showed an area under the receiver operating characteristic for non-cyanotic patients of 0.908 (95% CI 0.862-0.954). For patients with cyanotic CHD, using the original score, the area under the receiver operating characteristic was reduced to 0.731 (95% CI 0.637-0.824, p = 0.001) compared to 0.862 (95% CI 0.809-0.915, p = 0.207), when the modified score was used. Using the critical threshold of scores ≥ 4 in patients with cyanotic CHD, sensitivity and specificity for the modified score was higher than for the original (sensitivity 78.8 versus 72.7%, specificity 78.2 versus 58.4%). CONCLUSION The modified score is a uniform scoring system for identifying clinical deterioration, which can be used in children with and without cyanotic CHD.
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Affiliation(s)
- Simone Commotio
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Cologne, Cologne, Germany
| | - Nicolas Leister
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Cologne, Cologne, Germany
| | - Christoph Menzel
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Cologne, Cologne, Germany
| | - Christoph Ulrichs
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Cologne, Cologne, Germany
| | - Wolfgang A Wetsch
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Cologne, Cologne, Germany
| | - Mathias Emmel
- Department of Paediatric Cardiology, Heart Center, University Hospital Cologne, Cologne, Germany
| | - Uwe Trieschmann
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Cologne, Cologne, Germany
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Doğan NÖ, Özturan İU, Pekdemir M, Yaka E, Yılmaz S. Prognostic value of early warning scores in patients presenting to the emergency department with exacerbation of COPD. Med Klin Intensivmed Notfmed 2024; 119:129-135. [PMID: 37401954 DOI: 10.1007/s00063-023-01036-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 05/24/2023] [Accepted: 06/03/2023] [Indexed: 07/05/2023]
Abstract
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.
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Affiliation(s)
- Nurettin Özgür Doğan
- Faculty of Medicine, Dept. of Emergency Medicine, Kocaeli University, Kocaeli, Turkey.
| | - İbrahim Ulaş Özturan
- Faculty of Medicine, Dept. of Emergency Medicine, Kocaeli University, Kocaeli, Turkey
| | - Murat Pekdemir
- Faculty of Medicine, Dept. of Emergency Medicine, Kocaeli University, Kocaeli, Turkey
| | - Elif Yaka
- Faculty of Medicine, Dept. of Emergency Medicine, Kocaeli University, Kocaeli, Turkey
| | - Serkan Yılmaz
- Faculty of Medicine, Dept. of Emergency Medicine, Kocaeli University, Kocaeli, Turkey
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Bamkole O, Huysentruyt K, Watson J, De Mulder N, Katsagoni CN, Chaloutsi D, Kontostavlou M, Pancheva R, Vladimirova I, Gerasimidis K. Clinical performance of the infant nutrition early warning score in routine practice across four international clinical settings in Europe: A study by the ESPGHAN special interest group in clinical malnutrition. J Pediatr Gastroenterol Nutr 2024; 78:704-710. [PMID: 38314914 DOI: 10.1002/jpn3.12123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/19/2023] [Accepted: 01/02/2024] [Indexed: 02/07/2024]
Abstract
There is a scarcity of nutritional screening tools for use in infants (<1 year). The infant Nutrition Early Warning Score (iNEWS) has been developed to identify infants who need further dietetic review. We introduced the iNEWS into clinical practice and evaluated its performance in Scotland, Belgium, Athens and Bulgaria. Of the 352 infants screened, 72 (20%) were placed in the high iNEWS category, and of these, 70 (97%) were reviewed by a hospital dietitian. iNEWS produced a true positive rate of 80% which increased to 96% after accounting for anticipated misclassified cases due to prematurity. In Belgium, false positive screens had a shorter length of stay (p = 0.014). Otherwise, misclassification was not related to a specific iNEWS component. This study corroborates previous research, underscoring the validity of iNEWS as a dietetic referral tool and demonstrating that it can be integrated into "real-world" clinical practice across international settings with diverse healthcare resources.
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Affiliation(s)
- Omowunmi Bamkole
- Human Nutrition, School of Medicine, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
| | - Koen Huysentruyt
- Department of Paediatric Gastroenterology, KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | | | - Nele De Mulder
- Department of Paediatric Gastroenterology, KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | | | - Despoina Chaloutsi
- Department of Clinical Nutrition, Agia Sofia Children's Hospital, Athens, Greece
| | | | - Rouzha Pancheva
- Department of Hygiene and Epidemiology, Faculty of Public health, Medical University Prof Dr Paraskev Stoyanov, Varna, Bulgaria
| | - Irina Vladimirova
- Department of Hygiene and Epidemiology, Faculty of Public health, Medical University Prof Dr Paraskev Stoyanov, Varna, Bulgaria
| | - Konstantinos Gerasimidis
- Human Nutrition, School of Medicine, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
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Le Lagadec MD, Flenady T, Cleary M. Finally, a new Early Warning Score supporting critical thinking. J Adv Nurs 2024; 80:1241-1242. [PMID: 38018021 DOI: 10.1111/jan.16001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/19/2023] [Indexed: 11/30/2023]
Affiliation(s)
| | - Tracy Flenady
- School of Nursing Midwifery and Social Sciences, CQUniversity, Rockhampton, Queensland, Australia
| | - Michelle Cleary
- School of Nursing Midwifery and Social Sciences, CQUniversity, Rockhampton, Queensland, Australia
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Goodacre S, Sutton L, Ennis K, Thomas B, Hawksworth O, Iftikhar K, Croft SJ, Fuller G, Waterhouse S, Hind D, Stevenson M, Bradburn MJ, Smyth M, Perkins GD, Millins M, Rosser A, Dickson J, Wilson M. Prehospital early warning scores for adults with suspected sepsis: the PHEWS observational cohort and decision-analytic modelling study. Health Technol Assess 2024; 28:1-93. [PMID: 38551135 PMCID: PMC11017155 DOI: 10.3310/ndty2403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024] Open
Abstract
Background Guidelines for sepsis recommend treating those at highest risk within 1 hour. The emergency care system can only achieve this if sepsis is recognised and prioritised. Ambulance services can use prehospital early warning scores alongside paramedic diagnostic impression to prioritise patients for treatment or early assessment in the emergency department. Objectives To determine the accuracy, impact and cost-effectiveness of using early warning scores alongside paramedic diagnostic impression to identify sepsis requiring urgent treatment. Design Retrospective diagnostic cohort study and decision-analytic modelling of operational consequences and cost-effectiveness. Setting Two ambulance services and four acute hospitals in England. Participants Adults transported to hospital by emergency ambulance, excluding episodes with injury, mental health problems, cardiac arrest, direct transfer to specialist services, or no vital signs recorded. Interventions Twenty-one early warning scores used alongside paramedic diagnostic impression, categorised as sepsis, infection, non-specific presentation, or other specific presentation. Main outcome measures Proportion of cases prioritised at the four hospitals; diagnostic accuracy for the sepsis-3 definition of sepsis and receiving urgent treatment (primary reference standard); daily number of cases with and without sepsis prioritised at a large and a small hospital; the minimum treatment effect associated with prioritisation at which each strategy would be cost-effective, compared to no prioritisation, assuming willingness to pay £20,000 per quality-adjusted life-year gained. Results Data from 95,022 episodes involving 71,204 patients across four hospitals showed that most early warning scores operating at their pre-specified thresholds would prioritise more than 10% of cases when applied to non-specific attendances or all attendances. Data from 12,870 episodes at one hospital identified 348 (2.7%) with the primary reference standard. The National Early Warning Score, version 2 (NEWS2), had the highest area under the receiver operating characteristic curve when applied only to patients with a paramedic diagnostic impression of sepsis or infection (0.756, 95% confidence interval 0.729 to 0.783) or sepsis alone (0.655, 95% confidence interval 0.63 to 0.68). None of the strategies provided high sensitivity (> 0.8) with acceptable positive predictive value (> 0.15). NEWS2 provided combinations of sensitivity and specificity that were similar or superior to all other early warning scores. Applying NEWS2 to paramedic diagnostic impression of sepsis or infection with thresholds of > 4, > 6 and > 8 respectively provided sensitivities and positive predictive values (95% confidence interval) of 0.522 (0.469 to 0.574) and 0.216 (0.189 to 0.245), 0.447 (0.395 to 0.499) and 0.274 (0.239 to 0.313), and 0.314 (0.268 to 0.365) and 0.333 (confidence interval 0.284 to 0.386). The mortality relative risk reduction from prioritisation at which each strategy would be cost-effective exceeded 0.975 for all strategies analysed. Limitations We estimated accuracy using a sample of older patients at one hospital. Reliable evidence was not available to estimate the effectiveness of prioritisation in the decision-analytic modelling. Conclusions No strategy is ideal but using NEWS2, in patients with a paramedic diagnostic impression of infection or sepsis could identify one-third to half of sepsis cases without prioritising unmanageable numbers. No other score provided clearly superior accuracy to NEWS2. Research is needed to develop better definition, diagnosis and treatments for sepsis. Study registration This study is registered as Research Registry (reference: researchregistry5268). Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/136/10) and is published in full in Health Technology Assessment; Vol. 28, No. 16. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
- Emergency Department, Northern General Hospital, Sheffield, UK
| | - Laura Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Kate Ennis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ben Thomas
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Olivia Hawksworth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Susan J Croft
- Emergency Department, Northern General Hospital, Sheffield, UK
| | - Gordon Fuller
- Emergency Department, Northern General Hospital, Sheffield, UK
| | - Simon Waterhouse
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Hind
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mike J Bradburn
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Michael Smyth
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Mark Millins
- Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Andy Rosser
- West Midlands Ambulance Service University NHS Foundation Trust, Midlands, UK
| | - Jon Dickson
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
| | - Matthew Wilson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Castro Villamor MA, Alonso-Sanz M, López-Izquierdo R, Delgado Benito JF, Del Pozo Vegas C, López Torres S, Soriano JB, Martín-Conty JL, Sanz-García A, Martín-Rodríguez F. Comparison of eight prehospital early warning scores in life-threatening acute respiratory distress: a prospective, observational, multicentre, ambulance-based, external validation study. Lancet Digit Health 2024; 6:e166-e175. [PMID: 38395538 DOI: 10.1016/s2589-7500(23)00243-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 09/26/2023] [Accepted: 11/22/2023] [Indexed: 02/25/2024]
Abstract
BACKGROUND A myriad of early warning scores (EWSs) exist, yet there is a need to identify the most clinically valid score to be used in prehospital respiratory assessments to estimate short-term and midterm mortality, intensive-care unit admission, and airway management in life-threatening acute respiratory distress. METHODS This is a prospective, observational, multicentre, ambulance-based, external validation study performed in 44 ambulance services and four hospitals across three Spanish provinces (ie, Salamanca, Segovia, and Valladolid). We identified adults (ie, those aged 18 years and older) discharged to the emergency department with suspected acute respiratory distress. The primary outcome was 2-day all-cause in-hospital mortality, for all the patients or according to prehospital respiratory conditions, including dyspnoea, chronic obstructive pulmonary disease (COPD), COVID-19, other infections, and other conditions (asthma exacerbation, haemoptysis, and bronchoaspirations). 30-day mortality, intensive-care unit admission, and invasive and non-invasive mechanical ventilation were secondary outcomes. Eight EWSs, namely, the National Early Warning Score 2, the Modified Rapid Emergency Medicine Score, the Rapid Acute Physiology Score, the Quick Sequential Organ Failure Assessment Score, the CURB-65 Severity Score for Community-Acquired Pneumonia, the BAP-65 Score for Acute Exacerbation of COPD, the Quick COVID-19 Severity Index, and the Modified Sequential Organ Failure Assessment (mSOFA), were explored to determine their predictive validity through calibration, clinical net benefit as determined through decision curve analysis, and discrimination analysis (area under the curve of the receiver operating characteristic [AUROC], compared with Delong's test). FINDINGS Between Jan 1, 2020, and Nov 31, 2022, 902 patients were enrolled. The global 2-day mortality rate was 87 (10%); in proportion to various respiratory conditions, the rates were 35 (40%) for dyspnoea, nine (10%) for COPD, 13 (15%) for COVID-19, 28 (32%) for other infections, and two (2%) for others conditions. mSOFA showed the best calibration, a higher net benefit, and the best discrimination (AUROC 0·911, 95% CI 0·86-0·95) for predicting 2-day mortality, and its discrimination was statistically significantly more accurate (p<0·0001) compared with the other scores. The performance of mSOFA for predicting 2-day mortality was higher than the other scores when considering the prehospital respiratory conditions, and was also higher for the secondary outcomes, except for non-invasive mechanical ventilation. INTERPRETATION Our results showed that mSOFA outperformed other EWSs. The inclusion of mSOFA in prehospital decision making will entail a quick identification of patients in acute respiratory distress at high risk of deterioration, allowing prioritisation of resources and patient care. FUNDING Gerencia Regional de Salud, Public Health System of Castilla y León (GRS Spain). TRANSLATION For the Spanish translation of the abstract see Supplementary Materials section.
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Affiliation(s)
| | | | - Raúl López-Izquierdo
- Faculty of Medicine, Universidad de Valladolid, Valladolid, Spain; Emergency Department, Hospital Universitario Rio Hortega, Valladolid, Spain; Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | | | - Carlos Del Pozo Vegas
- Faculty of Medicine, Universidad de Valladolid, Valladolid, Spain; Emergency Department, Hospital Clínico Universitario, Valladolid, Spain
| | - Santiago López Torres
- Servicio de Asistencia Municipal de Urgencia y Rescate (SAMUR-Protección Civil), Ayuntamiento de Madrid, Madrid, Spain
| | - Joan B Soriano
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain; Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain; Servicio de Neumología, Hospital Universitario de La Princesa, Madrid, Spain
| | - José L Martín-Conty
- Technological Innovation Applied to Health Research Group (ITAS), Faculty of Health Sciences, Universidad de Castilla la Mancha, Talavera de la Reina, Spain
| | - Ancor Sanz-García
- Technological Innovation Applied to Health Research Group (ITAS), Faculty of Health Sciences, Universidad de Castilla la Mancha, Talavera de la Reina, Spain.
| | - Francisco Martín-Rodríguez
- Faculty of Medicine, Universidad de Valladolid, Valladolid, Spain; Advanced Life Support, Emergency Medical Services (SACYL), Valladolid, Spain
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Küçükceran K, Ayrancı MK, Koçak S, Girişgin AS, Dündar ZD, Ataman S, Bayındır E, Karaçadır O, Tatar İ, Doğru M. An Evaluation of the National Early Warning Score 2 and the Laboratory Data Decision Tree Early Warning Score in Predicting Mortality in Geriatric Patients. J Emerg Med 2024; 66:e284-e292. [PMID: 38278676 DOI: 10.1016/j.jemermed.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/02/2023] [Accepted: 10/01/2023] [Indexed: 01/28/2024]
Abstract
BACKGROUND Due to the high rate of geriatric patient visits, scoring systems are needed to predict increasing mortality rates. OBJECTIVE In this study, we aimed to investigate the in-hospital mortality prediction power of the National Early Warning Score 2 (NEWS2) and the Laboratory Data Decision Tree Early Warning Score (LDT-EWS), which consists of frequently performed laboratory parameters. METHODS We retrospectively analyzed 651 geriatric patients who visited the emergency department (ED), were not discharged on the same day from ED, and were hospitalized. The patients were categorized according to their in-hospital mortality status. The NEWS2 and LDT-EWS values of these patients were calculated and compared on the basis of deceased and living patients. RESULTS Median (interquartile range [IQR]) NEWS2 and LDT-EWS values of the 127 patients who died were found to be statistically significantly higher than those of the patients who survived (NEWS2: 5 [3-8] vs. 3 [1-5]; p < 0.001; LDT-EWS: 8 [7-10] vs. 6 [5-8]; p < 0.001). In the receiver operating characteristic curve analysis, the NEWS2, LDT-EWS, and NEWS2+LDT-EWS-formed by the sum of the two scoring systems-resulted in 0.717, 0.705, and 0.775 area under curve values, respectively. CONCLUSIONS The NEWS2 and LDT-EWS were found to be valuable for predicting in-hospital mortality in geriatric patients. The power of the NEWS2 to predict in-hospital mortality increased when used with the LDT-EWS.
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Affiliation(s)
- Kadir Küçükceran
- Emergency Department, Necmettin Erbakan University, Meram School of Medicine, Konya, Turkey
| | - Mustafa Kürşat Ayrancı
- Emergency Department, Necmettin Erbakan University, Meram School of Medicine, Konya, Turkey
| | - Sedat Koçak
- Emergency Department, Necmettin Erbakan University, Meram School of Medicine, Konya, Turkey
| | | | - Zerrin Defne Dündar
- Emergency Department, Necmettin Erbakan University, Meram School of Medicine, Konya, Turkey
| | - Sami Ataman
- Emergency Department, Necmettin Erbakan University, Meram School of Medicine, Konya, Turkey
| | - Enes Bayındır
- Emergency Department, Necmettin Erbakan University, Meram School of Medicine, Konya, Turkey
| | - Oğuz Karaçadır
- Emergency Department, Necmettin Erbakan University, Meram School of Medicine, Konya, Turkey
| | - İbrahim Tatar
- Emergency Department, Necmettin Erbakan University, Meram School of Medicine, Konya, Turkey
| | - Mustafa Doğru
- Emergency Department, Necmettin Erbakan University, Meram School of Medicine, Konya, Turkey
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10
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Stevens J, de Groot J, Luijmes M, Bouwens J, Rippen H, Hoogervorst-Schilp J, Fuijkschot J. Study protocol of a national multicentre prospective evaluation study assessing the validity and impact of the Dutch Paediatric Early Warning Score (PEWS) in the Netherlands. BMJ Paediatr Open 2024; 8:e002214. [PMID: 38325899 PMCID: PMC10860074 DOI: 10.1136/bmjpo-2023-002214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/21/2023] [Indexed: 02/09/2024] Open
Abstract
INTRODUCTION Early recognition of clinical deterioration and timely intervention are important to improve morbidity and mortality in paediatric care. The Paediatric Early Warning Score (PEWS) is a scoring system aiming to identify hospitalised children at risk for deterioration. Currently, there is a large heterogeneity of PEWS systems in the Netherlands, with a considerable number remaining unvalidated or self-designed. Therefore, a consensus-based Dutch PEWS has been developed in a national study using the Core Outcome Measures in Effectiveness Trials initiative. The Dutch PEWS is a uniform system that integrates a core set of vital parameters together with pre-existing risk factors and uses risk stratification to proactively follow-up on patients at risk (so-called 'watcher patients'). This study aims to validate the Dutch PEWS and to determine its impact on improving patient safety in various hospital settings. METHODS AND ANALYSIS This national study will be a large multicentre evaluation study, in which the Dutch PEWS will be implemented and evaluated in 12 hospitals in the Netherlands. In this study, a mixed methods methodology will be used and evaluated on predefined outcome measures. To examine the validity of the Dutch PEWS, statistical analyses will be undertaken on quantitative data retrieved from electronic health records. Surveys among physicians and nurses; semistructured interviews with healthcare providers and parents; and daily evaluation forms are being conducted to determine the impact of the Dutch PEWS. The study is being conducted from December 2020 to June 2024.
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Affiliation(s)
- Jikke Stevens
- Pediatrics, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Janke de Groot
- Kennisinstituut van de Federatie Medisch Specialisten, Utrecht, The Netherlands
| | - Marie Luijmes
- Pediatrics, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Janneke Bouwens
- Pediatrics, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - Hester Rippen
- Stichting Kind En Ziekenhuis, Utrecht, The Netherlands
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Akarca M, Ozturk TC, Patan T, Dogan FS, Akoglu EU. Comparison of Early Warning Scores in Determining the Prognosis of COVID-19 Patients. J Coll Physicians Surg Pak 2024; 34:166-171. [PMID: 38342866 DOI: 10.29271/jcpsp.2024.02.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 01/18/2024] [Indexed: 02/13/2024]
Abstract
OBJECTIVE To compare the effectiveness of early warning score systems in predicting 30-day poor outcomes in Coronavirus Disease (COVID-19) patients admitted to the emergency department. STUDY DESIGN Descriptive study. Place and and Duration of the Study: Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkiye, from March 2020 to March 2021. METHODOLOGY The patients who presented to the emergency department, diagnosed with COVID-19 and tested positive for polymerase chain reaction were analysed. The study included the calculation of the rapid emergency medicine score, risk stratification in the emergency department in acutely ill older patients score, 4C mortality score, and modified early warning score for the patients. These scores were then compared in terms of their ability to predict adverse outcomes, defined as intensive care admission and/or mortality. RESULTS During the study period, 10,281 COVID-19 patients were admitted to the emergency department. Out of them, 1,826 patients were included in the study. There were 159 (8.7%) cases with poor outcomes. The risk stratification in the emergency department in acutely ill older patients Score was the most successful in poor prognosis. CONCLUSION Based on the findings of this study, the risk stratification in the emergency department in acutely ill older patients score demonstrated greater efficacy compared to other early warning scores in identifying patients diagnosed with COVID-19 who had an early indication of a poor prognosis. KEY WORDS Early warning score, 4C mortality score, REMS, Rise-up score, MEWS, Emergency department, COVID-19.
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Affiliation(s)
- Mustafa Akarca
- Emergency Medicine Department, Erbaa State Hospital, Tokat, Turkiye
- Emergency Medicine Department, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkiye
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Lam RPK, Hung KKC, Lui CT, Kwok WS, Lam WWT, Lau EHY, Sridhar S, Ng PYT, Cheng CH, Tsang TC, Tsui MSH, Graham CA, Rainer TH. Early sepsis care with the National Early Warning Score 2-guided Sepsis Hour-1 Bundle in the emergency department: hybrid type 1 effectiveness-implementation pilot stepped wedge randomised controlled trial (NEWS-1 TRIPS) protocol. BMJ Open 2024; 14:e080676. [PMID: 38307529 PMCID: PMC10836386 DOI: 10.1136/bmjopen-2023-080676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 01/24/2024] [Indexed: 02/04/2024] Open
Abstract
INTRODUCTION Early sepsis treatment in the emergency department (ED) is crucial to improve patient survival. Despite international promulgation, the uptake of the Surviving Sepsis Campaign (SSC) Hour-1 Bundle (lactate measurement, blood culture, broad-spectrum antibiotics, 30 mL/kg crystalloid for hypotension/lactate ≥4 mmol/L and vasopressors for hypotension during/after fluid resuscitation within 1 hour of sepsis recognition) is low across healthcare settings. Delays in sepsis recognition and a lack of high-quality evidence hinder its implementation. We propose a novel sepsis care model (National Early Warning Score, NEWS-1 care), in which the SSC Hour-1 Bundle is triggered objectively by a high NEWS-2 (≥5). This study aims to determine the feasibility of a full-scale type 1 hybrid effectiveness-implementation trial on the NEWS-1 care in multiple EDs. METHODS AND ANALYSIS We will conduct a pilot type 1 hybrid trial and prospectively recruit 200 patients from 4 public EDs in Hong Kong cluster randomised in a stepped wedge design over 10 months. All study sites will start with an initial period of standard care and switch in random order at 2-month intervals to the NEWS-1 care unidirectionally. The implementation evaluation will employ mixed methods guided by the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, which includes qualitative and quantitative data from focus group interviews, staff survey and clinical record reviews. We will analyse the 14 feasibility outcomes as progression criteria to a full-scale trial, including trial acceptability to patients and staff, patient and staff recruitment rates, accuracy of sepsis screening, protocol adherence, accessibility to follow-up data, safety and preliminary clinical impacts of the NEWS1 care, using descriptive statistics. ETHICS AND DISSEMINATION The institutional review boards of all study sites approved this study. This study will establish the feasibility of a full-scale hybrid trial. We will disseminate the findings through peer-reviewed publications, conference presentations and educational activities. TRIAL REGISTRATION NUMBER NCT05731349.
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Affiliation(s)
- Rex Pui Kin Lam
- Department of Emergency Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- Accident and Emergency Department, Queen Mary Hospital, Hospital Authority, Hong Kong, China
| | - Kevin Kei Ching Hung
- Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Hong Kong, China
- Accident and Emergency Department, Prince of Wales Hospital, Hospital Authority, Hong Kong, China
| | - Chun Tat Lui
- Accident and Emergency Department, Tuen Mun Hospital, Hospital Authority, Hong Kong, China
| | - Wai Shing Kwok
- Accident and Emergency Department, Pamela Youde Nethersole Eastern Hospital, Hospital Authority, Hong Kong, China
| | - Wendy Wing Tak Lam
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Eric Ho Yin Lau
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Siddharth Sridhar
- Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Peter Yau Tak Ng
- Accident and Emergency Department, Tuen Mun Hospital, Hospital Authority, Hong Kong, China
| | - Chi Hung Cheng
- Accident and Emergency Department, Prince of Wales Hospital, Hospital Authority, Hong Kong, China
| | - Tat Chi Tsang
- Accident and Emergency Department, Queen Mary Hospital, Hospital Authority, Hong Kong, China
| | - Matthew Sik Hon Tsui
- Accident and Emergency Department, Queen Mary Hospital, Hospital Authority, Hong Kong, China
| | - Colin Alexander Graham
- Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Hong Kong, China
- Accident and Emergency Department, Prince of Wales Hospital, Hospital Authority, Hong Kong, China
| | - Timothy Hudson Rainer
- Department of Emergency Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- Accident and Emergency Department, Queen Mary Hospital, Hospital Authority, Hong Kong, China
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13
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Gonem S, Lemberger J, Baguneid A, Briggs S, McKeever TM, Shaw D. Real-world implementation of the National Early Warning Score-2 in an acute respiratory unit. BMJ Open Respir Res 2024; 11:e002095. [PMID: 38296608 PMCID: PMC10831462 DOI: 10.1136/bmjresp-2023-002095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/09/2024] [Indexed: 02/03/2024] Open
Abstract
INTRODUCTION The National Early Warning Score-2 (NEWS-2) is used to detect deteriorating patients in hospital settings. We aimed to understand how NEWS-2 functions in the real-life setting of an acute respiratory unit. METHODS Clinical observations data were extracted for adult patients (age ≥18 years), admitted under the care of respiratory medicine services from July to December 2019, who had at least one recorded task relating to clinical deterioration. The timing and nature of urgent out-of-hours medical reviews (escalations) were extracted through manual review of the case notes. RESULTS The data set comprised 765 admission episodes (48.9% women) with a mean (SD) age of 69.3 (14.8). 8971 out of 35 991 out-of-hours observation sets (24.9%) had a NEWS-2 ≥5, and 586 of these (6.5%) led to an escalation. Out of 687 escalations, 101 (14.7%) were associated with observation sets with NEWS-2<5. Rising oxygen requirement and extreme values of individual observations were associated with an increased risk of escalation. 57.6% of escalations resulted in a change in treatment. Inpatient mortality was higher in patients who were escalated at least once, compared with those who were not escalated. CONCLUSIONS Most observation sets with NEWS-2 scores ≥5 did not lead to a medical escalation in an acute respiratory setting out-of-hours, but more than half of escalations resulted in a change in treatment. Rising oxygen requirement is a key indicator of respiratory patient acuity which appears to influence the decision to request urgent out-of-hours medical reviews.
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Affiliation(s)
- Sherif Gonem
- Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Joseph Lemberger
- Department of Oncology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Abdulla Baguneid
- Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Steve Briggs
- Digital and Information, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Tricia M McKeever
- Lifespan and Population Health, University of Nottingham, Nottingham, UK
| | - Dominick Shaw
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
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Sanz-García A, López-Izquierdo R, Martín-Rodríguez F. Editorial: Biomarkers and early warning scores: the time for high-precision emergency medicine. Front Public Health 2024; 11:1349881. [PMID: 38259794 PMCID: PMC10800566 DOI: 10.3389/fpubh.2023.1349881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024] Open
Affiliation(s)
- Ancor Sanz-García
- Faculty of Health Sciences, Universidad de Castilla la Mancha, Talavera de la Reina, Spain
| | - Raúl López-Izquierdo
- Department of Emergency, Hospital Universitario Rio Hortega, Valladolid, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Francisco Martín-Rodríguez
- Faculty of Medicine, Universidad de Valladolid, Valladolid, Spain
- Advanced Life Support, Emergency Medical Services (SACYL), Valladolid, Spain
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Tang Q, Xie X, Li D. Enhancing Nursing Care for Children with Acute Gastroenteritis: Integrating Pediatric Early Warning Scores with the Situation-Background-Assessment-Recommendation System. Altern Ther Health Med 2024; 30:386-390. [PMID: 37793338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Background Acute gastroenteritis is a frequently encountered diarrheal illness in children, often self-limiting but occasionally linked to substantial mortality and morbidity, demanding effective approaches for assessment and intervention. While the utilization of the Pediatric Early Warning Score (PEWS) and the Situation-Background-Assessment-Recommendation system (SBAR) in pediatric patient management is recognized as effective, research in this area remains limited. Objective Our study aimed to investigate the potential impact of PEWS and SBAR systems on the outcomes of pediatric patients with acute gastroenteritis. Methods We conducted a randomized controlled trial at our hospital, enrolling 124 children aged 3 to 12 years diagnosed with acute gastroenteritis. These participants were randomly assigned to either a control group (62 cases) or an intervention group (62 cases). Different outcomes were assessed, including the frequency and duration of diarrhea and vomiting, the Modified Vesikari Scale (MVS), the Clinical Dehydration Scale (CDS), and follow-up physician visits. We utilized a two-group independent sample t test to compare outcomes between the two groups. Results Our study resulted in statistically significant findings favoring the intervention group regarding the frequency and duration of diarrhea and vomiting, the MVS, the CDS, and the need for repeat healthcare visits. Conclusions The integration of PEWS with SBAR appears to offer improved outcomes for children afflicted with acute gastroenteritis.
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Foote HP, Shaikh Z, Witt D, Shen T, Ratliff W, Shi H, Gao M, Nichols M, Sendak M, Balu S, Osborne K, Kumar KR, Jackson K, McCrary AW, Li JS. Development and Temporal Validation of a Machine Learning Model to Predict Clinical Deterioration. Hosp Pediatr 2024; 14:11-20. [PMID: 38053467 DOI: 10.1542/hpeds.2023-007308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
OBJECTIVES Early warning scores detecting clinical deterioration in pediatric inpatients have wide-ranging performance and use a limited number of clinical features. This study developed a machine learning model leveraging multiple static and dynamic clinical features from the electronic health record to predict the composite outcome of unplanned transfer to the ICU within 24 hours and inpatient mortality within 48 hours in hospitalized children. METHODS Using a retrospective development cohort of 17 630 encounters across 10 388 patients, 2 machine learning models (light gradient boosting machine [LGBM] and random forest) were trained on 542 features and compared with our institutional Pediatric Early Warning Score (I-PEWS). RESULTS The LGBM model significantly outperformed I-PEWS based on receiver operating characteristic curve (AUROC) for the composite outcome of ICU transfer or mortality for both internal validation and temporal validation cohorts (AUROC 0.785 95% confidence interval [0.780-0.791] vs 0.708 [0.701-0.715] for temporal validation) as well as lead-time before deterioration events (median 11 hours vs 3 hours; P = .004). However, LGBM performance as evaluated by precision recall curve was lesser in the temporal validation cohort with associated decreased positive predictive value (6% vs 29%) and increased number needed to evaluate (17 vs 3) compared with I-PEWS. CONCLUSIONS Our electronic health record based machine learning model demonstrated improved AUROC and lead-time in predicting clinical deterioration in pediatric inpatients 24 to 48 hours in advance compared with I-PEWS. Further work is needed to optimize model positive predictive value to allow for integration into clinical practice.
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Affiliation(s)
| | - Zohaib Shaikh
- Duke Institute for Health Innovation
- Department of Medicine, Weill Cornell Medical Center, New York, New York
| | - Daniel Witt
- Duke Institute for Health Innovation
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota
| | - Tong Shen
- Department of Biomedical Engineering
| | | | | | | | | | | | | | - Karen Osborne
- Duke University Health System, Duke University, Durham, North Carolina
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Lee S, Kim SJ, Han KS, Song J, Lee SW. Comparison of the new-Poisoning Mortality Score and the Modified Early Warning Score for predicting in-hospital mortality in patients with acute poisoning. Clin Toxicol (Phila) 2024; 62:1-9. [PMID: 38421362 DOI: 10.1080/15563650.2024.2310743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/22/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION The evaluation of acute poisoning is challenging due to varied toxic substances and clinical presentations. The new-Poisoning Mortality Score was recently developed to assess patients with acute poisoning and showed good performance in predicting in-hospital mortality. The objective of this study is to externally validate the performance of the new-Poisoning Mortality Score and to compare it with the Modified Early Warning Score. METHODS This retrospective analysis used data from the 2019-2020 Injury Surveillance Cohort, established by the Korea Center for Disease Control and Prevention, to perform external validation of the new-Poisoning Mortality Score. The statistical performances of the new-Poisoning Mortality and Modified Early Warning Scores were assessed and compared in terms of discrimination and calibration. Discrimination analysis involved metrics such as sensitivity, specificity, accuracy, and the area under the receiver operating characteristic curve. For calibration analysis, the Hosmer-Lemeshow goodness-of-fit test was utilized and calibration curves for each score were generated to elucidate the relationship between observed and predicted mortalities. RESULTS This study analysed 16,570 patients with acute poisoning. Significant differences were observed between survivors and those who died in-hospital, including age, sex, and vital signs. The new-Poisoning Mortality Score showed better performance over the Modified Early Warning Score in predicting in-hospital mortality, in terms of the area under the receiver operating characteristic curve (0.947 versus 0.800), sensitivity (0.863 versus 0.667), specificity (0.912 versus 0.817), and accuracy (0.911 versus 0.814). When evaluated through calibration curves, the new-Poisoning Mortality Score showed better concordance between predicted and observed mortalities. In subgroup analyses, the score system consistently showed strong performance, excelling particularly in substances with high mortality indices and remaining superior in all substances as a group. CONCLUSIONS Our study has helped to validate the new-Poisoning Mortality Score as an effective tool for predicting in-hospital mortality in patients with acute poisoning in the emergency department. The score system demonstrated superior performance over the Modified Early Warning Score in various metrics. Our findings suggest that the new-Poisoning Mortality Score can contribute to the enhancement of clinical decision-making and patient management.
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Affiliation(s)
- Sijin Lee
- Department of Emergency Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Su Jin Kim
- Department of Emergency Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Kap Su Han
- Department of Emergency Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Juhyun Song
- Department of Emergency Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Sung Woo Lee
- Department of Emergency Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
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Gysling S, Shanmuganathan S, Szafranek A, Stewart ID, Caruana EJ. Validation of NEWS2, SIRS, and qSOFA in Postoperative Cardiac Patients: A Retrospective Cohort Study. J Surg Res 2024; 293:364-372. [PMID: 37806223 DOI: 10.1016/j.jss.2023.08.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 07/31/2023] [Accepted: 08/26/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION The 'quick Sepsis Related Organ Failure Assessment' (qSOFA), 'Systemic Inflammatory Response Syndrome' (SIRS), and 'National Early Warning Score' 2 (NEWS2) scores are yet to be comparatively validated in ward-based cardiac surgical patients despite widespread routine use in clinical practice. We sought to assess the predictive validity of NEWS, SIRS, and qSOFA in identifying postoperative, ward-level cardiac surgical patients at risk of poor short-term mortality. METHODS All adult patients who underwent cardiac surgery at a single tertiary center between November 2014 and October 2017 were identified. Data for bedside observations, hematological results, and microbiology requests were obtained from electronic health records. Survival data were acquired from a national registry. The primary outcome was the discriminatory ability, measured by the area under the receiver operating characteristic (AUROC), of each score for in-hospital mortality. RESULTS One thousand five hundred forty three (male n = 1101, 71%) patients were included. Overall in-hospital mortality was 2.4%. There was no significant difference in discriminatory ability of NEWS (AUROC 0.5060), SIRS (AUROC 0.4874), and qSOFA (AUROC 0.5139) for in-hospital mortality (P = 0.881). Sensitivity for this outcome was ubiquitously low (13.51-40.54%). CONCLUSIONS Current illness-severity scores show a low discriminatory ability for in-hospital mortality in ward-based cardiac surgical patients. Caution should be used in the application of these prognostic screening tools for early detection of poor outcomes in this population.
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Affiliation(s)
- Savannah Gysling
- Academic Colorectal Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | | | - Adam Szafranek
- Cardiac Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Iain D Stewart
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Edward J Caruana
- Thoracic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
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Rickey L, Zhang A, Dean N. Use of Evidence-Based Vital Signs in Pediatric Early Warning Score to Predict Clinical Deterioration on Acute Care Units. Clin Pediatr (Phila) 2024; 63:126-134. [PMID: 37036078 DOI: 10.1177/00099228231166264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
The pediatric early warning score (PEWS) is a tool used to predict clinical deterioration. Referenced vital sign parameters are based on expert opinion but heart rate and respiratory rate percentiles in hospitalized children have been published. This retrospective case-control study of unplanned intensive care unit (ICU) transfers compares evidence-based vital signs (EBVS) effect on PEWS sensitivity and specificity, determines the impact of age categories on PEWS deterioration prediction, and evaluates whether EBVS PEWS is associated with need for invasive ICU supports. EBVS PEWS improved sensitivity (43%-71% vs 30%-63%) for unplanned transfers with slightly decreased specificity (88%-98% vs 93%-99%). Logistic regression analysis and odds ratios (ORs) demonstrated EBVS PEWS was associated with increased risk for ICU-specific supports (OR = 1.16, 95% confidence interval [CI] = 1.0-1.34, P = .0498). Evidence-based vital signs can improve PEWS sensitivity to identify unplanned ICU transfers and identify patients requiring ICU-specific interventions.
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Affiliation(s)
- Lisa Rickey
- Division of General Pediatrics of Pediatrics, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Anqing Zhang
- Division of Biostatistics and Study Methodology, Children's National Hospital, Washington, DC, USA
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Nathan Dean
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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Clarke J, Gallifant J, Grant D, Desai N, Glover G. Predictive value of the National Early Warning Score 2 for hospitalised patients with viral respiratory illness is improved by the addition of inspired oxygen fraction as a weighted variable. BMJ Open Respir Res 2023; 10:e001657. [PMID: 38114240 DOI: 10.1136/bmjresp-2023-001657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 11/30/2023] [Indexed: 12/21/2023] Open
Abstract
OBJECTIVES The National Early Warning Score 2 (NEWS2) is validated for predicting acute deterioration, however, the binary grading of inspired oxygen fraction (FiO2) may limit performance. We evaluated the incorporation of FiO2 as a weighted categorical variable on NEWS2 prediction of patient deterioration. SETTING Two hospitals at a single medical centre, Guy's and St Thomas' NHS Foundation Trust. DESIGN Retrospective cohort of all ward admissions, with a viral respiratory infection (SARS-CoV-2/influenza). PARTICIPANTS 3704 adult ward admissions were analysed between 01 January 2017 and 31 December 2021. METHODS The NEWS-FiO2 score transformed FiO2 into a weighted categorical variable, from 0 to 3 points, substituting the original 0/2 points. The primary outcome was a composite of cardiac arrest, unplanned critical care admission or death within 24 hours of the observation. Sensitivity, positive predictive value (PPV), number needed to evaluate (NNE) and area under the receiver operating characteristic curve (AUROC) were calculated. Failure analysis for the time from trigger to outcome was compared by log-rank test. RESULTS The mean age was 60.4±19.4 years, 52.6% were men, with a median Charlson Comorbidity of 0 (IQR 3). The primary outcome occurred in 493 (13.3%) patients, and the weighted FiO2 score was strongly associated with the outcome (p=<0.001). In patients receiving supplemental oxygen, 78.5% of scores were reclassified correctly and the AUROC was 0.81 (95% CI 0.81 to 0.81) for NEWS-FiO2 versus 0.77 (95% CI 0.77 to 0.77) for NEWS2. This improvement persisted in the whole cohort with a significantly higher failure rate for NEWS-FiO2 (p=<0.001). At the 5-point threshold, the PPV increased by 22.0% (NNE 6.7) for only a 3.9% decrease in sensitivity. CONCLUSION Transforming FiO2 into a weighted categorical variable improved NEWS2 prediction for patient deterioration, significantly improving the PPV. Prospective external validation is required before institutional implementation.
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Affiliation(s)
- Jonathan Clarke
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jack Gallifant
- Department of Critical Care, Imperial College Healthcare NHS Trust, London, UK
| | - David Grant
- Department of Medical Informatics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nishita Desai
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Guy Glover
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Price C, Prytherch D, Kostakis I, Briggs J. Evaluating the performance of the National Early Warning Score in different diagnostic groups. Resuscitation 2023; 193:110032. [PMID: 37931891 DOI: 10.1016/j.resuscitation.2023.110032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/27/2023] [Accepted: 10/24/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND The National Early Warning Score (NEWS) is used in hospitals across the UK to detect deterioration of patients within care pathways. It is used for most patients, but there are relatively few studies validating its performance in groups of patients with specific conditions. METHODS The performance of NEWS was evaluated against 36 other Early Warning Scores, in 123 patient groups, through use of the area under the receiver operating characteristic (AUROC) curve technique, to compare the abilities of each Early Warning Score to discriminate an outcome within 24hrs of vital sign recording. Outcomes evaluated were death, ICU admission, or a combined outcome of either death or ICU admission within 24 hours of an observation set. RESULTS The National Early Warning Score 2 performs either best or joint best within 120 of the 123 patient groups evaluated and is only outperformed in prediction of unanticipated ICU admission. When outperformed by other Early Warning Scores in the remaining 3 patient groups, the performance difference was marginal. CONCLUSIONS Consistently high performance indicates that NEWS is a suitable early warning score to use for all diagnostic groups considered by this analysis, and patients are not disadvantaged through use of NEWS in comparison to any of the other evaluated Early Warning Scores.
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Affiliation(s)
- Connor Price
- Centre for Healthcare Modelling & Informatics, University of Portsmouth, Portsmouth, UK.
| | - David Prytherch
- Centre for Healthcare Modelling & Informatics, University of Portsmouth, Portsmouth, UK
| | - Ina Kostakis
- Centre for Healthcare Modelling & Informatics, University of Portsmouth, Portsmouth, UK; Research Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Jim Briggs
- Centre for Healthcare Modelling & Informatics, University of Portsmouth, Portsmouth, UK
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22
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Guzelce MC, Colak N, Ucar G, Orhan E. Prognostic value of the NEWS + Lactate score in patients with decompensated heart failure in the emergency department. ESC Heart Fail 2023; 10:3604-3611. [PMID: 37771311 PMCID: PMC10682865 DOI: 10.1002/ehf2.14537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/04/2023] [Accepted: 09/08/2023] [Indexed: 09/30/2023] Open
Abstract
AIMS The National Early Warning Score (NEWS) is a scoring system that predicts increased mortality and morbidity in critical diseases. The National Early Warning Score + Lactate (NEWS + L) score was created by adding lactate values to this scoring system. In our study, we aimed to determine the value of the NEWS + L score in predicting clinical deterioration in patients presenting with acute decompensated heart failure (chronic heart failure). METHODS AND RESULTS In this observational, cross-sectional study, patients with decompensated heart failure who were admitted to the emergency department between 1 October 2020 and 31 December 2020 were included. Patients were divided into two groups: those with and without poor prognostic outcomes. The main outcomes were in-hospital mortality, discharge after treatment in the emergency department, admission to the ward, and admission to the intensive care unit. We analysed a total of 141 applications from 130 patients. The mean age was 72.6 ± 11.8 years, and 50.8% were female. Poor prognostic outcomes were observed in 92 (65%) patients. There was no difference between the patients with and without poor prognostic outcomes in terms of mean age, gender, and comorbidities, except for atrial fibrillation. There was a statistically significant difference between the patients without and with poor prognosis outcomes in terms of NEWS {3 [interquartile range (IQR): 0-5] and 6 [IQR: 3-8]} and NEWS + L scores [4.7 (IQR: 2.3-7.2) and 8.0 (IQR: 5.2-10.4)] (P < 0.001). The area under the curve values for predicting poor prognosis were calculated as 0.719 for NEWS, 0.734 for NEWS + L, and 0.601 for lactate values. The rate of poor prognostic outcomes was higher (79%) in patients with moderate and high NEWS scores. Patients with Q1 NEWS + L scores had a lower rate of poor prognostic outcomes, while patients with Q2, Q3, and Q4 scores of NEWS + L had a higher rate of poor prognostic outcomes. CONCLUSIONS The NEWS score and the addition of the lactate value to this score, the NEWS + L score, were higher in patients with poor prognostic outcomes who presented with decompensated heart failure in our emergency department. NEWS + L slightly outperformed the NEWS score in predicting prognosis. The NEWS + L score shows promise as a prognostic indicator for patients with decompensated heart failure presenting to the emergency department.
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Affiliation(s)
- Mustafa Can Guzelce
- Department of Emergency Medicine, Faculty of MedicineDokuz Eylul UniversityBalcova35340IzmirTurkey
| | - Nese Colak
- Department of Emergency Medicine, Faculty of MedicineDokuz Eylul UniversityBalcova35340IzmirTurkey
| | - Gucluhan Ucar
- Department of Emergency Medicine, Faculty of MedicineDokuz Eylul UniversityBalcova35340IzmirTurkey
| | - Ertug Orhan
- Department of Emergency Medicine, Faculty of MedicineDokuz Eylul UniversityBalcova35340IzmirTurkey
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23
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van Mourik N, Oomen JJ, van Vught LA, Biemond BJ, van den Bergh WM, Blijlevens NMA, Vlaar APJ, Müller MCA. The predictive value of the modified early warning score for admission to the intensive care unit in patients with a hematologic malignancy - A multicenter observational study. Intensive Crit Care Nurs 2023; 79:103486. [PMID: 37441816 DOI: 10.1016/j.iccn.2023.103486] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/26/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES The modified early warning score (MEWS) is used to detect clinical deterioration of hospitalized patients. We aimed to investigate the predictive value of MEWS and derived quick Sequential Organ Failure Assessment (qSOFA) scores for intensive care unit admission in patients with a hematologic malignancy admitted to the ward. DESIGN Retrospective, observational study in two Dutch university hospitals. SETTING Data from adult patients with a hematologic malignancy, admitted to the ward over a 2-year period, were extracted from electronic patient files. MAIN OUTCOME MEASURES Intensive care admission. RESULTS We included 395 patients with 736 hospital admissions; 2% (n = 15) of admissions resulted in admission to the intensive care unit. A higher MEWS (OR 1.5; 95 %CI 1.3-1.80) and qSOFA (OR 4.4; 95 %CI 2.1-9.3) were associated with admission. Using restricted cubic splines, a rise in the probability of admission for a MEWS ≥ 6 was observed. The AUC of MEWS for predicting admission was 0.830, the AUC of qSOFA was 0.752. MEWS was indicative for intensive care unit admission two days before admission. CONCLUSIONS MEWS was a sensitive predictor of ICU admission in patients with a hematologic malignancy, superior to qSOFA. Future studies should confirm cut-off values and identify potential additional characteristics, to further enhance identification of critically ill hemato-oncology patients. IMPLICATIONS FOR CLINICAL PRACTICE The Modified Early Warning Score (MEWS) can be used as a tool for healthcare providers to monitor clinical deterioration and predict the need for intensive care unit admission in patients with a hematologic malignancy. Yet, consistent application and potential reevaluation of current thresholds is crucial. This will enable bedside nurses to more effectively identify patients needing adjunctive care, facilitating timely interventions and improved outcome.
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Affiliation(s)
- Niels van Mourik
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands.
| | - Jesse J Oomen
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lonneke A van Vught
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Bart J Biemond
- Department of Hematology, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Marcella C A Müller
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
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24
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Solanki A, Batra P, Bhaskar V, Harit D. Comparison of Emergency Severity Index Version 4 and Modified Pediatric Early Warning Score as Triage Models in the Pediatric Emergency of a Tertiary Care Public Sector Hospital. Indian Pediatr 2023; 60:917-921. [PMID: 37950465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To identify the sensitivity of emergency severity index (ESI) version 4 and modified pediatric early warning score (PEWS) in identifying high urgency patients. METHODS This cross-sectional study was conducted between November, 2019 and October, 2021 in the pediatric emergency department of tertiary hospital in Delhi. 250 patients aged 0-12 years coming to pediatric emergency on pre-decided days for health-related complaints were enrolled. These were assessed with both triage systems within 30 minutes of their arrival by a single researcher. 'High urgency' patients were defined as the ones who either required admission in pediatric ICU or died or had critical value of vital parameters as per institution protocol. RESULTS ESI version 4 had a sensitivity of 95.5%, specificity of 80.3%, with AUC of 0.879 (95%CI 0.834-0.925) in identifying high urgency patients at levels 1 and 2. Modified PEWS had comparatively lower sensitivity of 79.1%, specificity of 97.8%, with AUC of 0.885 (95%CI 0.825-0.994) in identifying high urgency patients at score of ≥3. The ESI version 4 was found to be a better predictor of admission than the modified PEWS, with a sensitivity of 98.2%. Both the scores were able to identify patients at risk of mortality with a sensitivity of 100%. CONCLUSION ESI version 4 is a better triage tool than modified PEWS in pediatric population in a tertiary care public hospital setting in this region.
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Affiliation(s)
- Aashima Solanki
- Department of Pediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi
| | - Prerna Batra
- Department of Pediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi. Correspondence to: Dr Prerna Batra, Director Professor, Department of Pediatrics, UCMS and GTB Hospital, Delhi.
| | - Vikram Bhaskar
- Department of Pediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi
| | - Deepika Harit
- Department of Pediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi
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25
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Goodacre S, Sutton L, Thomas B, Hawksworth O, Iftikhar K, Croft S, Fuller G, Waterhouse S, Hind D, Bradburn M, Smyth MA, Perkins GD, Millins M, Rosser A, Dickson JM, Wilson MJ. Prehospital early warning scores for adults with suspected sepsis: retrospective diagnostic cohort study. Emerg Med J 2023; 40:768-776. [PMID: 37673643 PMCID: PMC10646863 DOI: 10.1136/emermed-2023-213315] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/18/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Ambulance services need to identify and prioritise patients with sepsis for early hospital assessment. We aimed to determine the accuracy of early warning scores alongside paramedic diagnostic impression to identify sepsis that required urgent treatment. METHODS We undertook a retrospective diagnostic cohort study involving adult emergency medical cases transported to Sheffield Teaching Hospitals ED by Yorkshire Ambulance Service in 2019. We used routine ambulance service data to calculate 21 early warning scores and categorise paramedic diagnostic impressions as sepsis, infection, non-specific presentation or other presentation. We linked cases to hospital records and identified those meeting the sepsis-3 definition who received urgent hospital treatment for sepsis (reference standard). Analysis determined the accuracy of strategies that combined early warning scores at varying thresholds for positivity with paramedic diagnostic impression. RESULTS We linked 12 870/24 955 (51.6%) cases and identified 348/12 870 (2.7%) with a positive reference standard. None of the strategies provided sensitivity greater than 0.80 with positive predictive value greater than 0.15. The area under the receiver operating characteristic curve for the National Early Warning Score, version 2 (NEWS2) applied to patients with a diagnostic impression of sepsis or infection was 0.756 (95% CI 0.729, 0.783). No other early warning score provided clearly superior accuracy to NEWS2. Paramedic impression of sepsis or infection had sensitivity of 0.572 (0.519, 0.623) and positive predictive value of 0.156 (0.137, 0.176). NEWS2 thresholds of >4, >6 and >8 applied to patients with a diagnostic impression of sepsis or infection, respectively, provided sensitivities and positive predictive values of 0.522 (0.469, 0.574) and 0.216 (0.189, 0.245), 0.447 (0.395, 0.499) and 0.274 (0.239, 0.313), and 0.314 (0.268, 0.365) and 0.333 (0.284, 0.386). CONCLUSION No strategy is ideal but using NEWS2 alongside paramedic diagnostic impression of infection or sepsis could identify one-third to half of sepsis cases without prioritising unmanageable numbers. No other score provided clearly superior accuracy to NEWS2. TRIAL REGISTRATION NUMBER researchregistry5268, https://www.researchregistry.com/browse-the-registry%23home/registrationdetails/5de7bbd97ca5b50015041c33/.
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Affiliation(s)
- Steve Goodacre
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Laura Sutton
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Ben Thomas
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Olivia Hawksworth
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | | | - Susan Croft
- Emergency Department, Northern General Hospital, Sheffield, UK
| | - Gordon Fuller
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Simon Waterhouse
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Daniel Hind
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Mike Bradburn
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | | | | | - Mark Millins
- Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Andy Rosser
- West Midlands Ambulance Service, West Midlands, UK
| | - Jon M Dickson
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Matthew Joseph Wilson
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
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26
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Psirides A, Mohan C. Comparison of the Aotearoa New Zealand Early Warning Score and National Early Warning Score to predict adverse inpatient events in a vital sign dataset. Anaesthesia 2023; 78:1422. [PMID: 37401898 DOI: 10.1111/anae.16093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2023] [Indexed: 07/05/2023]
Affiliation(s)
- A Psirides
- Wellington Regional Hospital, Wellington, New Zealand
| | - C Mohan
- Beaumont Hospital, Dublin, Ireland
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27
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Mackay JH. Early warning scores to assess risk before emergency laparotomy. Anaesthesia 2023; 78:1302. [PMID: 37314730 DOI: 10.1111/anae.16062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2023] [Indexed: 06/15/2023]
Affiliation(s)
- J H Mackay
- Retired anaesthetist, Cambridgeshire, UK
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28
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Gupta C, Suri J, Bachani S, Bharti R, Pandey D, Mittal P. Carle's obstetric early warning score as a screening tool for critical care admission. Indian J Med Res 2023; 158:339-346. [PMID: 37988032 DOI: 10.4103/ijmr.ijmr_2478_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND OBJECTIVES Early warning systems (EWS) involve serial observations (track) with criteria (trigger) to timely identify patients at risk of complications. Carle designed a statistically based clinically modified obstetric early warning score (Carle's OEWS). This study evaluated Carle's OEWS and its individual components for predicting admission to the obstetric critical care unit (OCCU). Maternal near-miss and maternal mortality were the secondary outcomes. METHODS A prospective observational study was conducted among 1250 pregnant women with a period of gestation ≥28 week admitted in the labour wards of a tertiary centre over 18 months. The physiological parameters of OEWS were recorded and aggregate score was calculated at admission and at regular intervals thereafter, till discharge or OCCU admission. RESULTS The area under receiver operating characteristic (ROC) curve of OEWS was 0.975 for predicting OCCU admission, 0.971 for near-miss, and 0.996 for predicting maternal mortality and was significant for all outcomes. All individual parameters, except diastolic blood pressure, had a significant relative risk for predicting OCCU requirement. INTERPRETATION CONCLUSIONS Carle's OEWS is a useful screening tool for predicting obstetric OCCU admission and can be routinely used in labour wards to ensure timely intervention.
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Affiliation(s)
- Chhavi Gupta
- Department of Obstetrics & Gynaecology, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
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29
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Su X, Zhang H, Yuan W, Yi M, Fu C, Jiang J, Gao H. [Comparison of four early warning scores in predicting the prognosis of critically ill patients in secondary hospitals]. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue 2023; 35:1093-1098. [PMID: 37873716 DOI: 10.3760/cma.j.cn121430-20230614-00441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
OBJECTIVE To explore the predictive value of acute physiology and chronic health evaluation II (APACHE II), sequential organ failure assessment (SOFA), quick sequential organ failure assessment (qSOFA) and modified early warning score (MEWS) in evaluating the prognosis of patients in intensive care unit (ICU) of secondary hospitals, and to provide guidance for clinical application. METHODS The clinical data of adult critical patients admitted to the ICU of Wanzhou District First People's Hospital from October 2022 to April 2023 were retrospectively analyzed. According to the clinical outcome of ICU, the patients were divided into improvement group and death group. The general information, blood routine, heart, liver and kidney function indicators, coagulation indicators, blood gas analysis, APACHE II score, SOFA score, qSOFA score, MEWS score at the time of admission to the ICU, the number of cases of invasive mechanical ventilation (IMV) and continuous blood purification (CBP) were compared between the two groups. Univariate analysis was performed, and multivariate Logistic regression analysis was used to analyze the related factors of death. Receiver operator characteristic curve (ROC curve) was used to analyze the predictive value of the four scores in ICU patients. RESULTS A total of 126 patients were included, of which 45 patients died in the ICU and 81 patients improved and transferred out. Univariate analysis of death-related critically ill patients showed that procalcitonin (PCT), serum creatinine (SCr), blood urea nitrogen (BUN), albumin (ALB), prothrombin time (PT), activated partial prothrombin time (APTT), D-dimer, pH value, HCO3-, blood lactic acid (Lac), number of patients treated with IMV and CBP, APACHE II score, SOFA score, qSOFA score and MEWS score were significantly different between the two groups (all P < 0.05). Multivariate Logistic regression analysis showed that the APACHE II score [odds ratio (OR) = 1.115, 95% confidence interval (95%CI) was 1.025-1.213, P = 0.011], SOFA score (OR = 1.204, 95%CI was 1.037-1.398, P = 0.015), MEWS score (OR = 1.464, 95%CI was 1.102-1.946, P = 0.009), and APTT (OR = 1.081, 95%CI was 1.015-1.152, P = 0.016) were independent risk factors affecting the mortality of critically ill patients in the ICU. ROC curve analysis showed that APACHE II, SOFA, qSOFA, and MEWS scores could predict the prognosis of critically ill ICU patients, among which SOFA score had the strongest predictive effect, and the area under the curve (AUC) was 0.808. There was a statistically significant difference in the time required for the four scores (F = 117.333, P < 0.001), among which the MEWS scoring required the shortest time [(1.03±0.39) minutes], and the APACHE II scoring required the longest time [(2.81±1.04) minutes]. CONCLUSIONS APACHE II, SOFA, qSOFA, and MEWS scores can be used to assess the severity of critically ill patients and predict in-hospital mortality. The SOFA score is superior to other scores in predicting severity. The MEWS is preferred because its assessment time is shortest. Early warning score can help secondary hospitals to detect potentially critical patients early and provide help for clinical rapid urgent emergency decision-making.
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Affiliation(s)
- Xiaoqin Su
- Department of Critical Care Medicine, Wanzhou District First People's Hospital, Chongqing 404100, China
| | - Hongyan Zhang
- Department of Critical Care Medicine, Wanzhou District First People's Hospital, Chongqing 404100, China
| | - Wenjun Yuan
- Department of Critical Care Medicine, Wanzhou District First People's Hospital, Chongqing 404100, China
| | - Meng Yi
- Department of Critical Care Medicine, Wanzhou District First People's Hospital, Chongqing 404100, China
| | - Chenghao Fu
- Department of Critical Care Medicine, Wanzhou District First People's Hospital, Chongqing 404100, China
| | - Jiawei Jiang
- Department of Critical Care Medicine, Tianjin First Central Hospital, Key Laboratory for Critical Care Medicine of the Ministry of Health, Tianjin 300192, China. Corresponding author: Jiang Jiawei,
| | - Hongmei Gao
- Department of Critical Care Medicine, Tianjin First Central Hospital, Key Laboratory for Critical Care Medicine of the Ministry of Health, Tianjin 300192, China. Corresponding author: Jiang Jiawei,
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30
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Rodríguez C, Muriel A, Carrasco L, González S, Briceño W, Durán D, Retegui A, Yusen RD, Bikdeli B, Jiménez D. National Early Warning Score-2 for Identification of Patients with Intermediate-High-Risk Pulmonary Embolism. Semin Thromb Hemost 2023; 49:716-724. [PMID: 37327883 DOI: 10.1055/s-0043-1769938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Consensus statements have proposed the use of the National Early Warning Score 2 (NEWS2) to identify stable patients with acute pulmonary embolism (PE) and an intermediate-high risk of adverse outcomes. We aimed to externally validate NEWS2 and compare it to another predictive score (Bova). Using NEWS2 (cutoff ≥5 and ≥7) and the Bova score (cutoff >4), we classified patients as intermediate-high risk (vs. non-intermediate-high risk), and we compared the test characteristics of these risk classification tools for a complicated course within 30 days after PE diagnosis. We also assessed the validity of NEWS2 for predicting a complicated course by adding the results of echocardiography and troponin testing to the model. Of the 848 enrolled patients, the NEWS2 score ≥5 classified 471 (55.5%) and the Bova score classified 37 (4.4%) as intermediate-high risk. NEWS2 had a significantly lower specificity for a 30-day complicated course than Bova (45.4 vs. 96.3%, respectively; p < 0.001). Using the higher score threshold (≥7), the NEWS2 classified 99 (11.7%) as intermediate-high risk, and the specificity was 88.9% (difference with Bova, 7.4%; p < 0.001). The proportion of patients with intermediate-high risk PE was 2.4% for the combination of a positive troponin testing and echocardiographic right ventricle dysfunction and a positive NEWS2 (score ≥7), while the specificity was 97.8% (difference with Bova, 1.5%; p = 0.07). Bova outperforms NEWS2 for predicting a complicated course among stable patients with PE. Addition of troponin testing and echocardiography improved the specificity of NEWS2, although it was not superior to Bova. CLINICALTRIALS.GOV NUMBER: : NCT02238639.
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Affiliation(s)
- Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Alfonso Muriel
- Department of Biostatistics, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Luis Carrasco
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Sara González
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Winnifer Briceño
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Diego Durán
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Ana Retegui
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Roger D Yusen
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, Connecticut
- Cardiovascular Research Foundation, New York, New York
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Department of Medicine, Universidad de Alcalá, Madrid, Spain
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31
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Darbyshire AR, Kostakis I, Briggs J. Early warning scores to assess risk before emergency laparotomy: a reply. Anaesthesia 2023; 78:1303. [PMID: 37387194 DOI: 10.1111/anae.16083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/01/2023]
Affiliation(s)
- A R Darbyshire
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - I Kostakis
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - J Briggs
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Zayas CE, Whorton JM, Sexton KW, Mabry CD, Dowland SC, Brochhausen M. Development and validation of the early warning system scores ontology. J Biomed Semantics 2023; 14:14. [PMID: 37730667 PMCID: PMC10510162 DOI: 10.1186/s13326-023-00296-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 09/09/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Clinical early warning scoring systems, have improved patient outcomes in a range of specializations and global contexts. These systems are used to predict patient deterioration. A multitude of patient-level physiological decompensation data has been made available through the widespread integration of early warning scoring systems within EHRs across national and international health care organizations. These data can be used to promote secondary research. The diversity of early warning scoring systems and various EHR systems is one barrier to secondary analysis of early warning score data. Given that early warning score parameters are varied, this makes it difficult to query across providers and EHR systems. Moreover, mapping and merging the parameters is challenging. We develop and validate the Early Warning System Scores Ontology (EWSSO), representing three commonly used early warning scores: the National Early Warning Score (NEWS), the six-item modified Early Warning Score (MEWS), and the quick Sequential Organ Failure Assessment (qSOFA) to overcome these problems. METHODS We apply the Software Development Lifecycle Framework-conceived by Winston Boyce in 1970-to model the activities involved in organizing, producing, and evaluating the EWSSO. We also follow OBO Foundry Principles and the principles of best practice for domain ontology design, terms, definitions, and classifications to meet BFO requirements for ontology building. RESULTS We developed twenty-nine new classes, reused four classes and four object properties to create the EWSSO. When we queried the data our ontology-based process could differentiate between necessary and unnecessary features for score calculation 100% of the time. Further, our process applied the proper temperature conversions for the early warning score calculator 100% of the time. CONCLUSIONS Using synthetic datasets, we demonstrate the EWSSO can be used to generate and query health system data on vital signs and provide input to calculate the NEWS, six-item MEWS, and qSOFA. Future work includes extending the EWSSO by introducing additional early warning scores for adult and pediatric patient populations and creating patient profiles that contain clinical, demographic, and outcomes data regarding the patient.
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Affiliation(s)
- Cilia E Zayas
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
| | - Justin M Whorton
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Kevin W Sexton
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- University of Arkansas for Medical Sciences, Institute for Digital Health & Innovation, 4301 West Markham Street, Slot 781, Little Rock, AR, 72205, USA
| | - Charles D Mabry
- Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - S Clint Dowland
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mathias Brochhausen
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Department of Medical Humanities and Bioethics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Neiman AE, Campanharo CRV, Lopes MCBT, Piacezzi LHV, Batista REA. COVID-19: Association of risk classification with the Modified Early Warning Score and hospital outcomes. Rev Lat Am Enfermagem 2023; 31:e3977. [PMID: 37729245 PMCID: PMC10508216 DOI: 10.1590/1518-8345.6666.3977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/06/2023] [Indexed: 09/22/2023] Open
Abstract
OBJECTIVE to evaluate the association of the risk classification categories with the Modified Early Warning Score and the outcomes of COVID-19 patients in the emergency service. METHOD a crosssectional study carried out with 372 patients hospitalized with a COVID-19 diagnosis and treated at the Risk Classification Welcoming area from the Emergency Room. In this study, the patients' Modified Early Warning Score was categorized into without and with clinical deterioration, from 0 to 4 and from 5 to 9, respectively. Clinical deterioration was considered to be acute respiratory failure, shock and cardiopulmonary arrest. RESULTS the mean Modified Early Warning Score was 3.34. In relation to the patients' clinical deterioration, it was observed that, in 43%, the time for deterioration was less than 24 hours and that 65.9% occurred in the Emergency Room. The most frequent deterioration was acute respiratory failure (69.9%) and the outcome was hospital discharge (70.3%). CONCLUSION COVID-19 patients who had a Modified Early Warning Scores > 4 were associated with the urgent, very urgent and emergency risk classification categories, had more clinical deterioration, such as respiratory failure and shock, and evolved more to death, which shows that the Risk Classification Protocol correctly prioritized patients at risk of life.
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Affiliation(s)
| | - Cássia Regina Vancini Campanharo
- Universidade Federal de São Paulo, Escola Paulista de Enfermagem, Departamento de Enfermagem Clínica e Cirúrgica, São Paulo, SP, Brasil
| | | | - Luiz Humberto Vieri Piacezzi
- Universidade Federal de São Paulo, Escola Paulista de Enfermagem, Departamento de Enfermagem Clínica e Cirúrgica, São Paulo, SP, Brasil
| | - Ruth Ester Assayag Batista
- Universidade Federal de São Paulo, Escola Paulista de Enfermagem, Departamento de Enfermagem Clínica e Cirúrgica, São Paulo, SP, Brasil
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Barbosa IDS, Jaques AE, Radovanovic CAT, Andrade LD, Dermatte LPG, Souza CMD, Tonon MM. Development of a mobile application for emergency shift handovers using the National Early Warning Score. Rev Gaucha Enferm 2023; 44:e20220130. [PMID: 37729267 DOI: 10.1590/1983-1447.2023.20220130.en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 03/08/2023] [Indexed: 09/22/2023] Open
Abstract
OBJECTIVE To develop and validate a prototype of a mobile application shift handover between nurses in the emergency room using a severity scale. METHOD This is a technological tool carried out at the Universidade Estadual de Maringá using design thinking, divided into four phases: discovering, defining, developing, and delivering. To structure the information, a checklist was used based on the Situation Background Assessment Recommendation, and to categorize patients in terms of severity, the National Early Warning Score was used. The validation of the sample was carried out by 10 nurses, specialized in the field of urgency and emergency, using the System Usability Scale questionnaire to assess usability. The content validity coefficient was used for analysis. RESULTS The application scored 75.75 in usability and had a content validity coefficient of 0.8. CONCLUSION The prototype obtained an excellent evaluation of usability and agreement between evaluators. Future studies are needed for implementation in practice, evaluating the practicality, applicability, efficiency and time savings in shift information transfer.
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Affiliation(s)
- Iran Dos Santos Barbosa
- Universidade Estadual de Maringá (UEM), Programa de Mestrado Profissional em Gestão, Tecnologia e Inovação em Urgência e Emergência. Maringá, Paraná, Brasil
| | - André Estevam Jaques
- Universidade Estadual de Maringá (UEM), Programa de Pós-Graduação em Enfermagem. Maringá, Paraná, Brasil
| | | | - Luciano de Andrade
- Universidade Estadual de Maringá (UEM), Programa de Pós-Graduação em Ciências da Saúde. Maringá, Paraná, Brasil
| | | | - Carla Moretti de Souza
- Universidade Estadual de Maringá (UEM), Programa de Pós-Graduação em Enfermagem. Maringá, Paraná, Brasil
| | - Martina Mesquita Tonon
- Universidade Estadual de Maringá (UEM), Programa de Pós-Graduação em Enfermagem. Maringá, Paraná, Brasil
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Kuo YT, Hsiao CT, Wu PH, Wu KH, Chang CP. Comparison of National Early Warning Score with shock index in patients with necrotizing fasciitis. Medicine (Baltimore) 2023; 102:e34651. [PMID: 37682200 PMCID: PMC10489463 DOI: 10.1097/md.0000000000034651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/18/2023] [Indexed: 09/09/2023] Open
Abstract
Shock index (SI) and national early warning score (NEWS) are more frequently used as assessment tools in acute illnesses, patient disposition and early identification of critical condition. Both they are consisted of common vital signs and parameters including heart rate, systolic blood pressure, respiratory rate, oxygen saturation and level of conscious, which made it easy to evaluate in medical facilities. Its ability to predict mortality in patients with necrotizing fasciitis (NF) in the emergency department remains unclear. This study was conducted to compare the predictive capability of the risk scores among NF patients. A retrospective cohort study of hospitalized patients with NF was conducted in 2 tertiary teaching hospitals in Taiwan between January 2013 and March 2015. We investigated the association of NEWS and SI with mortality in NF patients. Of the 395 NF patients, 32 (8.1%) died in the hospital. For mortality, the area under the receiver curve value of NEWS (0.81, 95% confidence interval 0.76-0.86) was significantly higher than SI (0.76, 95% confidence interval 0.73-0.79, P = .016). The sensitivities of NEWS of 3, 4, and 5 for mortality were 98.1%, 95.6%, and 92.3%. On the contrast, the sensitivities of SI of 0.5, 0.6, and 0.7 for mortality were 87.8%, 84.7%, and 81.5%. NEWS had advantage in better discriminative performance of mortality in NF patients. The NEWS may be used to identify relative low risk patients among NF patients.
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Affiliation(s)
- Yen-Ting Kuo
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Cheng-Ting Hsiao
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- Department of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Po-Han Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Kai-Hsiang Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chia-Peng Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
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Covino M, Sandroni C, Della Polla D, De Matteis G, Piccioni A, De Vita A, Russo A, Salini S, Carbone L, Petrucci M, Pennisi M, Gasbarrini A, Franceschi F. Predicting ICU admission and death in the Emergency Department: A comparison of six early warning scores. Resuscitation 2023; 190:109876. [PMID: 37331563 DOI: 10.1016/j.resuscitation.2023.109876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/30/2023] [Accepted: 06/09/2023] [Indexed: 06/20/2023]
Abstract
AIM To compare the ability of the most used Early Warning Scores (EWS) to identify adult patients at risk of poor outcomes in the emergency department (ED). METHODS Single-center, retrospective observational study. We evaluated the digital records of consecutive ED admissions in patients ≥ 18 years from 2010 to 2019 and calculated NEWS, NEWS2, MEWS, RAPS, REMS, and SEWS based on parameters measured on ED arrival. We assessed the discrimination and calibration performance of each EWS in predicting death/ICU admission within 24 hours using ROC analysis and visual calibration. We also measured the relative weight of clinical and physiological derangements that identified patients missed by EWS risk stratification using neural network analysis. RESULTS Among 225,369 patients assessed in the ED during the study period, 1941 (0.9%) were admitted to ICU or died within 24 hours. NEWS was the most accurate predictor (area under the receiver operating characteristic [AUROC] curve 0.904 [95% CI 0.805-0.913]), followed by NEWS2 (AUROC 0.901). NEWS was also well calibrated. In patients judged at low risk (NEWS < 2), 359 events occurred (18.5% of the total). Neural network analysis revealed that age, systolic BP, and temperature had the highest relative weight for these NEWS-unpredicted events. CONCLUSIONS NEWS is the most accurate EWS for predicting the risk of death/ICU admission within 24 h from ED arrival. The score also had a fair calibration with few events occurring in patients classified at low risk. Neural network analysis suggests the need for further improvements by focusing on the prompt diagnosis of sepsis and the development of practical tools for the measurement of the respiratory rate.
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Affiliation(s)
- Marcello Covino
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
| | - Claudio Sandroni
- Università Cattolica del Sacro Cuore, Roma, Italy; Department of Anaesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Davide Della Polla
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Giuseppe De Matteis
- Department of Internal Medicina and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Andrea Piccioni
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Antonio De Vita
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Andrea Russo
- Department of Geriatrics, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Sara Salini
- Department of Geriatrics, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Luigi Carbone
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy; Department of Emergency Medicine, Ospedale Fatebenefratelli Isola Tiberina, Gemelli, Isola, Roma, Italy
| | - Martina Petrucci
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Mariano Pennisi
- Università Cattolica del Sacro Cuore, Roma, Italy; Department of Anaesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Antonio Gasbarrini
- Università Cattolica del Sacro Cuore, Roma, Italy; Department of Internal Medicina and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Francesco Franceschi
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
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Klén R, Huespe IA, Gregalio FA, Lalueza Blanco AL, Pedrera Jimenez M, Garcia Barrio N, Valdez PR, Mirofsky MA, Boietti B, Gómez-Huelgas R, Casas-Rojo JM, Antón-Santos JM, Pollan JA, Gómez-Varela D. Development and validation of COEWS (COVID-19 Early Warning Score) for hospitalized COVID-19 with laboratory features: A multicontinental retrospective study. eLife 2023; 12:e85618. [PMID: 37615346 PMCID: PMC10479961 DOI: 10.7554/elife.85618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 08/23/2023] [Indexed: 08/25/2023] Open
Abstract
Background The emergence of new SARS-CoV-2 variants with significant immune-evasiveness, the relaxation of measures for reducing the number of infections, the waning of immune protection (particularly in high-risk population groups), and the low uptake of new vaccine boosters, forecast new waves of hospitalizations and admission to intensive care units. There is an urgent need for easily implementable and clinically effective Early Warning Scores (EWSs) that can predict the risk of complications within the next 24-48 hr. Although EWSs have been used in the evaluation of COVID-19 patients, there are several clinical limitations to their use. Moreover, no models have been tested on geographically distinct populations or population groups with varying levels of immune protection. Methods We developed and validated COVID-19 Early Warning Score (COEWS), an EWS that is automatically calculated solely from laboratory parameters that are widely available and affordable. We benchmarked COEWS against the widely used NEWS2. We also evaluated the predictive performance of vaccinated and unvaccinated patients. Results The variables of the COEWS predictive model were selected based on their predictive coefficients and on the wide availability of these laboratory variables. The final model included complete blood count, blood glucose, and oxygen saturation features. To make COEWS more actionable in real clinical situations, we transformed the predictive coefficients of the COEWS model into individual scores for each selected feature. The global score serves as an easy-to-calculate measure indicating the risk of a patient developing the combined outcome of mechanical ventilation or death within the next 48 hr.The discrimination in the external validation cohort was 0.743 (95% confidence interval [CI]: 0.703-0.784) for the COEWS score performed with coefficients and 0.700 (95% CI: 0.654-0.745) for the COEWS performed with scores. The area under the receiver operating characteristic curve (AUROC) was similar in vaccinated and unvaccinated patients. Additionally, we observed that the AUROC of the NEWS2 was 0.677 (95% CI: 0.601-0.752) in vaccinated patients and 0.648 (95% CI: 0.608-0.689) in unvaccinated patients. Conclusions The COEWS score predicts death or MV within the next 48 hr based on routine and widely available laboratory measurements. The extensive external validation, its high performance, its ease of use, and its positive benchmark in comparison with the widely used NEWS2 position COEWS as a new reference tool for assisting clinical decisions and improving patient care in the upcoming pandemic waves. Funding University of Vienna.
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Affiliation(s)
- Riku Klén
- Turku PET Centre, University of Turku and Turku University HospitalTurkuFinland
| | - Ivan A Huespe
- Italian Hospital of Buenos AiresBuenos AiresArgentina
| | | | - Antonio Lalueza Lalueza Blanco
- 12 de Octubre University Hospital, Research Institute of Hospital 12 de Octubre (imas+12), Complutense UniversityMadridSpain
| | - Miguel Pedrera Jimenez
- 12 de Octubre University Hospital, Research Institute of Hospital 12 de Octubre (imas+12), Complutense UniversityMadridSpain
| | - Noelia Garcia Barrio
- 12 de Octubre University Hospital, Research Institute of Hospital 12 de Octubre (imas+12), Complutense UniversityMadridSpain
| | | | - Matias A Mirofsky
- Hospital Municipal de Agudos Dr Leónidas LuceroBahía BlancaArgentina
| | - Bruno Boietti
- Italian Hospital of Buenos AiresBuenos AiresArgentina
| | - Ricardo Gómez-Huelgas
- Regional University Hospital of Málaga, Biomedical Research Institute of Málaga (IBIMA), University of MalagaMálagaSpain
| | | | | | | | - David Gómez-Varela
- Division of Pharmacology & Toxicology, Department of Pharmaceutical Sciences, University of ViennaViennaAustria
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Lindskou TA, Ward LM, Søvsø MB, Mogensen ML, Christensen EF. Prehospital Early Warning Scores to Predict Mortality in Patients Using Ambulances. JAMA Netw Open 2023; 6:e2328128. [PMID: 37556138 PMCID: PMC10413164 DOI: 10.1001/jamanetworkopen.2023.28128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 06/29/2023] [Indexed: 08/10/2023] Open
Abstract
IMPORTANCE Early warning scores (EWSs) are designed for in-hospital use but are widely used in the prehospital field, especially in select groups of patients potentially at high risk. To be useful for paramedics in daily prehospital clinical practice, evaluations are needed of the predictive value of EWSs based on first measured vital signs on scene in large cohorts covering unselected patients using ambulance services. OBJECTIVE To validate EWSs' ability to predict mortality and intensive care unit (ICU) stay in an unselected cohort of adult patients who used ambulances. DESIGN, SETTING, AND PARTICIPANTS This prognostic study conducted a validation based on a cohort of adult patients (aged ≥18 years) who used ambulances in the North Denmark Region from July 1, 2016, to December 31, 2020. EWSs (National Early Warning Score 2 [NEWS2], modified NEWS score without temperature [mNEWS], Quick Sepsis Related Organ Failure Assessment [qSOFA], Rapid Emergency Triage and Treatment System [RETTS], and Danish Emergency Process Triage [DEPT]) were calculated using first vital signs measured by ambulance personnel. Data were analyzed from September 2022 through May 2023. MAIN OUTCOMES AND MEASURES The primary outcome was 30-day-mortality. Secondary outcomes were 1-day-mortality and ICU admission. Discrimination was assessed using area under the receiver operating characteristic curve (AUROC) and area under the precision recall curve (AUPRC). RESULTS There were 107 569 unique patients (52 650 females [48.9%]; median [IQR] age, 65 [45-77] years) from the entire cohort of 219 323 patients who used ambulance services, among whom 119 992 patients (54.7%) had called the Danish national emergency number. NEWS2, mNEWS, RETTS, and DEPT performed similarly concerning 30-day mortality (AUROC range, 0.67 [95% CI, 0.66-0.68] for DEPT to 0.68 [95% CI, 0.68-0.69] for mNEWS), while qSOFA had lower performance (AUROC, 0.59 [95% CI, 0.59-0.60]; P vs other scores < .001). All EWSs had low AUPRCs, ranging from 0.09 (95% CI, 0.09-0.09) for qSOFA to 0.14 (95% CI, 0.13-0.14) for mNEWS.. Concerning 1-day mortality and ICU admission NEWS2, mNEWS, RETTS, and DEPT performed similarly, with AUROCs ranging from 0.72 (95% CI, 0.71-0.73) for RETTS to 0.75 (95% CI, 0.74-0.76) for DEPT in 1-day mortality and 0.66 (95% CI, 0.65-0.67) for RETTS to 0.68 (95% CI, 0.67-0.69) for mNEWS in ICU admission, and all EWSs had low AUPRCs. These ranged from 0.02 (95% CI, 0.02-0.03) for qSOFA to 0.04 (95% CI, 0.04-0.04) for DEPT in 1-day mortality and 0.03 (95% CI, 0.03-0.03) for qSOFA to 0.05 (95% CI, 0.04-0.05) for DEPT in ICU admission. CONCLUSIONS AND RELEVANCE This study found that EWSs in daily clinical use in emergency medical settings performed moderately in the prehospital field among unselected patients who used ambulances when assessed based on initial measurements of vital signs. These findings suggest the need of appropriate triage and early identification of patients at low and high risk with new and better EWSs also suitable for prehospital use.
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Affiliation(s)
- Tim Alex Lindskou
- Centre for Prehospital and Emergency Research, Aalborg University Hospital and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Morten Breinholt Søvsø
- Centre for Prehospital and Emergency Research, Aalborg University Hospital and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Emergency Medical Services, North Denmark Region, Aalborg, Denmark
| | | | - Erika Frischknecht Christensen
- Centre for Prehospital and Emergency Research, Aalborg University Hospital and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Emergency Medical Services, North Denmark Region, Aalborg, Denmark
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Castagno E, Balbo M, Procacci A, Parisi A, Paglia F, Bergese I, Versace A, Bondone C. [ Early warning scores of clinical deterioration in pediatric patients: a literature review]. Assist Inferm Ric 2023; 42:137-151. [PMID: 37721339 DOI: 10.1702/4095.40918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
. Early warning scores for clinical deterioration in pediatric patients: a literature review. INTRODUCTION An early recognition of clinical worsening (the manifestation of signs and symptoms resulting in physiological instability) in pediatric inpatients may prevent the evolution towards cardiorespiratory arrest. In recent decades, several tools known as PEWS (Pediatric Early Warning Scores), have been developed, aiming to reduce in-hospital morbidity and mortality. OBJECTIVE To describe efficacy, sensitivity and specificity of the available tools for early detection of clinical worsening in children, based on literature review. METHODS Systematic review through the consultation of PubMed and Google Scholar, cross-combining Mesh terms and free text words. RESULTS Out of 266 analysed papers, 34 were included in this review: 23 retrospective observational studies, 8 reviews, 1 reliability study, and 2 pilot studies. Overall, 23 main PEWS with sufficient evidence of efficacy were described (11 track and trigger and 12 aggregate). Ranges of sensibility and specificity were available only for 18 PEWS. It is not possible to recognize a gold standard, however, some PEWS are better in terms of validity and efficacy in different clinical settings. Internationally, the BPEWS (Brighton Pediatric Early Warning Score) is the most commonly adopted tool, able to identify clinical worsening of in-hospital children almost 11 hours before cardiac arrest. CONCLUSIONS Although with limited evidence, validated PEWS have shown good ability to prevent the risk of clinical worsening by reducing adverse events. Further studies and greater standardization according to the clinical context are still needed.
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Affiliation(s)
- Emanuele Castagno
- S.C. Pediatria d'Urgenza, Ospedale Infantile Regina Margherita, A.O.U. Città della Salute e della Scienza di Torino, Italia
| | - Margherita Balbo
- Corso di Laurea Infermieristica, Università Cattolica del Sacro Cuore, Presidio Ospedale Cottolengo, Torino, Italia
| | - Arianna Procacci
- Corso di Laurea Infermieristica, Università Cattolica del Sacro Cuore, Presidio Ospedale Cottolengo, Torino, Italia
| | - Alessandro Parisi
- S.C. Pediatria d'Urgenza, Ospedale Infantile Regina Margherita, A.O.U. Città della Salute e della Scienza di Torino, Italia
| | - Federica Paglia
- S.C. Pediatria d'Urgenza, Ospedale Infantile Regina Margherita, A.O.U. Città della Salute e della Scienza di Torino, Italia
| | - Ilaria Bergese
- S.C. Rianimazione 5 Pediatrica, Ospedale Infantile Regina Margherita, A.O.U. Città della Salute e della Scienza di Torino, Italia
| | - Antonia Versace
- S.C. Pediatria d'Urgenza, Ospedale Infantile Regina Margherita, A.O.U. Città della Salute e della Scienza di Torino, Italia
| | - Claudia Bondone
- S.C. Pediatria d'Urgenza, Ospedale Infantile Regina Margherita, A.O.U. Città della Salute e della Scienza di Torino, Italia
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Murali M, Inada-Kim M. Early warning scores: the case for aggregate vs. single extreme parameter activation to detect patient deterioration. Anaesthesia 2023; 78:803-806. [PMID: 37195103 DOI: 10.1111/anae.16048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 05/18/2023]
Affiliation(s)
- M Murali
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - M Inada-Kim
- Department of Acute Medicine, Royal Hampshire County Hospital, Hampshire Hospitals NHS Foundation Trust, Winchester, UK
- Department of Clinical and Experimental Sciences, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
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Qiu X, Lei YP, Zhou RX. SIRS, SOFA, qSOFA, and NEWS in the diagnosis of sepsis and prediction of adverse outcomes: a systematic review and meta-analysis. Expert Rev Anti Infect Ther 2023; 21:891-900. [PMID: 37450490 DOI: 10.1080/14787210.2023.2237192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/20/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND We compared Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), Quick Sepsis-related Organ Failure Assessment (qSOFA), and National Early Warning Score (NEWS) for sepsis diagnosis and adverse outcomes prediction. METHODS Clinical studies that used SIRS, SOFA, qSOFA, and NEWS for sepsis diagnosis and prognosis assessment were included. Data were extracted, and meta-analysis was performed for outcome measures, including sepsis diagnosis, in-hospital mortality, 7/10/14-day mortality, 28/30-day mortality, and ICU admission. RESULTS Fifty-seven included studies showed good overall quality. Regarding sepsis prediction, SIRS demonstrated high sensitivity (0.85) but low specificity (0.41), qSOFA showed low sensitivity (0.42) but high specificity (0.98), and NEWS exhibited high sensitivity (0.71) and specificity (0.85). For predicting in-hospital mortality, SOFA demonstrated the highest sensitivity (0.89) and specificity (0.69). In terms of predicting 7/10/14-day mortality, SIRS exhibited high sensitivity (0.87), while qSOFA had high specificity (0.75). For predicting 28/30-day mortality, SOFA showed high sensitivity (0.97) but low specificity (0.14), whereas qSOFA displayed low sensitivity (0.41) but high specificity (0.88). CONCLUSIONS NEWS independently demonstrates good diagnostic capability for sepsis, especially in high-income countries. SOFA emerges as the optimal choice for predicting in-hospital mortality and can be employed as a screening tool for 28/30-day mortality in low-income countries.
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Affiliation(s)
- Xia Qiu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yu-Peng Lei
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Rui-Xi Zhou
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Chengdu, Sichuan, China
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Candel BGJ, Nissen SK, Nickel CH, Raven W, Thijssen W, Gaakeer MI, Lassen AT, Brabrand M, Steyerberg EW, de Jonge E, de Groot B. Development and External Validation of the International Early Warning Score for Improved Age- and Sex-Adjusted In-Hospital Mortality Prediction in the Emergency Department. Crit Care Med 2023; 51:881-891. [PMID: 36951452 PMCID: PMC10262984 DOI: 10.1097/ccm.0000000000005842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
OBJECTIVES Early Warning Scores (EWSs) have a great potential to assist clinical decision-making in the emergency department (ED). However, many EWS contain methodological weaknesses in development and validation and have poor predictive performance in older patients. The aim of this study was to develop and externally validate an International Early Warning Score (IEWS) based on a recalibrated National Early warning Score (NEWS) model including age and sex and evaluate its performance independently at arrival to the ED in three age categories (18-65, 66-80, > 80 yr). DESIGN International multicenter cohort study. SETTING Data was used from three Dutch EDs. External validation was performed in two EDs in Denmark. PATIENTS All consecutive ED patients greater than or equal to 18 years in the Netherlands Emergency department Evaluation Database (NEED) with at least two registered vital signs were included, resulting in 95,553 patients. For external validation, 14,809 patients were included from a Danish Multicenter Cohort (DMC). MEASUREMENTS AND MAIN RESULTS Model performance to predict in-hospital mortality was evaluated by discrimination, calibration curves and summary statistics, reclassification, and clinical usefulness by decision curve analysis. In-hospital mortality rate was 2.4% ( n = 2,314) in the NEED and 2.5% ( n = 365) in the DMC. Overall, the IEWS performed significantly better than NEWS with an area under the receiving operating characteristic of 0.89 (95% CIs, 0.89-0.90) versus 0.82 (0.82-0.83) in the NEED and 0.87 (0.85-0.88) versus 0.82 (0.80-0.84) at external validation. Calibration for NEWS predictions underestimated risk in older patients and overestimated risk in the youngest, while calibration improved for IEWS with a substantial reclassification of patients from low to high risk and a standardized net benefit of 5-15% in the relevant risk range for all age categories. CONCLUSIONS The IEWS substantially improves in-hospital mortality prediction for all ED patients greater than or equal to18 years.
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Affiliation(s)
- Bart Gerard Jan Candel
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Emergency Medicine, Máxima Medical Center, Veldhoven, The Netherlands
| | - Søren Kabell Nissen
- Institute of Regional Health Research, Center South-West Jutland, University of Southern Denmark, Esbjerg, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Christian H Nickel
- Department of Emergency Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Wendy Thijssen
- Department of Emergency Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Admiraal de Ruyter Hospital, Goes, The Netherlands
| | | | - Mikkel Brabrand
- Institute of Regional Health Research, Center South-West Jutland, University of Southern Denmark, Esbjerg, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Emergency Medicine, Hospital of South-West Jutland, Esbjerg, Denmark
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Marincowitz C, Sbaffi L, Hasan M, Hodkinson P, McAlpine D, Fuller G, Goodacre S, Bath PA, Omer Y, Wallis LA. External validation of triage tools for adults with suspected COVID-19 in a middle-income setting: an observational cohort study. Emerg Med J 2023; 40:509-517. [PMID: 37217302 PMCID: PMC10359554 DOI: 10.1136/emermed-2022-212827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 05/04/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Tools proposed to triage ED acuity in suspected COVID-19 were derived and validated in higher income settings during early waves of the pandemic. We estimated the accuracy of seven risk-stratification tools recommended to predict severe illness in the Western Cape, South Africa. METHODS An observational cohort study using routinely collected data from EDs across the Western Cape, from 27 August 2020 to 11 March 2022, was conducted to assess the performance of the PRIEST (Pandemic Respiratory Infection Emergency System Triage) tool, NEWS2 (National Early Warning Score, version 2), TEWS (Triage Early Warning Score), the WHO algorithm, CRB-65, Quick COVID-19 Severity Index and PMEWS (Pandemic Medical Early Warning Score) in suspected COVID-19. The primary outcome was intubation or non-invasive ventilation, death or intensive care unit admission at 30 days. RESULTS Of the 446 084 patients, 15 397 (3.45%, 95% CI 34% to 35.1%) experienced the primary outcome. Clinical decision-making for inpatient admission achieved a sensitivity of 0.77 (95% CI 0.76 to 0.78), specificity of 0.88 (95% CI 0.87 to 0.88) and the negative predictive value (NPV) of 0.99 (95% CI 0.99 to 0.99). NEWS2, PMEWS and PRIEST scores achieved good estimated discrimination (C-statistic 0.79 to 0.82) and identified patients at risk of adverse outcomes at recommended cut-offs with moderate sensitivity (>0.8) and specificity ranging from 0.41 to 0.64. Use of the tools at recommended thresholds would have more than doubled admissions, with only a 0.01% reduction in false negative triage. CONCLUSION No risk score outperformed existing clinical decision-making in determining the need for inpatient admission based on prediction of the primary outcome in this setting. Use of the PRIEST score at a threshold of one point higher than the previously recommended best approximated existing clinical accuracy.
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Affiliation(s)
- Carl Marincowitz
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Laura Sbaffi
- Information School, The University of Sheffield, Sheffield, UK
| | - Madina Hasan
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Peter Hodkinson
- Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - David McAlpine
- Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Gordon Fuller
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Peter A Bath
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
- Information School, The University of Sheffield, Sheffield, UK
| | - Yasein Omer
- Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
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Miles I, Anderson M, Ren D, Coker T, Fennimore L. Use of the Modified Early Warning Score by Medical-Surgical Nurses to Initiate the Rapid Response Team: Impact on Patient Outcomes. J Nurs Care Qual 2023; 38:171-176. [PMID: 36729965 DOI: 10.1097/ncq.0000000000000680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Cardiac arrests are often preceded by several hours of physiological deterioration that may go undetected. LOCAL PROBLEM Cardiac arrests frequently occurred on medical-surgical units without prior rapid response team intervention. METHODS A pre/postintervention design was used to evaluate a protocol to guide the use of the Modified Early Warning Score (MEWS) by medical-surgical nurses to escalate the care of deteriorating adult patients. INTERVENTIONS Following staff education, the MEWS protocol was implemented across 8 medical-surgical units. RESULTS There was a significant increase in patients experiencing a rapid response prior to a cardiac arrest after implementing the MEWS protocol ( P < .0001). CONCLUSION Implementing a consistent review of MEWS values allows medical-surgical nurses to initiate assistance from a rapid response team that may prevent an inpatient cardiac arrest.
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Affiliation(s)
- Iman Miles
- WellStar Cobb Hospital, Austell, Georgia (Dr Miles); University of Pittsburgh School of Nursing; Pittsburgh, Pennsylvania (Drs Anderson, Ren, and Fennimore); and WellStar Center for Nursing Excellence, Austell, Georgia (Ms Coker)
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Candel BG, de Groot B, Nissen SK, Thijssen WA, Lameijer H, Kellett J. The prediction of 24-h mortality by the respiratory rate and oxygenation index compared with National Early Warning Score in emergency department patients: an observational study. Eur J Emerg Med 2023; 30:110-116. [PMID: 36729955 PMCID: PMC9946171 DOI: 10.1097/mej.0000000000000989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/10/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The ROX index combines respiratory rate and oxygenation to predict the response to oxygen therapy in pneumonia. It is calculated by dividing the patient's oxygen saturation, by the inspired oxygen concentration, and then by the respiratory rate (e.g. 95%/0.21/16 = 28). Since this index includes the most essential physiological variables to detect deterioration, it may be a helpful risk tool in the emergency department (ED). Although small studies suggest it can predict early mortality, no large study has compared it with the National Early Warning Score (NEWS), the most widely validated risk score for death within 24 h. AIM The aim of this study was to compare the ability of the ROX index with the NEWS to predict mortality within 24 h of arrival at the hospital. METHODS This was a retrospective observational multicentre analysis of data in the Netherlands Emergency Department Evaluation Database (NEED) on 270 665 patients attending four participating Dutch EDs. The ROX index and NEWS were determined on ED arrival and prior to ED treatment. RESULTS The risk of death within 24 h increased with falling ROX and rising NEWS values. The area under the receiving operating characteristic curves for 24-h mortality of NEWS was significantly higher than for the ROX index [0.92; 95% confidence interval (CI), 0.91-0.92 versus 0.87; 95% CI, 0.86-0.88; P < 0.01]. However, the observed and predicted mortality by the ROX index was identical to mortality of 5%, after which mortality was underestimated. In contrast, up to a predicted 24-h mortality of 3% NEWS slightly underestimates mortality, and above this level over-estimates it. The standardized net benefit of ROX is slightly higher than NEWS up to a predicted 24-h mortality of 3%. CONCLUSION The prediction of 24-h mortality by the ROX index is more accurate than NEWS for most patients likely to be encountered in the ED. ROX may be used as a first screening tool in the ED.
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Affiliation(s)
- Bart G.J. Candel
- Emergency Department, Maxima Medical Centre, Veldhoven, Noord-Brabant
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
| | - Bas de Groot
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
| | - Søren Kabell Nissen
- Institute of Regional Health Research, Center South-West Jutland, University of Southern Denmark, Esbjerg
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | | | - Heleen Lameijer
- Department of Emergency Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - John Kellett
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
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Alhmoud B, Bonnici T, Melley D, Patel R, Banerjee A. Performance of digital early warning score (NEWS2) in a cardiac specialist setting: retrospective cohort study. BMJ Open 2023; 13:e066131. [PMID: 36914194 PMCID: PMC10015672 DOI: 10.1136/bmjopen-2022-066131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 02/23/2023] [Indexed: 03/16/2023] Open
Abstract
INTRODUCTION Patients with cardiovascular diseases (CVD) are at significant risk of developing critical events. Early warning scores (EWS) are recommended for early recognition of deteriorating patients, yet their performance has been poorly studied in cardiac care settings. Standardisation and integrated National Early Warning Score 2 (NEWS2) in electronic health records (EHRs) are recommended yet have not been evaluated in specialist settings. OBJECTIVE To investigate the performance of digital NEWS2 in predicting critical events: death, intensive care unit (ICU) admission, cardiac arrest and medical emergencies. METHODS Retrospective cohort analysis. STUDY COHORT Individuals admitted with CVD diagnoses in 2020; including patients with COVID-19 due to conducting the study during the COVID-19 pandemic. MEASURES We tested the ability of NEWS2 in predicting the three critical outcomes from admission and within 24 hours before the event. NEWS2 was supplemented with age and cardiac rhythm and investigated. We used logistic regression analysis with the area under the receiver operating characteristic curve (AUC) to measure discrimination. RESULTS In 6143 patients admitted under cardiac specialties, NEWS2 showed moderate to low predictive accuracy of traditionally examined outcomes: death, ICU admission, cardiac arrest and medical emergency (AUC: 0.63, 0.56, 0.70 and 0.63, respectively). Supplemented NEWS2 with age showed no improvement while age and cardiac rhythm improved discrimination (AUC: 0.75, 0.84, 0.95 and 0.94, respectively). Improved performance was found of NEWS2 with age for COVID-19 cases (AUC: 0.96, 0.70, 0.87 and 0.88, respectively). CONCLUSION The performance of NEWS2 in patients with CVD is suboptimal, and fair for patients with CVD with COVID-19 to predict deterioration. Adjustment with variables that strongly correlate with critical cardiovascular outcomes, that is, cardiac rhythm, can improve the model. There is a need to define critical endpoints, engagement with clinical experts in development and further validation and implementation studies of EHR-integrated EWS in cardiac specialist settings.
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Affiliation(s)
| | - Tim Bonnici
- University College London, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Riyaz Patel
- University College London, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Amitava Banerjee
- University College London, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
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Ye L, Zhu M, Hong F, Zhang W, Song L. The value of Pediatric Early Warning Score combined with SBAR in neonatal pneumonia nursing: A retrospective cohort study. Medicine (Baltimore) 2023; 102:e33197. [PMID: 36897705 PMCID: PMC9997798 DOI: 10.1097/md.0000000000033197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/14/2023] [Indexed: 03/11/2023] Open
Abstract
To observe the effect of the Pediatric Early Warning System (PEWS) score combined with the situation-background-assessment-recommendation (SBAR) shift communication system in neonates with severe pneumonia in the pediatric intensive care unit. A total of 230 neonates admitted to the pediatric intensive care unit of our hospital from January 2018 to January 2021 were enrolled in this study. Participants were divided into an experimental group (110 patients, PEWS score combined with SBAR shift communication system) and a control group (120 patients, routine diagnosis and treatment and shift change). The early recognition rate, incidence of handover problems, and prognosis of critically ill children in the 2 groups were analyzed. Compared to the control group, the correct recognition rate of disease observation and early recognition rate of critically ill children in the experimental group were significantly higher, and the incidence of handover problems was significantly lower (P < .05). There was no significant difference in the incidence of asphyxia, heart failure, and toxic encephalopathy between both groups. The application of the PEWS score combined with the SBAR shift communication system can facilitate timely identification of deterioration of the condition of children with severe pneumonia, reduce handover problems, and help to implement interventions or rescue according to the changes in a patient's condition, which may be beneficial in improving the patient's prognosis.
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Affiliation(s)
- Lei Ye
- Department of Pediatrics, Nantong First People’s Hospital, Nantong, Jiangsu, China
| | - Meijun Zhu
- Department of Pediatrics, Nantong First People’s Hospital, Nantong, Jiangsu, China
| | - Fei Hong
- Department of Pediatrics, Nantong First People’s Hospital, Nantong, Jiangsu, China
| | - Weiyan Zhang
- Department of Pediatrics, Nantong First People’s Hospital, Nantong, Jiangsu, China
| | - Lei Song
- Department of Pediatrics, Nantong First People’s Hospital, Nantong, Jiangsu, China
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Holland M, Kellett J. The United Kingdom's National Early Warning Score: should everyone use it? A narrative review. Intern Emerg Med 2023; 18:573-583. [PMID: 36602553 PMCID: PMC9813902 DOI: 10.1007/s11739-022-03189-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 12/24/2022] [Indexed: 01/06/2023]
Abstract
This review critiques the benefits and drawbacks of the United Kingdom's National Early Warning Score (NEWS). Potential developments for the future are considered, as well as the role for NEWS in an emergency department (ED). The ability of NEWS to predict death within 24 h has been well validated in multiple clinical settings. It provides a common language for the assessment of clinical severity and can be used to trigger clinical interventions. However, it should not be used as the only metric for risk stratification as its ability to predict mortality beyond 24 h is not reliable and greatly influenced by other factors. The main drawbacks of NEWS are that measuring it requires trained professionals, it is time consuming and prone to calculation error. NEWS is recommended for use in acute UK hospitals, where it is linked to an escalation policy that reflects postgraduate experience; patients with lower NEWS are first assessed by a junior clinician and those with higher scores by more senior staff. This policy was based on expert opinion that did not consider workload implications. Nevertheless, its implementation has been shown to improve the efficient recording of vital signs. How and who should respond to different NEWS levels is uncertain and may vary according to the clinical setting and resources available. In the ED, simple triage scores which are quicker and easier to use may be more appropriate determinants of acuity. However, any alternative to NEWS should be easier and cheaper to use and provide evidence of outcome improvement.
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Affiliation(s)
- Mark Holland
- School of Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, A676 Deane Road, Bolton, BL3 5AB UK
| | - John Kellett
- Department of Emergency Medicine, University Hospital, Odense, Denmark
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Abuzer Ö. Evaluation of Short-Term Mortality Prediction Using Initial Lactate and NEWS+L at Admission in COVID-19 Patients. Disaster Med Public Health Prep 2023; 17:e333. [PMID: 36594175 DOI: 10.1017/dmp.2022.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To predict the short-term mortality of the serum lactate level and the National Early Warning Score + lactate (NEWS+L) at the time of first admission to the emergency department in COVID-19 patients. MATERIALS AND METHODS This retrospective analysis was performed by screening the data of COVID-19 patients over a 6-month period (from January 15, 2021, to June 15, 2021). The demographic, comorbidities, vital parameters, and lactate values, as well as C- reactive protein (CRP), blood urea nitrogen (BUN), and 28-day mortality data were recorded. RESULTS A total of 70 patients were included in our study. The median (25th - 75th percentile) age was 58 (47.3 - 73.5) years, and 33 (47.1%) patients were female. The mean lactate value was 1.6 (1.2 - 1.98) mmol/L, the mean NEWS was 6 (4-7.75), and the mean NEWS+L was 7.24 ± 2.54. Mortality occurred in 13 (18.2%) of the 70 patients at 28 days. Lactate, NEWS, and NEWS+L had no significant relationship with mortality. None of these parameters was able to predict mortality (P = 0.132, 0.670, and 0.994, respectively). CONCLUSION Our findings showed that the NEWS+L, NEWS, and lactate level could not predict short-term mortality in COVID-19 patients at the time of first admission.
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Affiliation(s)
- Özkan Abuzer
- Department of Emergency Medicine, University of Health Sciences Umraniye Training and Research Hospital, Istanbul, Turkey
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