国家早期预警评分系统评估急诊老年危重症患者死亡风险的有效性研究

A validation study of national early warning score in evaluation of death risk in elderly patients with critical illness

目的验证国家早期预警评分系统（NEWS）预测急诊老年危重症患者死亡风险的有效性及可行性，探讨更适合急诊老年危重症患者的评分方法。方法采用前瞻性病例对照研究方法，连续选择2015年1月至12月青岛大学医学院附属青岛市市立医院急诊抢救室收治的年龄≥60岁、住院时间〉24h的危重症患者，收集患者临床资料和急诊数据，以人急诊抢救室第一次生命体征监测值进行NEWS评分及危险度分级，追踪患者30d转归和预后并分为死亡组与存活组，采用多因素logistic回归模型分析NEWS危险度分级与患者死亡风险的关系。结果共纳入1950例急诊老年危重症患者，30d内死亡78例（4．0％），存活1872例（96．O％）。与存活组比较，死亡组年龄更大（岁：79．8±10．8比75．3±8．9，t=4．335，P〈0．001）、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分更高（分：22．9±4．6比18．2±4．8，t=8．487，P〈0．001），格拉斯哥昏迷评分（GCS）更低（分：12．2±4．5比13．4±5．2，t=-2．007，P=0．045），呼吸系统疾病患者比例较高（29．5％比17．9％，x2=12．742，P=0．013），NEWS评分明显升高（分：11．2±5．5比3．9±2．7，t=22．063，P〈0．001），NEWS分级高危和极高危患者比例明显升高（65．4％比15．8％，x2=263．125，P〈0．001）。随着NEWS危险度分级的升高，患者病死率也随之增高，低危、中危、高危、极高危患者病死率分别为0．81％（9／1108）、3．63％（18，496）、5．83％（13／223）、30．89％（38／123），差异有统计学意义（x2=179．741，P〈0．001）。Logistic回归分析显示，NEWS中危、高危和极高危的急诊老年危重症患者与30d内死亡存在显著的正相关关系，是预后死亡的高危人群；中危、高危和极高危患者30d内死亡风险分别是低危患者的4．600、9．052和54．598倍。结论NEWS评分可以较好地评估急诊老年危重症患者死亡风险，NEWS危险度分级可以量化、分类急诊老年危重症患者的死亡风险。

Objective To verify the validity and feasibility of national early warning score （NEWS） in evaluation of death risk in elderly patients with critical illness, in order to find out which scoring method is more suitable for elderly critical illness patients. Methods A prospective case-control study was conducted. The critical illness patients aged over 60 years old with the length of hospital stay over 24 hours, and admitted to Department of Emergency of Qingdao Municipal Hospital from January to December 2015 were enrolled. The clinical data including in emergency and the actual outcome of patients were collected, and the patients were divided into death group and survival group according to 30-day outcome. Patients in the two groups were assessed by using NEWS and risk classification according to the first results of vital signs monitoring. Multivariate logistic regression model was used to analyze the relationship between the NEWS classification and the risk of death in elderly critical ill patients. Results 1 950 emergency elderly patients with critical illness were enrolled, with 78 cases （4.0%） dead within 30 clays and 1 872 survived （96.0%）. Compared with the survival group, patients in death group were older （years： 79.8± 10.8 vs. 75.3 ± 8.9, t = 4.335, P 〈 0.001）, and had higher acute physiology and chronic health evaluation Ⅱ （APACHE Ⅱ ） score （22.9 ± 4.6 vs. 18.2 ± 4.8, t = 8.487, P 〈 0.001）, lower Glasgow coma scale （GCS） score （12.2±4.5 vs. 13.4±5.2, t = -2.007, P = 0.045）, higher incidence of respiratory system diseases （29.5% vs. 17.9%, X 2 = 12.742, P = 0.013）, higher NEWS score （11.2 ± 5.5 vs. 3.9 ± 2.7, t = 22.063, P 〈 0.001）, as well as higher proportion of patients with NEWS classification of high risk and very high risk （65.4% vs. 15.8%, X2 = 263.125, P 〈 0.001）. With the increase of NEWS risk classification, mortality rate was also increased, and the mortality rate in the patients with low, medium, high and very high risk were 0.81% （9/1 108）, 3.63% （18/496）, 5.83% （13/223）, 30.89% （38/123）, respectively, with statistically significant difference （X2 = 179.741, P 〈 0.001）. It was showed by logistic regression analysis that the NEWS score of elderly patients with critical illness were positively correlated with 30-day death. The 30-day death risk of patients with middle risk, high risk and very high risk was 4.600, 9.052 and 54.598 folds of the patients with low risk respectively. Conclusion NEWS score can be used to assess the risk of death in emergency elderly patients with critical illness. NEWS risk classification can quantify and classify the risk of death in the elderly patients with critical illness.