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

BACKGROUND:This study aimed to evaluate the discriminatory performance of 11 vital sign-based early warning scores(EWSs)and three shock indices in early sepsis prediction in the emergency department(ED).METHODS:We performed a retrospective study on consecutive adult patients with an infection over 3 months in a public ED in Hong Kong.The primary outcome was sepsis(Sepsis-3 definition)within 48 h of ED presentation.Using c-statistics and the DeLong test,we compared 11 EWSs,including the National Early Warning Score 2(NEWS2),Modified Early Warning Score,and Worthing Physiological Scoring System(WPS),etc.,and three shock indices(the shock index[SI],modified shock index[MSI],and diastolic shock index[DSI]),with Systemic Inflammatory Response Syndrome(SIRS)and quick Sequential Organ Failure Assessment(qSOFA)in predicting the primary outcome,intensive care unit admission,and mortality at different time points.RESULTS:We analyzed 601 patients,of whom 166(27.6%)developed sepsis.NEWS2 had the highest point estimate(area under the receiver operating characteristic curve[AUROC]0.75,95%CI 0.70-0.79)and was significantly better than SIRS,qSOFA,other EWSs and shock indices,except WPS,at predicting the primary outcome.However,the pooled sensitivity and specificity of NEWS2≥5 for the prediction of sepsis were 0.45(95%CI 0.37-0.52)and 0.88(95%CI 0.85-0.91),respectively.The discriminatory performance of all EWSs and shock indices declined when used to predict mortality at a more remote time point.CONCLUSION:NEWS2 compared favorably with other EWSs and shock indices in early sepsis prediction but its low sensitivity at the usual cut-off point requires further modification for sepsis screening.

Effectiveness of Combined Application of Shock Index and Early Warning Scoring System in Patients with Acute Gastrointestinal Hemorrhage

Objective:To explore the effect of the combined application of the Shock Index(SI)and the Early Warning Score(EWS)in patients with acute gastrointestinal bleeding.Methods:Seventy patients with acute gastrointestinal bleeding admitted to a hospital from June 2022 to May 2024 were selected and randomly divided into two groups:the control group and the observation group,with 35 patients in each group.The control group received conventional emergency care measures,while the observation group received SI combined with NEWS emergency care measures.The treatment effects in both groups were compared.Results:The observation group had shorter waiting times for consultation(4.45±1.59 minutes),intravenous access establishment(6.79±2.52 minutes),hemostasis time(4.41±1.52 hours),and hospital stays(8.39±2.13 days)compared to the control group,which had times of 5.46±1.34 minutes,8.41±2.16 minutes,5.16±1.47 hours,and 10.26±2.98 days,respectively.The differences were statistically significant(P<0.05).Before management,there were no significant differences in the levels of hemoglobin,prealbumin,and serum protein between the two groups(P>0.05).However,after systematic emergency management,the serum indexes in both groups significantly improved,with the observation group showing greater improvement than the control group,and these differences were statistically significant(P<0.05).In the observation group,only one case of cardiovascular complications occurred during the rescue period,with an incidence rate of 2.86%.In contrast,the control group experienced eight cases of complications,including hemorrhagic shock,anemia,multi-organ failure,cardiovascular complications,and gastrointestinal rebleeding,with an incidence rate of 22.85%.The difference between the groups was statistically significant(P<0.05).Conclusion:The application of SI combined with EWS emergency care measures in patients with acute gastrointestinal hemorrhage can effectively improve serum indexes,shorten resuscitation time and hospital stay,and reduce the risk of complications such as hemorrhagic shock,anemia,infection,multi-organ failure,cardiovascular complications,acute renal failure,and gastrointestinal rebleeding.This approach has positive clinical application value.

Outcome prediction value of National Early Warning Score in septic patients with community-acquired pneumonia in emergency department: A single-center retrospective cohort study

BACKGROUND:To evaluate the accuracy of National Early Warning Score(NEWS)in predicting clinical outcomes(28-day mortality,intensive care unit[ICU]admission,and mechanical ventilation use)for septic patients with community-acquired pneumonia(CAP)compared with other commonly used severity scores(CURB65,Pneumonia Severity Index[PSI],Sequential Organ Failure Assessment[SOFA],quick SOFA[qSOFA],and Mortality in Emergency Department Sepsis[MEDS])and admission lactate level.METHODS:Adult patients diagnosed with CAP admitted between January 2017 and May 2019 with admission SOFA≥2 from baseline were enrolled.Demographic characteristics were collected.The primary outcome was the 28-day mortality after admission,and the secondary outcome included ICU admission and mechanical ventilation use.Outcome prediction value of parameters above was compared using receiver operating characteristics(ROC)curves.Cox regression analyses were carried out to determine the risk factors for the 28-day mortality.Kaplan-Meier survival curves were plotted and compared using optimal cut-off values of qSOFA and NEWS.RESULTS:Among the 340 enrolled patients,90 patients were dead after a 28-day follow-up,62 patients were admitted to ICU,and 84 patients underwent mechanical ventilation.Among single predictors,NEWS achieved the largest area under the receiver operating characteristic(AUROC)curve in predicting the 28-day mortality(0.861),ICU admission(0.895),and use of mechanical ventilation(0.873).NEWS+lactate,similar to MEDS+lactate,outperformed other combinations of severity score and admission lactate in predicting the 28-day mortality(AUROC 0.866)and ICU admission(AUROC 0.905),while NEWS+lactate did not outperform other combinations in predicting mechanical ventilation(AUROC 0.886).Admission lactate only improved the predicting performance of CURB65 and qSOFA in predicting the 28-day mortality and ICU admission.CONCLUSIONS:NEWS could be a valuable predictor in septic patients with CAP in emergency departments.Admission lactate did not predict well the outcomes or improve the severity scores.A qSOFA≥2 and a NEWS≥9 were strongly associated with the 28-day mortality,ICU admission,and mechanical ventilation of septic patients with CAP in the emergency departments.

Poor performance of the modified early warning score for predicting mortality in critically ill patients presenting to an emergency department

BACKGROUND:This study was undertaken to validate the use of the modified early warning score(MEWS) as a predictor of patient mortality and intensive care unit(ICU)/ high dependency(HD)admission in an Asian population.METHODS:The MEWS was applied to a retrospective cohort of 1 024 critically ill patients presenting to a large Asian tertiary emergency department(ED) between November 2006 and December2007.Individual MEWS was calculated based on vital signs parameters on arrival at ED.Outcomes of mortality and ICU/HD admission were obtained from hospital records.The ability of the composite MEWS and its individual components to predict mortality within 30 days from ED visit was assessed.Sensitivity,specificity,positive and negative predictive values were derived and compared with values from other cohorts.A MEWS of ≥4 was chosen as the cut-off value for poor prognosis based on previous studies.RESULTS:A total of 311(30.4%) critically ill patients were presented with a MEWS ≥4.Their mean age was 61.4 years(SD 18.1) with a male to female ratio of 1.10.Of the 311 patients,53(17%)died within 30 days,64(20.6%) were admitted to ICU and 86(27.7%) were admitted to HD.The area under the receiver operating characteristic curve was 0.71 with a sensitivity of 53.0%and a specificity of 72.1%in addition to a positive predictive value(PPV) of 17.0%and a negative predictive value(NPV)of 93.4%(MEWS cut-off of ≥4) for predicting mortality.CONCLUSION:The composite MEWS did not perform well in predicting poor patient outcomes for critically ill patients presenting to an ED.

Formulation of an Early Warning Infectivity Score System for Adult Patients with Acute Bacterial Diarrhea

The aim of our study was to develop a scoring system to predict whether diarrhea is of a bacterial origin and whether the diarrheal patients constitute a potential source of infection to others. Adults with acute diarrhea （n=424） were enrolled in the study. Logistic regression and standard regression coefficients were used to formulate the Early Warning Infectivity Score System for Adults with Acute Bacterial Diarrhea （EWIS-ABD）. Four risk factors were identified by logistic regression, including body temperature （P〈0.01）, abdominal pain （P〈0.01）, leukocyte count in stool （P〈0.01）, and unclean dietary history （P〈0.01）. EWIS-ABD was thus developed, in which the value 〉5 points was set as an indicator of bacterial diarrhea. The incidence of bacterial diarrhea increased along with the elevated score. EWIS-ABD was more specific for bacterial diarrhea than for viral diarrhea. The accuracy and reliability of EWIS-ABD was high by prospective validation in 478 patients with acute diarrhea.

The effect of the quality of vital sign recording on clinical decision making in a regional acute care trauma ward

Purpose： Recording vital signs is important in the hospital setting and the quality of this documentation influences clinical decision making. The Modified Early Warning Score （MEWS） uses vital signs to categorise the severity of a patient＇s physiological derangement and illustrates the clinical impact of vital signs in detecting patient deterioration and making management decisions. This descriptive study measured the quality of vital sign recordings in an acute care trauma setting, and used the MEWS to determine the impact the documentation quality had on the detection of physiological derangements and thus, clinical decision making. Methods： Vital signs recorded by the nursing staff of all trauma patients in the acute care trauma wards at a regional hospital in South Africa were collected from January 2013 to February 2013. Investigator- measured values taken within 2 hours of the routine observations and baseline patient information were also recorded. A MEWS for each patient was calculated from the routine and investigator-measured observations. Basic descriptive statistics were performed using EXCEL Results： The details of lgl newly admitted patients were collected. Completion of recordings was 81% for heart rate, 88~; for respiratory rate, 98~; for blood pressure, 92% for temperature and 41~ for GCS. The recorded heart rate was positively correlated with the investigator＇s measurement （Pearson＇s correlation coefficient of 0.76）; while the respiratory rate did not correlate （Pearson＇s correlation coefficient of 0.02）. In 59~ of patients the recorded respiratory rate （RR） was exactly 20 breaths per minute and 27~ had a recorded RR of exactly 15. Seven percent of patients had aberrant Glasgow Coma Scale readings above the maximum value of 15. The average MEWS was 2 for both the recorded （MEWS（R）） and investigator （MEWS（1）） vitals, with the range of MEWS（R） 0-7 and MEWS（1） 0-9. Analysis showed 59% of the MEWS（R） underestimated the physiological derangement （scores were lower than the MEWS（1））; 80%; of patients had a MEWS（R） requiring 4 hourly checks which was only completed in 2%;; 86% of patients had a MEWS（R） of less than three （i.e. not necessitating escalation of care）, but 33% of these showed a MEWS（1） greater than three （i.e. actually necessitating escalation of care）. Conclusion： Documentation of vital signs aids management decisions, indicating the physiological derangement of a patient and dictating treatment. This study showed that there was a poor quality of vital sign recording in this acute care trauma setting, which led to underestimation of patients＇ physi- ological derangement and an inability to detect deteriorating patients. The MEWS could be a powerful tool to empower nurses to become involved in the diagnosis and detection of deteriorating patients, as well as providing a framework to communicate the severity of derangement between health workers. However, it requires a number of strategies to improve the quality of vital sign recording, including continuing education, increasing the numbers of competent staff and administrative changes in vital sign charts.