Recognizing Early Warning Signs (EWS) in Patients Is Critically Important

Introduction: Monitoring vital signs is a basic indicator of a patient’s health status and allows prompt detection of delayed recovery or adverse effects and early intervention. Patients with adverse events during hospitalization often display clinical decline for several hours before the event is observed. Non-critical care Nurses’ inconsistent recognition and response to patient deterioration lead to an increase in the length of hospital stay, unexpected admissions to the ICU, and increased morbidity and mortality. Aim: The study aimed to assess the factors that facilitate or impede the detection of early warning signs among adult patients hospitalized in tertiary care settings. Training should be provided to improve nurses’ knowledge, practice and attitude toward early warning signs of deteriorating patients leading to enhanced clinical judgment, skills and decision-making in addressing alerts. Methodology: A literature search was carried out in various databases;these were Cumulative Index to Nursing and Allied Health Literature (CINHAL), Google Scholar, PubMed, Science Direct, and Sage. The search area was narrowed from 2017 to 2022. The keywords used were “prevalence” AND “unplanned ICU admission”, “the importance of early warning signs” “outcome failure in rescue” “patient deterioration, communication” “improvement in early detection” AND “patient outcome admission” AND “early warning signs” AND “Pakistan”. After the analysis process, around 33 articles that met the inclusion criteria and were most relevant to the scope and context of the current study were considered. Conclusion: Most of the studies had reviewed literature in a qualitative retrospective observational study, content analysis, mixed method, and quasi-experimental study. The literature review identified that long hours of shift, nurse staffing levels, missed vital signs, lack of nursing training and education, and communication impact nurses’ ability to recognize and respond to early warning signs.

Perceptions of Health Warning Signs in Seriously Ill Woman of Childbearing Age in Kinshasa

Introduction: For seriously ill women of childbearing age, perceived health warning signs may influence decision of whether or not to seek care. Inaccurate perceptions of patients and those around them may lead to attitudes that delay seeking care. This study analyzes perceptions of danger and related delays to seek care in Kinshasa. Methods: Sixty deceased women who died between March and April 2004 were taken away from two Kinshasa mortuaries. History of disease and deaths were reconstructed through medical records and semi-structured interviews of family members and leaders. The Qualitative Software Research was used to conduct a qualitative analysis. Results: Perceived health warning signs had five manifestations: Specific clinical health warning signs, aggravation of non-specific signs, persistence of signs, indirect danger signs and superstitious signs. The incorrect perception of the signs was an important cause of late awareness of the danger and delayed decision to seek care. Conclusion: Misunderstandings of signs often delayed awareness of danger as well as decisions to seek appropriate care. Educational programs teaching health warning signs should be designed to promote the timely use of facilities.

Recognition of Warning Signs by the Patient with Ischemic Stroke and Impact on Emergency Department Admission Times

The general objective of this study was to assess the impact of the recognition of warning, signs of ischemic stroke, on the reduction of emergency admission times and the improvement of the prognosis of the patient suffering from ischemic stroke in the emergency department of the Yaounde central hospital. Methods: This was a prospective study with a descriptive and analytical aim carried out in the medical emergency department of the central hospital of Yaounde over a period of 3 months, going from October to December 2020. All patients admitted to emergency departement, during this period, for a diagnosis of ischemic stroke confirmed by a brain CT scan were included in the study. The data was collected on a survey sheet divided into 3 sections: the patient, the assessment of his knowledge and his reaction to the stroke. The variables studied were socio-demographic data, cardiovascular risk factors and warning signs of stroke. Data analysis was conducted with Census and Survey Processing System (CSPRO). Results: During the study period, 62 patients met the inclusion criteria. Adults under 50 (41.94%) were the most represented age group. The mean age of the patients was 52.3 years with ranges ranging from 36 to 82 years. The sex ratio was 1.38 in favor of women. The most common unmodifiable cardiovascular risk factor was age over 55 years 44%. High blood pressure 61% was the most common modifiable risk factor. More than half of the study population had no knowledge of the warning signs of ischemic stroke. The most well-known warning sign was 40% mouth deformation. The anamnesis noted that the weakness of the hemibody, the limb or the leg was found in our cohort in 77% of cases, followed by balance disorder (73%) and speech disorder (50%). The main associated sign was asthenia 32%. Direct admission to hospital through the emergency department was the first call for alert 58%, followed by self-medication 32% and seeking help from a family member 31%. The emergency department admission time was over 4 hours 30 minutes in more than half of the cases. Conclusion: Ischemic stroke is an important cause of death in sub-Saharan Africa in the acute phase. Information, education and communication about the warning signs of ischemic stroke reduce the time to emergency room visits and improve the prognosis of these patients.

Incidence and warning signs for complications of human brucellosis: a multi-center observational study from China

Background Brucellosis is a severe zoonotic disease that is often overlooked, particularly in impoverished countries. Timely identification of focal complications in brucellosis is crucial for improving treatment outcomes. However, there is currently a lack of established indicators or biomarkers for diagnosing these complications. Therefore, this study aimed to investigate potential warning signs of focal complications in human brucellosis, with the goal of providing practical parameters for clinicians to aid in the diagnosis and management of patients.Methods A multi-center cross-sectional study was conducted in China from December 2019 to August 2021. The study aimed to investigate the clinical characteristics and complications of patients with brucellosis using a questionnaire survey and medical record system. The presence of warning signs for complications was assessed using univariate and multivariate logistic regression models. Receiver operating characteristic (ROC) curves and the area under the curve (AUC) were used for variable screening and model evaluation.Results A total of 880 participants diagnosed with human brucellosis were enrolled. The median age of the patients was 50 years [interquartile range (IQR): 41.5-58.0], and 54.8% had complications. The most common organ system affected by complications was the osteoarticular system (43.1%), with peripheral arthritis (30.0%), spondylitis (16.6%), paravertebral abscess (5.0%), and sacroiliitis (2.7%) being the most prevalent. Complications in other organ systems included the genitourinary system (4.7%), respiratory system (4.7%), and hematologic system (4.6%). Several factors were found to be associated with focal brucellosis. These factors included a long delay in diagnosis [odds ratio (OR) = 3.963, 95% confidence interval(CI): 1.906-8.238 for > 90 days], the presence of underlying disease (OR = 1.675, 95%CI: 1.176-2.384), arthralgia (OR = 3.197, 95%CI: 1.986-5.148), eye bulging pain (OR = 3.482, 95%CI: 1.349-8.988), C-reactive protein (CRP) > 10 mg/L (OR = 1.910, 95%CI: 1.310-2.784) and erythrocyte sedimentation rate (ESR) elevation (OR = 1.663, 95%CI: 1.145-2.415). The optimal cutoff value in ROC analysis was > 5.4 mg/L for CRP (sensitivity 73.4% and specificity 51.9%) and > 25 mm/h for ESR (sensitivity 47.9% and specificity 71.1%).Conclusions More than 50% of patients with brucellosis experienced complications. Factors such as diagnostic delay, underlying disease, arthralgia, eye pain, and elevated levels of CRP and ESR were identified as significant markers for the development of complications. Therefore, patients presenting with these conditions should be closely monitored for potential complications, regardless of their culture results and standard tube agglutination test titers.

The accuracy of newly proposed warning signs in the third edition of Malaysian guideline on the management of dengue infection in adult

Objective:To evaluate the accuracy of persistent vomiting and persistent diarrhoea proposed in the Malaysian dengue guideline.Methods:The eligibility criteria were dengue patients with vomiting or/and diarrhoea at the earliest day of illness without other warning signs.Vomiting and diarrhoea categorised by three or more episodes over 24 h were considered as warning signs.Sensitivity,specificity,positive predictive value and negative predictive value were calculated.Results:There were a total of 479 patients,of whom 36(7.5%)got severe dengue and 443(92.5%)got dengue with warning signs.The overall accuracy ranged from 33.3%to 72.7%for sensitivity,28.8%to 56.5%for specificity,1.8%to 14.5%for positive predictive value and 88.5%to 96.3%for negative predictive value.There were 16 false negative.Conclusions:The newly proposed warning signs in the third edition of Malaysian dengue guideline may not be effective in predicting severe dengue.

Predicting severe dengue using quantified warning signs.A retrospective cohort study

Objective:To develop and evaluate predictive models by quantifying warning signs prior to the development of severe dengue.Methods:A retrospective cohort study was conducted in which the total number of warning signs each day was compared between dengue with warning signs and severe dengue.Multivariate logistic regression with forward likelihood ratio method was employed to achieve the best fit models for the prediction of severe dengue.The models were also being explored by adding diarrhoea and removing lethargy.Receiver operating characteristics were then used in these best fit models to identify suitable cut-off probability values derived from the equation of the models.Results:Median age of patients was 26 years old(interquartile range was 15 years)and 65.3%(1110)were males.Age with total number of warning signs at day one of illness(model T1)and age with total number of warning signs at day two of illness(model T2)were identified as the best fit models.The best probability cut-offs for model T1 was 0.0506 with 10.1%positive predictive value,96.4%negative predictive value,99.4%sensitivity,1.8%specificity;for model T2 was 0.0503 with 10.2%positive predictive value,96.4%negative predictive value,99.4%sensitivity,1.8%specificity.Conclusions:The models developed in this study might not reduce the burden effectively.Clinicians may use the models but the models must be re-validated in their clinical settings as the effect size might vary.Furthermore,the risk and benefit in selecting the cut-off values should be evaluated before implementing such models.

Comparison of vomiting and diarrhoea frequency among dengue-infected patients

Objective:To compare the differences of vomiting and diarrhoea frequency between dengue with warning signs and severe dengue,and to describe the sites of mucosal bleeding among dengue-infected patients.Methods:This was a retrospective cohort study which included patients with laboratory-confirmed dengue infection along with clinical diagnosis of dengue.Exclusion criteria were patients with haematological disorders or any other malignancy.The vomiting and diarrhoea frequency on each day(Day 1 to Day 5)between dengue with warning signs and severe dengue were compared by using Mann-Whitney U test.The different sites of mucosal bleeding were stratified according to the diagnoses and displayed by bar charts.Results:Out of 1700 patients,1003(59.0%)had vomiting and 587(34.5%)had diarrhoea.Both vomiting and diarrhoea frequency were not statistically different between dengue with warning signs and severe dengue from Day 1 to Day 5.Gum bleeding,hematemesis and menorrhagia were the only sites of mucosal bleeding seen in severe dengue for the first three days of illness.Hematemesis was seen only in severe dengue during the first day of illness but not in dengue with warning signs.Conclusions:The frequency of vomiting and diarrhoea could not differentiate severe dengue from dengue with warning signs.Nevertheless,it is important to have high index of suspicion for dengue when patients are presented with diarrhoea.The different sites of mucosal bleeding could possibly predict severe dengue,especially hematemesis on the first three days of illness.

Biomarkers in differentiating clinical dengue cases:A prospective cohort study

Objective:To evaluate five biomarkers(neopterin,vascular endothelial growth factor-A,thrombomodulin,soluble vascular cell adhesion molecule 1 and pentraxin 3)in differentiating clinical dengue cases.Methods:A prospective cohort study was conducted whereby the blood samples were obtained at day of presentation and the final diagnosis were obtained at the end of patients’follow-up.All patients included in the study were 15 years old or older,not pregnant,not infected by dengue previously and did not have cancer,autoimmune or haematological disorder.Median test was performed to compare the biomarker levels.A subgroup Mann-Whitney U test was analysed between severe dengue and non-severe dengue cases.Monte Carlo method was used to estimate the 2-tailed probability(P)value for independent variables with unequal number of patients.Results:All biomarkers except thrombomodulin has P value<0.001 in differentiating among the healthy subjects,non-dengue fever,dengue without warning signs and dengue with warning signs/severe dengue.Subgroup analysis for all the biomarkers between severe dengue and non-severe dengue cases was not statistically significant except vascular endothelial growth factor-A(P<0.05).Conclusions:Certain biomarkers were able to differentiate the clinical dengue cases.This could be potentially useful in classifying and determining the severity of dengue infected patients in the hospital.

Clinical predictors of severe dengue:a systematic review and meta-analysis

Background:Severe dengue is a life-threatening complication;rapid identifcation of these cases,followed by adequate management is crucial to improve the clinical prognosis.Therefore,this study aimed to identify risk factors and predictors of severe dengue.Methods:A literature search for studies reporting risk factors of severe dengue among individuals with dengue virus infection was conducted in PubMed,Scopus and Web of Science database from inception to December 31,2020.Pooled odds ratios(ORs)for patients’demographic characteristics,co-morbidities,and warning signs were estimated using an inverse variance heterogeneity model.Results:We included 143 articles in the meta-analysis from a total of 13090 articles retrieved from the literature search.The risk factors of severe dengue were:being a child[OR=1.96;95%confdence interval(CI):1.22–3.13],secondary infection(OR=3.23;95%CI:2.28–4.57),and patients with pre-existing diabetes(OR=2.88;95%CI:1.72–4.81)and renal disease(OR=4.54;95%CI:1.55–13.31).Warning signs strongly associated with severe disease were increased haematocrit with a concurrent decrease in platelet count(OR=5.13;95%CI:1.61–16.34),abdominal pain(OR=2.00;95%CI:1.49–2.68),lethargy(OR=2.73;95%CI:1.05–7.10),vomiting(OR=1.80;95%CI:1.43–2.26),hepa‑tomegaly(OR=5.92;95%CI:3.29–10.66),ascites(OR=6.30;95%CI:3.75–10.60),pleural efusion(OR=5.72;95%CI:3.24–10.10)and melena(OR=4.05;95%CI:1.64–10.00).Conclusions:Our meta-analysis identifed children,secondary infection,diabetes and renal disease(s)as important predictors of severe dengue.Our fnding also supports the predictive ability of the WHO warning signs to iden‑tify severe dengue.These fndings are useful for clinicians to identify severe dengue for management and timely interventions.

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.

Changing pattern of symptoms in dengue patients over the years:A review and meta-analysis

Objective:To describe the pattern of vomiting,diarrhoea and abdominal pain among dengue patients over the years in different age groups.Methods:Electronic databases were used to include studies that reported symptoms of vomiting,diarrhoea or/and abdominal pain.Confirmation of dengue was conducted by laboratory diagnosis.The exclusion criteria were case reports and studies which only described specific settings,focused only on dengue haemorrhagic fever or severe dengue and co-infection.Meta-analysis was performed on the overall prevalence of vomiting,diarrhoea and abdominal pain which was then stratified according to years and different age groups.Results:Out of the 2002 studies,32 studies were included.All studies were conducted between 1995 and 2014.The studies were conducted in 18 countries with a total sample size of 69466.The predominant symptom was abdominal pain before 2004 but became vomiting thereafter.The prevalence of vomiting was constant throughout the years(20%-40%),but the prevalence of abdominal pain reduced from 30%-50%to 20%-30%.The prevalence of diarrhoea increased steadily from 5%to 30%.Abdominal pain was the predominant symptom in children(75.03%)[95%confidence interval(CI):64.89%-85.17%],while diarrhoea was predominant in adults(32.42%)(95%CI:23.96%-40.88%).For studies which included all ages,the predominant symptom was vomiting(45.18%)(95%CI:33.87%-56.49%).Conclusions:The knowledge of symptomatic pattern change could assist clinicians in diagnosing and managing dengue patients.Future studies could address the occurrence of this change and the difference in symptoms between children and adults.