Accuracy Of Early Warning Score Research Articles

Diagnostic accuracy of early warning system scores in the prehospital setting.

The utilisation of pre-hospital early warning scores in ambulance services is widely endorsed to promptly identify patients at risk of clinical deterioration. Early warning scores enable clinicians to estimate risk based on clinical observations and vital signs, with higher scores indicating an elevated risk of adverse outcomes. Local healthcare systems establish threshold values for these scores to guide clinical decision-making, triage, and response, necessitating a careful balance between identifying critically unwell patients and managing the challenge of prioritisation. Given the limited evidence for optimal early warning scores in emergency department and pre-hospital care settings, a systematic review by Guan et al. (2022) was undertaken to assess the diagnostic accuracy of early warning scores for predicting in-hospital deterioration when applied in the emergency department or pre-hospital setting. This commentary aims to critically appraise the methods used within the review Guan et al (2022) and expand upon the findings in the context of clinical practice.

Prognostic Accuracy of Early Warning Scores for Clinical Deterioration in Patients With COVID-19.

Background: Early Warning Scores (EWS), including the National Early Warning Score 2 (NEWS2) and Modified NEWS (NEWS-C), have been recommended for triage decision in patients with COVID-19. However, the effectiveness of these EWS in COVID-19 has not been fully validated. The study aimed to investigate the predictive value of EWS to detect clinical deterioration in patients with COVID-19.Methods: Between February 7, 2020 and February 17, 2020, patients confirmed with COVID-19 were screened for this study. The outcomes were early deterioration of respiratory function (EDRF) and need for intensive respiratory support (IRS) during the treatment process. The EDRF was defined as changes in the respiratory component of the sequential organ failure assessment (SOFA) score at day 3 (ΔSOFAresp = SOFA resp at day 3–SOFAresp on admission), in which the positive value reflects clinical deterioration. The IRS was defined as the use of high flow nasal cannula oxygen therapy, noninvasive or invasive mechanical ventilation. The performances of EWS including NEWS, NEWS 2, NEWS-C, Modified Early Warning Scores (MEWS), Hamilton Early Warning Scores (HEWS), and quick sepsis-related organ failure assessment (qSOFA) for predicting EDRF and IRS were compared using the area under the receiver operating characteristic curve (AUROC).Results: A total of 116 patients were included in this study. Of them, 27 patients (23.3%) developed EDRF and 24 patients (20.7%) required IRS. Among these EWS, NEWS-C was the most accurate scoring system for predicting EDRF [AUROC 0.79 (95% CI, 0.69–0.89)] and IRS [AUROC 0.89 (95% CI, 0.82–0.96)], while NEWS 2 had the lowest accuracy in predicting EDRF [AUROC 0.59 (95% CI, 0.46–0.720)] and IRS [AUROC 0.69 (95% CI, 0.57–0.81)]. A NEWS-C ≥ 9 had a sensitivity of 59.3% and a specificity of 85.4% for predicting EDRF. For predicting IRS, a NEWS-C ≥ 9 had a sensitivity of 75% and a specificity of 88%.Conclusions: The NEWS-C was the most accurate scoring system among common EWS to identify patients with COVID-19 at risk for EDRF and need for IRS. The NEWS-C could be recommended as an early triage tool for patients with COVID-19.

Improving accuracy and efficiency of early warning scores in acute care

Early warning scores (EWS) are an integral part of the care of acutely ill patients. Unfortunately, in the few studies where the accuracy of EWS has been tested it has been found to be lacking, with serious implications for quality of care. To determine if the provision of computer-aided scoring could increase the accuracy and efficiency of EWS calculations, when compared with the traditional pen-and-paper method, and to determine if it was acceptable to users. 26 nurses from two surgical assessment wards in two hospitals were studied. The study was conducted in three phases. Phase 1--a classroom-based exercise where nurses were given ten patient vignettes and asked to derive EWS using traditional pen-and-paper methods; Phase 2--the same as phase 1, but using a hand-held computer to derive EWS; Phase 3--the same as phase 2, but was a follow-up exercise undertaken in the ward environment, 4 weeks after computer-aided scoring was implemented in the two wards. Each phase closed with a user perception/attitudes questionnaire. Accuracy and efficiency--phase 1 was associated with a significantly lower overall accuracy (152/260, 58%) compared with phase 2 (96%; difference in proportions 38%, 95% confidence interval 31-44%, P < 0.0001). There was a small but significant reduction in accuracy from phase 2 (96%) to phase 3 (88%) (8% difference, P=0.006). The mean time to derive an EWS reduced from 37.9 seconds in phase 1 to 35.1 seconds in phase 2 (P=0.016), down to 24.0 seconds in phase 3 (P<0.0001). User acceptability: in phase 1, nurses favoured the pen-and-paper method in all respects except accuracy. In phase 2, nurses' views shifted significantly in favour of the hand-held computer, with little deterioration in the follow-up phase 3. A hand-held computer helps to improve the accuracy and efficiency of EWS in acute hospital care and is acceptable to nurses.

Predictors of Severity and Survival in Acute Pancreatitis

Early Warning Scores (EWS) is a widely used scoring system monitoring patient progress, which we have previously shown to predict outcome from acute pancreatitis. This study examined EWS from a larger group of patients to confirm if this predictive value held true. The EWS scores were compared with the Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, modified organ dysfunction scores, Imrie scores, computed tomography grading scores, and Ranson criteria for 181 admissions with acute pancreatitis. The accuracy of EWS in predicting outcome was determined by receiver operator characteristics. A total of 181 patients were identified with acute pancreatitis. On day 1 of admission, APACHE II scores were the most accurate predictor of mortality with an area under curve (AUC) values of 0.876, closely followed by EWS (AUC, 0.827). By day 2 and 3 after admission, the EWS was the most accurate predictor of mortality (AUC, 0.910 and 0.934, respectively). The APACHE II was the second most accurate scoring system at 48 and 72 hours (AUC, 0.892 and 0.911, respectively). The EWSs on days 2 and 3 after admission are sensitive and specific in predicting mortality from acute pancreatitis. It is as accurate as the APACHE II scores and easier to implement in daily practice.

Physiological observation track and trigger system

A patient observation chart was developed to combine physiological observation charting with the calculation and recording of an early warning score (EWS); this was named the Physiological Observation Track and Trigger System (POTTS). Reference to a table of instructions is no longer needed and the EWS can be calculated with minimal error. Increased frequency and accuracy of EWS recording assist in identifying patients at risk of deterioration and enhance patient safety.