Early Warning Score Research Articles

Real-time machine learning model to predict short-term mortality in critically ill patients: development and international validation

BackgroundA real-time model for predicting short-term mortality in critically ill patients is needed to identify patients at imminent risk. However, the performance of the model needs to be validated in various clinical settings and ethnicities before its clinical application. In this study, we aim to develop an ensemble machine learning model using routinely measured clinical variables at a single academic institution in South Korea.MethodsWe developed an ensemble model using deep learning and light gradient boosting machine models. Internal validation was performed using the last two years of the internal cohort dataset, collected from a single academic hospital in South Korea between 2007 and 2021. External validation was performed using the full Medical Information Mart for Intensive Care (MIMIC), eICU-Collaborative Research Database (eICU-CRD), and Amsterdam University Medical Center database (AmsterdamUMCdb) data. The area under the receiver operating characteristic curve (AUROC) was calculated and compared to that for the National Early Warning Score (NEWS).ResultsThe developed model (iMORS) demonstrated high predictive performance with an internal AUROC of 0.964 (95% confidence interval [CI] 0.963–0.965) and external AUROCs of 0.890 (95% CI 0.889–0.891) for MIMIC, 0.886 (95% CI 0.885–0.887) for eICU-CRD, and 0.870 (95% CI 0.868–0.873) for AmsterdamUMCdb. The model outperformed the NEWS with higher AUROCs in the internal and external validation (0.866 for the internal, 0.746 for MIMIC, 0.798 for eICU-CRD, and 0.819 for AmsterdamUMCdb; p < 0.001).ConclusionsOur real-time machine learning model to predict short-term mortality in critically ill patients showed excellent performance in both internal and external validations. This model could be a useful decision-support tool in the intensive care units to assist clinicians.

Is the National Early Warning Score able to identify nursing activity load? A prospective observational study

BackgroundThe National Early Warning Score scale correlates well with the intensity of the patient's acute condition. It could also correlate with the nursing activity load and prove useful in defining and redistributing nursing resources based on the acuity of patients. AimTo assess whether patients' National Early Warning Score at hospital admission correlates with objective nursing demands and can be used to optimize the distribution of available care resources. MethodsThis single-center prospective study included patients admitted to the Department of Internal Medicine at the Civil Hospital in Altovicentino (Italy) between September 1 and December 31, 2022. Nursing activities were recorded for the first three days after admission and standardized to the daily mean as performance/5 min/patient/day. Linear regression was used to assess the correlation between nursing demands for different National Early Warning Scores. ResultsThis study included 333 patients. Their mean National Early Warning Score was 3.9 (standard deviation: 2.9), with 61 % (203/333) in the National Early Warning Score <5 category, 19.5 % (65/333) in the National Early Warning Score 5–6 category, and 19.5 % (65/333) in the National Early Warning Score >6 category. Their average daily care requirements increased from 22 (16–30) activities/5 min/patient/day in the low National Early Warning Score category to 30 (20–39) activities/5 min/patient/day in the intermediate National Early Warning Score category (p < 0.001) and 35 (23–45) activities/5 min/patient/day in the high National Early Warning Score category (p < 0.001). ConclusionThe National Early Warning Score correlates with nursing care activities for patients with an acute condition and can be used to optimize the distribution of available care resources.

Clinical and Laboratory Features and Maternal Outcomes in Pregnant Women with Critical Lung Damage in the COVID-19

Introduction. The spread of the delta strain of the SARS-CoV-2 virus during the third and fourth waves of the pandemic led to the fact that a large cohort of pregnant women and maternity women needed respiratory support, standard treatment methods had no effect, and negative outcomes for the mother and fetus has increased.Purpose of the study. The aim is to determine clinical and laboratory features and maternal outcomes in pregnant women with the coronavirus disease 2019 (COVID-19) and critical lung damage.Materials and methods. A comparative study was conducted, followed by a retrospective analysis of clinical and laboratory features, maternal outcomes in 56 pregnant women with COVID-19 treated in this maternity hospital in the first-fourth wave of the pandemic. The research method is continuous, sequential. The first group (main) consisted of 28 women with severe or extremely severe form of the course of COVID-19 and critical lung damage (more 75 %); The second group (comparison) — 28 pregnant women with a moderate form of the disease and lung damage of 25–50 %. Screening assessment of the degree of endogenous intoxication was carried out. The severity of the disease was determined by the evaluation scale National Early Warning Score (NEWS).Results. Laboratory parameters of patients at admission and at the height of the disease have statistically significant differences in the general blood test, such as higher levels of leukocytes, eosinophils, rod-shaped neutrophils, hemoglobin, as well as lymphopenia and monocytopenia in women of the main group at the height of the disease. At the same time, the hematological indices of intoxication in the main group exceed the value of these indicators in the comparison group by two times. Patients of both groups had high levels of acute-phase markers of inflammation — C-reactive protein and ferritin, — an indicator of tissue destruction of lactate dehydrogenase, however, both at admission and at the height of the disease, these indicators were statistically significantly higher in the group of women with critical lung damage. In general, 20/28 patients (71.4 %) of group 1 had an extremely severe course of the disease, 8/28 (28.6 %) had a severe course. In second group, 28/28 patients (100 %) had moderate-severe NCI (p = 0.000), while recovery was noted in all of them. Outcomes of COVID-19 in women with critical lung damage: recovered — 25/28 (89 %); 3/28 (10.7 %) the patients died from complications of COVID-19 of an extremely severe degree.Discussion. The most frequent laboratory anomaly was leukocytosis and a rod-shaped shift in the midst of the disease in women with critical lung damage, as well as a statistically significant increase in the level of C-reactive protein, lactate dehydrogenase, D-dimer. Pulmonary complications (parapneumonic pleurisy, pneumothorax, pneumomediastinum, hydrothorax, lung abscess) and extrapulmonary complications (encephalopathy, panic attacks, acute liver injury, sepsis, thromboembolic complications) were observed only with critical lung damage.Conclusion. In the laboratory, at the height of the disease, in the group of pregnant women with critical lung damage, leukocytosis and stab shift are statistically significantly more common. Hematological indices of intoxication, leukocyte and hematological, confirm endogenous intoxication at the height of the disease. A statistically significantly higher level of aspartate aminotransferase, lactate dehydrogenase, C-reactive protein, D-dimer is determined upon admission to the hospital and at the height of the disease as markers of systemic inflammatory response and cytolysis, which demonstrates the defeat of several organ systems simultaneously.

Comparing indicators of disease severity among patients presenting to hospital for urinary tract infections before and during the COVID-19 pandemic.

During the COVID-19 pandemic, patients may have delayed seeking healthcare for urinary tract infections (UTIs). This could have resulted in more severe presentation to hospital and different antibiotic usage. We explored evidence for such changes through existing national indicators of prescribing, and routine clinical data collected in the electronic health record (EHR). We carried out a retrospective cohort study of patients presenting to two UK hospitals for UTIs, comparing two indicators of disease severity on admission before and during the pandemic: intravenous (IV) antibiotic use, and National Early Warning Score 2 (NEWS2). We developed regression models to estimate the effect of the pandemic on each outcome, adjusting for age, sex, ethnicity and index of multiple deprivation. During the pandemic, patients were less likely to present to hospital for UTI with NEWS2 of 0 or 1 [adjusted odds ratio (aOR): 0.66; 95% confidence interval (CI): 0.52-0.85] compared with before, more likely to present with score 2 (aOR: 1.52; 95% CI: 1.18-1.94), whereas the likelihood of presenting with a NEWS2 of >2 remained the same (aOR: 1.06; 95% CI: 0.87-1.29). We did not find evidence that this limited increase in disease severity resulted in changes to IV antibiotic use on admission (adjusted risk ratio: 1.02; 95% CI: 0.91-1.15). There may have been a small increase in disease severity at hospital presentation for UTI during the pandemic, which can be detected using routine data and not through national indicators of prescribing. Further research is required to validate these findings and understand whether routine data could support a more nuanced understanding of local antimicrobial prescribing practices.

Role of the National Early Warning score and Modified Early Warning score for predicting mortality in geriatric patients with non-traumatic coma

Geriatric patients arriving in a non-traumatic coma (NTC) at the emergency department (ED) present substantial risks and necessitate prompt and appropriate care. The National Early Warning Score (NEWS) is a promising tool that can efficiently evaluate this vulnerable population. Current study was designed to assess the effectiveness of the NEWS for predicting the severity of illness in geriatric patients with NTC and identifying those at highest risk. Current study was performed involving geriatric patients (aged ≥65 years) with NTC who visited Chonnam National University Hospital between January and December 2022. NEWS and Modified Early Warning Scores (MEWS) were calculated at ED visits. The association of NEWS and MEWS for in-hospital death was evaluated by multivariable analysis. Out of 683 patients, 202 were non-survivors (29.6%). The NEWS and MEWS values of non-survivors were higher than those of survivors (NEWS, 7 [5–10] vs. 10 [8–12]; MEWS, 5 [4–6] vs. 7 [5–8]). The NEWS (adjusted odds ratio [aOR]; 1.253, 95% confidence interval [CI]: 1.181–1.329) and MEWS (aOR; 1.323, 95% CI: 1.206–1.451) were also significantly associated with in-hospital death. The area under the curve for the NEWS and MEWS was 0.721 (95% CI: 0.685–0.754) and 0.695 (95% CI: 0.659–0.730), respectively. The NEWS can be an effective tool for predicting severity of illness via in-hospital death in geriatric patients with NTC.

Safer and more efficient vital signs monitoring protocols to identify the deteriorating patients in the general hospital ward: an observational study.

The frequency at which patients should have their vital signs (e.g. blood pressure, pulse, oxygen saturation) measured on hospital wards is currently unknown. Current National Health Service monitoring protocols are based on expert opinion but supported by little empirical evidence. The challenge is finding the balance between insufficient monitoring (risking missing early signs of deterioration and delays in treatment) and over-observation of stable patients (wasting resources needed in other aspects of care). Provide an evidence-based approach to creating monitoring protocols based on a patient's risk of deterioration and link these to nursing workload and economic impact. Our study consisted of two parts: (1) an observational study of nursing staff to ascertain the time to perform vital sign observations; and (2) a retrospective study of historic data on patient admissions exploring the relationships between National Early Warning Score and risk of outcome over time. These were underpinned by opinions and experiences from stakeholders. Observational study: observed nursing staff on 16 randomly selected adult general wards at four acute National Health Service hospitals. Retrospective study: extracted, linked and analysed routinely collected data from two large National Health Service acute trusts; data from over 400,000 patient admissions and 9,000,000 vital sign observations. Observational study found a variety of practices, with two hospitals having registered nurses take the majority of vital sign observations and two favouring healthcare assistants or student nurses. However, whoever took the observations spent roughly the same length of time. The average was 5:01 minutes per observation over a 'round', including time to locate and prepare the equipment and travel to the patient area. Retrospective study created survival models predicting the risk of outcomes over time since the patient was last observed. For low-risk patients, there was little difference in risk between 4 hours and 24 hours post observation. We explored several different scenarios with our stakeholders (clinicians and patients), based on how 'risk' could be managed in different ways. Vital sign observations are often done more frequently than necessary from a bald assessment of the patient's risk, and we show that a maximum threshold of risk could theoretically be achieved with less resource. Existing resources could therefore be redeployed within a changed protocol to achieve better outcomes for some patients without compromising the safety of the rest. Our work supports the approach of the current monitoring protocol, whereby patients' National Early Warning Score 2 guides observation frequency. Existing practice is to observe higher-risk patients more frequently and our findings have shown that this is objectively justified. It is worth noting that important nurse-patient interactions take place during vital sign monitoring and should not be eliminated under new monitoring processes. Our study contributes to the existing evidence on how vital sign observations should be scheduled. However, ultimately, it is for the relevant professionals to decide how our work should be used. This study is registered as ISRCTN10863045. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/03) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 6. See the NIHR Funding and Awards website for further award information.

Comparison of eight prehospital early warning scores in life-threatening acute respiratory distress: a prospective, observational, multicentre, ambulance-based, external validation study

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. 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). 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. 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. Gerencia Regional de Salud, Public Health System of Castilla y León (GRS Spain). For the Spanish translation of the abstract see Supplementary Materials section.

Health-related quality of life after 12 months post discharge in patients hospitalised with COVID-19-related severe acute respiratory infection (SARI): a prospective analysis of SF-36 data and correlation with retrospective admission data on age, disease severity, and frailty

Long-term outcome and ‘health-related quality of life’ (HRQoL) following hospitalisation for COVID-19-related severe acute respiratory infection (SARI) is limited.ObjectiveTo assess the impact of HRQoL in patients hospitalised with COVID-19-related SARI...

MiVitals–Mixed Reality Interface for Vitals Monitoring: A HoloLens based prototype for healthcare practices

In this paper, we introduce MiVitals—a Mixed Reality (MR) system designed for healthcare professionals to monitor patients in wards or clinics. We detail the design, development, and evaluation of MiVitals, which integrates real-time vital signs from a biosensor-equipped wearable, VitalitiTM. The system generates holographic visualizations, allowing healthcare professionals to interact with medical charts and information panels holographically. These visualizations display vital signs, trends, other significant physiological signals, and medical early warning scores in a comprehensive manner. We conducted a User Interface/User Experience (UI/UX) study focusing on novel holographic visualizations and interfaces that intuitively present medical information. This approach brings traditional bedside medical information to life in the real environment through non-contact 3D images, supporting rapid decision-making, vital pattern and anomaly detection, and enhancing clinicians' performance in wards. Additionally, we present findings from a usability study involving medical doctors and healthcare practitioners to assess MiVitals' efficacy. The System Usability Scale study yielded a score of 84, indicating that the MiVitals system has high usability.

Compliance with maternal sepsis guidelines in a tertiary hospital in the Netherlands

ABSTRACT Objectives Sepsis is a common cause of maternal mortality and morbidity. Early detection and rapid management are essential. In this study, we evaluate the compliance with the implemented maternity-specific Early Warning Score (EWS), Rapid Response Team (RRT) protocol and the Surviving Sepsis Campaign (SSC) Hour-1 Bundle in a tertiary hospital in the Netherlands. Methods We performed a retrospective patient chart review from July 2019 to June 2020 at the Leiden University Medical Centre. We included women who received therapeutic antibiotics and were admitted for at least 24 hours. Results We included 240 women: ten were admitted twice and one woman three times, comprising 252 admissions. A clinical diagnosis of sepsis was made in 22 women. The EWS was used in 29% (n = 73/252) of admissions. Recommendations on the follow-up of the EWS were carried out in 53% (n = 46/87). Compliance with the RRT protocol was highest for assessment by a medical doctor within 30 minutes (n = 98/117, 84%) and lowest for RRT involvement (n = 7/23, 30%). In women with sepsis, compliance with the SSC Bundle was highest for acquiring blood cultures (n = 19/22, 85%), while only 64% (n = 14/22) received antibiotics within 60 minutes of the sepsis diagnosis. Conclusion The adherence to the maternity-specific EWS and the SSC Hour-1 bundle was insufficient, even within this tertiary setting in a high-income country.

A Quality Improvement Project to Reduce Rapid Response System Inequities for Patients with Limited English Proficiency at a Quaternary Academic Medical Center.

Recognition of clinically deteriorating hospitalized patients with activation of rapid response (RR) systems can prevent patient harm. Patients with limited English proficiency (LEP), however, experience less benefit from RR systems than do their English-speaking counterparts. To improve outcomes among hospitalized LEP patients experiencing clinical deteriorations. Quasi-experimental pre-post design using quality improvement (QI) statistics. All adult hospitalized non-intensive care patients with LEP who were admitted to a large academic medical center from May 2021 through March 2023 and experienced RR system activation were included in the evaluation. All patients included after May 2022 were exposed to the intervention. Implementation of a modified RR system for LEP patients in May 2022 that included electronic dashboard monitoring of early warning scores (EWSs) based on electronic medical record data; RR nurse initiation of consults or full RR system activation; and systematic engagement of interpreters. Process of care measures included monthly rates of RR system activation, critical response nurse consultations, and disease severity scores prior to activation. Main outcomes included average post-RR system activation length of stay, escalation of care, and in-hospital mortality. Analyses used QI statistics to identify special cause variation in pre-post control charts based on monthly data aggregates. In total, 222 patients experienced at least one RR system activation during the study period. We saw no special cause variation for process measures, or for length of hospitalization or escalation of care. There was, however, special cause variation in mortality rates with an overall pre-post decrease in average monthly mortality from 7.42% (n = 8/107) to 6.09% (n = 7/115). In this pilot study, prioritized tracking, utilization of EWS-triggered evaluations, and interpreter integration into the RR system for LEP patients were feasible to implement and showed promise for reducing post-RR system activation mortality.

Early warning scores for sepsis identification and prediction of in-hospital mortality in adults with sepsis: A systematic review and meta-analysis.

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. A systematic review with meta-analysis. 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. 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. 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. Healthcare systems in which EWS is already in place should consider whether there is any clinical benefit in adopting qSOFA or SIRS. This systematic review did not directly involve patient or public contribution to the manuscript.

A Systematic Review: Early Warning System for Hospital Wards

Most of the unexpected events occur in the hospital wards. An Early Warning System (EWS) is a system created to identify worsening patients outside the Intensive Care Unit (ICU). EWS is one of the requirements that must be met to get hospital accreditation. Hospitals have to choose the appropriate EWS to get optimal outcomes. This study aims to describe some of the EWS in the wards that have been researched and developed, as well as their performance in predicting severe adverse events (SAE). This study is a literature review design, conducting a systematic review by selecting relevant articles on Pub Med and Science Direct using the keyword "Early Warning Systems" in the 2018-2023 period. Out of 269 articles, only 12 articles that met the criteria. The selected articles are then systematically reviewed and analyzed. Based on the extraction results of 12 articles, 9 EWS were grouped into National Early Warning Score (NEWS) and its variants, Modified Early Warning Score (MEWS) and its variants, and EWS integrated with Electronic Medical Record (EMR). In choosing an EWS, hospitals must consider the complexity of the cases being managed and the capabilities of existing resources. The recommended EWS in hospital wards with limited resources is weighted EWS or EWS with combinations, such as NEWS and MEWS with variants. Meanwhile, hospitals that have used EMR can choose EWS integrated with EMR to increase their predictive value for SAE, as well as improve protocol compliance.

The prehospital NEW score to assess septic shock in-hospital, 30-day and 90-day mortality

BackgroundThe early identification of sepsis presenting a high risk of deterioration is a daily challenge to optimise patient pathway. This is all the most crucial in the prehospital setting to optimize triage and admission into the appropriate unit: emergency department (ED) or intensive care unit (ICU). We report the association between the prehospital National Early Warning Score 2 (NEWS-2) and in-hospital, 30 and 90-day mortality of SS patients cared for in the pre-hospital setting by a mobile ICU (MICU).MethodsSeptic shock (SS) patients cared for by a MICU between 2016, April 6th and 2021 December 31st were included in this retrospective cohort study. The NEWS-2 is based on 6 physiological variables (blood pressure, heart rate, respiratory rate, temperature, oxygen saturation prior oxygen supplementation, and level of consciousness) and ranges from 0 to 20. The Inverse Probability Treatment Weighting (IPTW) propensity method was applied to assess the association with in-hospital, 30 and 90-day mortality. A NEWS-2 ≥ 7 threshold was chosen for increased clinical deterioration risk definition and usefulness in clinical practice based on previous reports.ResultsData from 530 SS patients requiring MICU intervention in the pre-hospital setting were analysed. The mean age was 69 ± 15 years and presumed origin of sepsis was pulmonary (43%), digestive (25%) or urinary (17%) infection. In-hospital mortality rate was 33%, 30 and 90-day mortality were respectively 31% and 35%. A prehospital NEWS-2 ≥ 7 is associated with an increase in-hospital, 30 and 90-day mortality with respective RRa = 2.34 [1.39–3.95], 2.08 [1.33–3.25] and 2.22 [1.38–3.59]. Calibration statistic values for in-hospital mortality, 30-day and 90-day mortality were 0.54; 0.55 and 0.53 respectively.ConclusionA prehospital NEWS-2 ≥ 7 is associated with an increase in in-hospital, 30 and 90-day mortality of septic shock patients cared for by a MICU in the prehospital setting. Prospective studies are needed to confirm the usefulness of NEWS-2 to improve the prehospital triage and orientation to the adequate facility of sepsis.

Incorporation of age into patient early warning scores significantly improves mortality prediction.

Age is a critical factor for the assessment of patients attended by emergency medical services (EMSs). However, how age modifies early warning scores' (EWSs) predictive ability should be unveiled. To determine how age influences the performance of EWS [National Early Warning Score 2 (NEWS2), VitalPAC-Early Warning Score (ViEWS), Rapid Acute Physiology Score (RAPS) and modified Rapid Emergency Medicine Score (mREMS)] to predict 2-day mortality. The secondary objective was to determine the performance of EWSs at different age ranges. A prospective, observational study performed between November 2019 and July 2023. A multicenter, ambulance-based study, considering 38 basic life support units and six advanced life support units referring to four tertiary care hospitals. Eligible patients were adults recruited from among all phone requests for emergency assistance who were later evacuated to emergency departments. The primary outcome was 2-day in-hospital mortality (includes all-cause mortality). The main measures were demographical and vital signs needed for EWS calculation. A total of 8028 participants fulfilled the inclusion criteria, with 7654 survivors and 374 non-survivors. Among age ranges, the 2-day mortality was 2.8% for the ≤44 years, 3.3% for the 45-64 years, 4.1% for the 65-74 years and 6.7% for the ≥75-year age group. The inclusion of age significantly improved the Area Under the Curve (AUC) in all the scores (P = 0.006 for non-age-adjusted mREMS, P = 0.001 for NEWS2, P = 0.002 for ViEWS, P = 0.028 for RAPS, all compared with their counterparts with age). Our results demonstrated that the incorporation of age into the EWS improved the performance of the scores. These results will allow the EMS to improve patient management and resource optimization by including an easy-to-obtain variable.

Development and inter-rater reliability of a simple prehospital mobility score for use in emergency patients

BackgroundMobility assessment enhances the ability of vital sign-based early warning scores to predict risk. Currently mobility is not routinely assessed in a standardized manner in Denmark during the ambulance transfer of unselected emergency patients. The aim of this study was to develop and test the inter-rater reliability of a simple prehospital mobility score for pre-hospital use in ambulances and to test its inter-rater reliability.MethodFollowing a pilot study, we developed a 4-level prehospital mobility score based of the question”How much help did the patient need to be mobilized to the ambulance trolley”. Possible scores were no-, a little-, moderate-, and a lot of help. A cross-sectional study of inter-rater agreement among ambulance personnel was then carried out. Paramedics on ambulance runs in the North- and Central Denmark Region, as well as The Fareoe Islands, were included as a convenience sample between July 2020—May 2021. The simple prehospital mobility score was tested, both by the paramedics in the ambulance and by an additional observer. The study outcomes were inter-rater agreements by weighted kappa between the paramedics and between observers and paramedics.ResultsWe included 251 mobility assessments where the patient mobility was scored. Paramedics agreed on the mobility score for 202 patients (80,5%). For 47 (18.7%), there was a deviation of one between scores, in two (< 1%) there was a deviation of two and none had a deviation of three (Table 1).Inter-rater agreement between paramedics in all three regions showed a kappa-coefficient of 0.84 (CI 95%: 0.79;0.88). Between observers and paramedics in North Denmark Region and Faroe Islands the kappa-coefficient was 0.82 (CI 95%: 0.77;0.86).ConclusionWe developed a simple prehospital mobility score, which was feasible in a prehospital setting and with a high inter-rater agreement between paramedics and observers.

Preparedness for severe maternal morbidity in European hospitals: The MaCriCare study

PurposeTo evaluate obstetric units (OUs) and intensive care units (ICUs) preparedness for severe maternal morbidity (SMM). MethodsFrom September 2021 to January 2022, an international multicentre cross-sectional study surveyed OUs in 26 WHO Europe Region countries. We assessed modified early obstetric warning score usage (MEOWS), approaches to four SMM clinical scenarios, invasive monitoring availability in OUs, and access to high-dependency units (HDUs) and onsite ICUs. Within ICUs, we examined the availability of trained staff, response to obstetric emergencies, leadership, and data collection. Results1133 responses were evaluated. MEOWS use was 34.5%. Non-obstetric early warning scores were being used. 21.4% (242) of OUs provided invasive monitoring in the OU. A quarter lacked access to onsite HDU beds. In cases of SMM, up to 13.8% of all OUs indicated the need for transfer to another hospital. The transfer rate was highest (74.0%) in small units. 81.9% of centers provided onsite ICU facilities to obstetric patients. Over 90% of the onsite ICUs provided daily specialist obstetric reviews but lacked immediate access to key resources: 3.4% - uterotonic drugs, 7.5% - neonatal resuscitation equipment, 9.2% - neonatal resuscitation team, 11.4% - perimortem cesarean section equipment. 41.2% reported obstetric data to a national database. ConclusionGaps in provision exist for obstetric patients with SMM in Europe, potentially compromising patient safety and experience. MEOWS use in OUs was low, while access to invasive monitoring and onsite HDU and ICU facilities was variable. ICUs frequently lacked resources and did not universally collect obstetric data for quality control.

Comparison of NEWS2 and CURB65 Score in Predicting Mortality of Hospitalized patients with AECOPD

Aim: To determine the diagnostic accuracy of the NEWS2 and CURB-65 scores in predicting in-hospital mortality in patients with acute exacerbations of COPD, mortality during hospital stays is considered the gold standard. Study Design: Cross-sectional study-design. Place and duration of study: Department of Chest Medicine, JPMC, Karachi, from September 25, 2020, to January 25, 2021. Two hundred and twelve patients of both genders were included who were admitted because of acute COPD exacerbations. The National Early Warning Score 2 (NEWS2) and CURB-65 Score in the estimation and evaluation of hospital-related mortality were noted. Results: NEWS2 predicted 156(73.6%), CURB-65 predicted 72(34%) as high-risk patients, and in-hospital mortality was 39(18.4%). NEWS2 had shown sensitivity of 100%, specificity of 32.4%, diagnostic accuracy of 45%, PPV of 25.1%, and NPV of 100% as a prediction value of in-hospital mortality. CURB-65 had shown sensitivity of 76.9%, specificity of 75.7%, and diagnostic accuracy of 76%, PPV of 41.7%, and NPV of 93.6% as a prediction value of in-hospital mortality. Implication: It is recommended that individual analyses of these associated factors be performed in future studies for the formulation of novel, efficient scores that may be better predictors of mortality in AECOPD patients. Conclusion: Both of the scoring systems can be used for the purpose of AECOPD patients risk stratification as per clinicians’ preference and as the basic tools of assessment in a resource-poor country. Keywords: Acute exacerbation of COPD, NEWS2, CURB-65, In-hospital mortality

The role of lactate-to-albumin ratio to predict 30-day risk of death in patients with sepsis in the emergency department: a decision tree analysis

Background Accurately estimating the prognosis of septic patients on arrival in the emergency department (ED) is clinically challenging. The lactate-to-albumin ratio (LAR) has recently been proposed to improve the predictive performance of septic patients admitted to the ICU. Objectives This study aims to assess whether the LAR could be used as an early prognostic marker of 30-day mortality in patients with sepsis in the ED. Methods A prospective observational study was conducted in the ED of the Hospital of Merano. All patients with a diagnosis of sepsis were considered. The LAR was recorded on arrival in the ED. The primary outcome measure was mortality at 30 days. The predictive role of the LAR for mortality was evaluated with the area under the ROC curve, logistic regression adjusted for the Charlson Comorbidity Index value, National Early Warning Score, and Sequential Organ Failure score, and with decision tree analysis. Results 459 patients were enrolled, of whom 17% (78/459) died at 30 days. The median LAR of the patients who died at 30 days (0.78 [0.45–1.19]) was significantly higher than the median LAR of survivors (0.42 [0.27–0.65]) (p < 0.001). The discriminatory ability of the LAR for death at 30 days was 0.738, higher than that of lactate alone (0.692), and slightly lower than that of albumin alone (0.753). The decision trees confirmed the role of the LAR as an independent risk factor for mortality. Conclusion The LAR can be used as an index to better predict the 30-day risk of death in septic patients.

Effect of a lower target oxygen saturation range on the risk of hypoxaemia and elevated NEWS2 scores at a university hospital: a retrospective study

BackgroundThe optimal target oxygen saturation (SpO2) range for hospital inpatients not at risk of hypercapnia is unknown. The objective of this study was to assess the impact on oxygen usage...