National Early Warning Score Score Research Articles

Editorial Volume 18 Issue 4 – Decision-making in acute medicine

Acute physicians make patient-centred decisions at the start of the patient’s hospital journey. Dozens more decisions are made by the individual members of the MDT (and, of course, by the patient) during the in-patient period. Decisions are made at every level of seniority and experience and range widely in scope and impact. The original articles in this issue are connected by a common thread: phenomena that inform and influence the decisions made by acute physicians. How do you obtain adequate data to make sound decisions about individual patient care? It is often necessary to collate data around previous admissions and investigations at other healthcare institutions; a process fraught with complications. In this issue Ghelani et al1 undertook the onerous task of calling the main switchboard of all 175 acute hospitals in England on six occasions. Their aim was to identify how long it takes for an outside caller to finally contact a human operative who could put them through to the the correct person or extension. Most healthcare professionals will have some insight into the communication barriers that lie between practitioners in different hospitals, and the inordinate amount of time spent on the phone trying to gain patient information from another institution. The authors’ findings that automated messages and call steering systems impact significantly upon the time required for straightforward datagathering tasks should resonate with many for us. Hopefully, this study will provide substrate for future quality improvement efforts in the UK. How do you decide if your patient is well enough for transfer? The National Early Warning Score (NEWS) is now common currency in acute hospitals. This simple aggregate scoring system uses physiological parameters measures at the bedside and is used to inform assessments about patient acuity. There is currently significant research attention focused on the NEWS’ powers of prognostication. In a previous issues of this journal, we reported how vital sign abnormalities in the Emergency Department are predictors of poor outcomes (although not mortality) 2; monitoring of post-discharge vital signs in the community may predict readmission;3 and minor fluctuations in respiratory rate (in combination with other vital signs) may predicted clinical outcomes several days in advance.4 In this issue Subbe et all5 explore whether patients with low or unchanging NEWS scores are unlikely to deteriorate in future and could therefore be considered for transfer. How do you decide whether your patient requires intravenous fluids? In their qualitative study, Lloyd et al 6thematically analysed data from interviews with clinicians to better delineate the decision-making processes surrounding fluid therapy. They describe how doctors use vital signs, clinical presentation and their own gestalt, and – curiously – these approaches may be affected by the clinical environment and workload, and are not informed by local or national guidelines.

Predictive role of monocyte-to-lymphocyte ratio in patients with Klebsiella pneumonia infection: A single-center experience.

The aim of the study is to explore whether monocyte–to-lymphocyte ratio (MLR) provides predictive value of the severity in patients with Klebsiella pneumonia infection (KPI).Patients in a tertiary medical center with Klebsiella pneumonia infection from 2014 to 2017 were recruited in this study. Patients with Klebsiella pneumonia infection were stratified into two groups based on the National Early Warning Score (NEWS). MLR was calculated by dividing monocytes count by lymphocytes count obtained from routine blood examination. The area under the curve (AUC) values was determined using the receiver-operating characteristic (ROC) curve. The correlation between the variables was tested with Pearson or Spearman correlation analysis. Ordinal logistic regression analysis was used to assess the relationship between MLR and the severity of Klebsiella pneumonia infection.One hundred fifty-two patients were finally enrolled for analysis. Among those, 43 (28.29%) cases had severe KPI. MLR was found to be an independent risk factor of the serious Klebsiella pneumonia infection (OR: 23.74, 95% CI: 5.41–104.11, P < .001). Besides, MLR was positively correlated with NEWS score (r = 0.57, P < .001). In the receiver-operating characteristic (ROC) curve analysis, MLR, with an optimal cut-off value of 0.665, predicted the severe coronary lesion with a sensitivity of 79.4% and specificity of 84.4%.MLR was an independent predictor of the severe Klebsiella pneumonia infection. Compared with neutrophil-to-lymphocyte ratio (NLR), MLR has a better performance to evaluate the severity of Klebsiella pneumonia infection.

Comparison of early warning scores in patients with COPD exacerbation: DECAF and NEWS score

BackgroundThe National Early Warning Score 2 (NEWS2) includes two oxygen saturation scales; the second adjusts target saturations to 88%–92% for those with hypercapnic respiratory failure. Using this second scale in...

Application value of thromboelastography in patients with multiple trauma in emergency department

To explore the value of thromboelastography (TEG) in patients with multiple trauma in emergency department. The clinical data of 302 patients with multiple trauma hospitalized in the emergency department of Gansu Provincial People's Hospital from August 2015 to December 2018 were retrospectively analyzed. The general clinical data of the patients were collected. The patients were divided into three groups according to injury severity score (ISS): mild injury group (ISS ≤ 16), serious injury group (ISS 17-25), and severe injury group (ISS > 25). The results of vital signs, routine coagulation test, blood routine, blood biochemistry, and arterial blood gas analysis were recorded, and the National early warning score (NEWS) was calculated. TEG parameters were analyzed. Pearson correlation analysis and linear regression analysis were used to analyze the correlation between TEG indicators and NEWS score. Receiver operator characteristic (ROC) curve was plotted to analyze the diagnostic efficacy of TEG indicators for disseminated intravascular coagulation (DIC) in patients with severe injury. 299 patients were enrolled in the final analysis, including 92 patients in the mild injury group, 109 in the serious injury group and 98 in the severe injury group. With the increase in trauma severity, the NEWS score and TEG indicators including coagulation reaction time (R value) and blood clot generation time (K value) were gradually increased [NEWS score in mild, serious, and severe injury group was 3.46±0.89, 5.85±0.62, 9.75±1.76, R value (minutes) was 5.8±2.8, 7.8±2.6, 11.7±3.0, and K value (minutes) was 2.4±1.0, 4.2±1.4, 5.5±2.9, respectively], and blood clot generation rate (α angle), maximum width value (MA value) and coagulation index (CI) were gradually decreased [α angle (degree angle) in mild, serious, and severe injury group was 66.9±13.5, 55.7±22.9, 46.8±26.3, MA value (mm) was 51.8±9.7, 48.1±17.0, 38.5±15.2, and CI was 2.0±3.6, -2.8±3.5, -6.7±2.9, respectively], the differences were statistically significant among the groups (all P < 0.05). Pearson correlation analysis showed that the NEWS score was positively correlated with R and K values (r value was 0.463,0.588, respectively, both P < 0.01), and it was negatively correlated with α angle, MA value and CI (r value was -0.622, -0.689, -0.902, respectively, all P < 0.01). Linear correlation analysis showed that for every 1 minute increase in R value, NEWS score increased by 0.882 [95% confidence interval (95%CI) = 0.691 to 1.073]; for every 1 minute increase in K value, NEWS score increased by 0.484 (95%CI = 0.408 to 0.559); for every 1degree angleincrease in α angle, NEWS score decreased by 2.910 (95%CI = -3.325 to -2.494); for every 1 mm increase in MA value, NEWS score decreased by 2.223 (95%CI = -2.488 to -1.958); for every 1 increase in CI, NEWS score decreased by 1.292 (95%CI = -1.362 to -1.221). The R and K values in DIC patients (n = 37) of the severe injury group were significantly higher than those in non-DIC patients [n = 61; R value (minutes): 15.8±5.6 vs. 9.8±2.6, K value (minutes): 7.6±3.1 vs. 4.3±2.2], and α angle, MA value and CI were significantly lowered [α angle (degree angle): 48.7±19.8 vs. 59.6±26.2, MA value (mm): 37.5±19.2 vs. 49.2±18.6, CI: -8.5±3.4 vs. -5.2±3.1], the differences were statistically significant between the two groups (all P < 0.05). ROC curve analysis showed that the area under ROC curve (AUC) of the R and K values for predicting DIC was 0.999 and 0.958, respectively. When the optimal cut-off value of R value was 12.3 minutes, the sensitivity and specificity were 97.5% and 100%; when the optimal cut-off value of K value was 5.7 minutes, the sensitivity and specificity were 92.5% and 82.0%. The AUC of α angle, MA value and CI were 0.084, 0.060 and 0.114, which had no predictive value. TEG indicators have clinical value on predicting the severity of illness in patients with multiple trauma. The changes in R and K values are effective indicators to judge the risk of DIC in patients with severe multiple trauma.

P094: Evaluation of the National Early Warning Score (NEWS) to guide the orientation of patients with sepsis in the emergency department

Introduction: The Canadian Triage and Acuity Scale (CTAS) identifies the level of urgency when patients arrive to the Emergency department (ED). Sepsis is challenging to recognize and is associated with significant mortality (30 to 50%). The integration of the COP criteria allows for earlier detection and management of sepsis.The CTAS's validity and reliability are debated. The NEWS score has been suggested to allow a timely recognition of sepsis.Objectives:To describe patient orientation at ED triage with the NEWS vs. the CTAS and COP criteria and to identify the NEWS's ability to detect patients who will require admission to critical care. Methods: Design: A retrospective cohort study of ED 225 patients (January-November 2018) is was constituted. Participants: Patients were included if they were aged ≥18, consulting to the ED, presented one of the 32 diagnoses included in the CMI-10. Measurements: Retained variables are sex, age, CTAS score and level of care. The NEWS score was calculated from triage vital signs. Main outcome was Patient orientation after ED triage using CTAS vs the NEWS score. Descriptive statistics to determine patient orientation based on the NEWS and CTAS were performed. Fisher tests (α = 0.05) were used to assess a possible association between both triage scales and identify the NEWS's ability to detect patients who will require admission to critical care during. Sample size was calculated in order to detect a 15% difference between actual orientation and theoretical orientation based on the NEWS. Results: The retained cohort (45% men) were aged 66 ± 21 years. 67% were admitted, 14% of which to a critical care unit. Average length of hospital stay was 6.3 ± 7.8 days. Primary objective: patient orientation after triage using CTAS vs the NEWS was: 29% vs. 18% for high risk patients; 2% vs. 67% for low risk patients (p &amp;lt; 0.0001), respectively. Secondary objective: Among patients with stable NEWS score, 53% were admitted to hospital among patients with medium NEWS score, 9% of patients were admitted to the critical care (p = 0.0003) Conclusion: Patient orientation after ED triage using CTAS vs the NEWS is significantly different. The NEWS alone does not seem to be able to detect patients who will require admission to critical care. Future studies exploring an aggregate scoring system combining the NEWS and CTAS could be performed to determine if sepsis recognition and patient orientation can be improved

Heart rate variability based machine learning models for risk prediction of suspected sepsis patients in the emergency department.

Early identification of high-risk septic patients in the emergency department (ED) may guide appropriate management and disposition, thereby improving outcomes. We compared the performance of machine learning models against conventional risk stratification tools, namely the Quick Sequential Organ Failure Assessment (qSOFA), National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), and our previously described Singapore ED Sepsis (SEDS) model, in the prediction of 30-day in-hospital mortality (IHM) among suspected sepsis patients in the ED.Adult patients who presented to Singapore General Hospital (SGH) ED between September 2014 and April 2016, and who met ≥2 of the 4 Systemic Inflammatory Response Syndrome (SIRS) criteria were included. Patient demographics, vital signs and heart rate variability (HRV) measures obtained at triage were used as predictors. Baseline models were created using qSOFA, NEWS, MEWS, and SEDS scores. Candidate models were trained using k-nearest neighbors, random forest, adaptive boosting, gradient boosting and support vector machine. Models were evaluated on F1 score and area under the precision-recall curve (AUPRC).A total of 214 patients were included, of whom 40 (18.7%) met the outcome. Gradient boosting was the best model with a F1 score of 0.50 and AUPRC of 0.35, and performed better than all the baseline comparators (SEDS, F1 0.40, AUPRC 0.22; qSOFA, F1 0.32, AUPRC 0.21; NEWS, F1 0.38, AUPRC 0.28; MEWS, F1 0.30, AUPRC 0.25).A machine learning model can be used to improve prediction of 30-day IHM among suspected sepsis patients in the ED compared to traditional risk stratification tools.

Prehospital National Early Warning Score predicts early mortality.

National Early Warning Score (NEWS) has been shown to be the best early warning score to predict in-hospital mortality but there is limited information on its predictive value in a prehospital setting. The aim of the current study was to investigate the diagnostic accuracy of NEWS in a prehospital setting using large population-based databases in terms of short-term mortality. We calculated the NEWS scores from retrospective prehospital electronic patient record data and analysed their possible relationship to mortality. We included all patient records for patients 18years or older with sufficient prehospital data to calculate NEWS from 17 August 2008 to 18 December 2015 encountered by the emergency medical services (EMS) in the Hospital District of Helsinki and Uusimaa, Finland. The primary outcome measure was death within 1day of EMS dispatch. 35800 patients were included. Their mean (SD) age was 65.8 (19.9) years. The median value of NEWS was 3 (IQR 1-6). The primary outcome of death within 1day of EMS dispatch occurred in 378 (1.1%) cases. Area under receiver operating characteristic curve (AUROC) for primary outcome of death within 1day was 0.840 (95% CI 0.823-0.858). AUROC for 1day mortality in trauma subgroup was 0.901 (95% CI 0.859-0.942). Prehospital NEWS predicts mortality within 1 day of EMS dispatch with good diagnostic accuracy.

Validating the National Early Warning Score(NEWS) in Emergency Department of a tertiary care hospital in Pakistan.

BACKGROUND National Early Warning Score has been studied well in indoor settings of developed countries but hasn’t been tested before in the Emergency Department of developing countries with fewer resources. Our objective was to determine whether the emergency department (ED) NEWS can be associated with Triage, admission, disposition, length of emergency/hospital stay, reappearance and mortality. METHODOLOGY A random sample of 1000 patients’ first encounter in the ED was extracted in the study period (between November 2018 and April 2019). Statistical analysis was done to analyze whether ED NEWS severity category can be associated with Triage, admission, disposition, length of emergency stay, length of hospital stay, reappearance in two weeks and mortality. RESULTS ED NEWS Score is associated with triage as shown by mean 2.68 (SD ± 0.6, p=0.01). Also, a high NEWS score also had impact on admission including 75 (66.4%) patients in severe and 55(74.3%) in moderate NEWS severity category respectively. NEWS score is also associated with Critical care admission and length of Emergency stay likely hood ratio of 26.0(p=0.038). Reappearance in emergency within next two weeks of discharge had no relation to NEWS severity. On the other hand both ED mortality and Hospital mortality were related to High NEWS. It correlates weakly with Length of Stay in emergency or with Length of Stay in Hospital. CONCLUSION NEWS Score can be used in the emergency department to identify and predict adverse outcome of patients presenting to ED. NEWS can be used as a triage tool when deciding whether and where patients should be admitted.

A Composite and Wearable Sensor Kit for Location-Aware Healthcare Monitoring and Real-Time Trauma Scoring for Survival Prediction

With the advances in the microfabrication of analogue front-end devices, and embedded and signal processing technology, it has now become possible to devise miniaturized health monitoring kits for non-invasive real time monitoring at any location. The current commonly available kits only measure singleton physiological parameters, and a composite analysis that covers all vital signs and trauma scores seems to be missing with these kits. The research aims at using vital signs and other physiological parameters to calculate trauma scores National Early Warning Score (NEWS), Revised Trauma Score (RTS), Trauma Score - Injury Severity Score (TRISS) and Prediction of survival (Ps), and to log the trauma event to electronic health records using standard coding schemes. The signal processing algorithms were implemented in MATLAB and could be ported to TI AM335x using MATLAB/Embedded Coder. Motion artefacts were removed using a level ‘5’ stationary wavelet transform and a ‘sym4’ wavelet, which yielded a signal-to-noise ratio of 27.83 dB. To demonstrate the operation of the device, an existing Physionet, MIMIC II Numerics dataset was used to calculate NEWS and RTS scores, and to generate the correlation and regression models for a clinical class of patients with respiratory failure and admitted to Intensive Care Unit (ICU). Parameters such as age, heart rate, Systolic Blood Pressure (SysBP), respiratory rate, and Oxygen Saturation (SpO2) as predictors to Ps, showed significant positive regressions of 93% at p &lt; 0.001. The NEWS and RTS scores showed no significant correlation (r = 0.25, p &lt; 0.001) amongst themselves; however, the NEWS and RTS together showed significant correlations with Ps (blunt) (r = 0.70, p &lt; 0.001). RTS and Ps (blunt) scores showed some correlations (r = 0.63, p &lt; 0.001), and the NEWS score showed significant correlation (r = 0.79, p &lt; 0.001) with Ps (blunt) scores. Global Positioning System (GPS) system was built into the kit to locate the individual and to calculate the shortest path to the nearest healthcare center using the Quantum Geographical Information System (QGIS) Network Analysis tool. The physiological parameters from the sensors, along with the calculated trauma scores, were encoded according to a standard Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) coding system, and the trauma information was logged to electronic health records using Fast Health Interoperability Resources (FHIR) servers. The FHIR servers provided interoperable web services to log the trauma event information in real time and to prepare for medical emergencies.

A novel heart rate variability based risk prediction model for septic patients presenting to the emergency department.

A quick, objective, non-invasive means of identifying high-risk septic patients in the emergency department (ED) can improve hospital outcomes through early, appropriate management. Heart rate variability (HRV) analysis has been correlated with mortality in critically ill patients. We aimed to develop a Singapore ED sepsis (SEDS) predictive model to assess the risk of 30-day in-hospital mortality in septic patients presenting to the ED. We used demographics, vital signs, and HRV parameters in model building and compared it with the modified early warning score (MEWS), national early warning score (NEWS), and quick sequential organ failure assessment (qSOFA) score.Adult patients clinically suspected to have sepsis in the ED and who met the systemic inflammatory response syndrome (SIRS) criteria were included. Routine triage electrocardiogram segments were used to obtain HRV variables. The primary endpoint was 30-day in-hospital mortality. Multivariate logistic regression was used to derive the SEDS model. MEWS, NEWS, and qSOFA (initial and worst measurements) scores were computed. Receiver operating characteristic (ROC) analysis was used to evaluate their predictive performances.Of the 214 patients included in this study, 40 (18.7%) met the primary endpoint. The SEDS model comprises of 5 components (age, respiratory rate, systolic blood pressure, mean RR interval, and detrended fluctuation analysis α2) and performed with an area under the ROC curve (AUC) of 0.78 (95% confidence interval [CI]: 0.72–0.86), compared with 0.65 (95% CI: 0.56–0.74), 0.70 (95% CI: 0.61–0.79), 0.70 (95% CI: 0.62–0.79), 0.56 (95% CI: 0.46–0.66) by qSOFA (initial), qSOFA (worst), NEWS, and MEWS, respectively.HRV analysis is a useful component in mortality risk prediction for septic patients presenting to the ED.

Changes in vital signs post discharge as a potential target for intervention to avoid readmission

Readmissions are treated as adverse events in many healthcare systems. Causes can be physiological deterioration or breakdown of social support systems. We investigated data from a European multi-centre study of readmissions for changes in vital signs between index admission and readmission. Data sets were graded according to the National Early Warning Score (NEWS). Of 487 patients in whom NEWS could be calculated on discharge and again on re-admission, 39.6% had worse vital signs with a NEWS score difference ≥ 2 points while only 7.6% had improved by ≥ 2 points. Changes in individual vital signs of 20% or more were most common in respiratory rate and heart rate. Monitoring of respiratory rate and pulse rate post-discharge might predict some deteriorations.

Comparison of national early warning score, rapid emergency medicine score and acute physiology and chronic health evaluation II score for predicting outcome among emergency severe patients

To analyze the comparation of national early warning score (NEWS), rapid emergency medicine score (REMS) and acute physiology and chronic health evaluation II (APACHE II) score in predicting prognosis of critically ill patients in emergency department (ED). A retrospective study was conducted. Critically ill patients, aged > 16 years, hospitalized > 24 hours, and admitted to the ED of Nanhua Hospital Affiliated to South China University from January 2016 to June 2017 were enrolled. NEWS, REMS and APACHE II score were calculated based on the worst value of each index within 24 hours after emergency admission. The primary endpoint was 28-day mortality. The relationship between the three scoring systems and the prognosis of patients was analyzed. The predictive value of three scoring systems for the prognosis of critically ill patients in ED was analyzed by receiver operating characteristic curve (ROC). A total of 119 emergency severe patients were enrolled in the study, and the 28-day mortality was 21.0%. The scores of NEWS, REMS and APACHE II in the death group were significantly higher than those in the survival group (NEWS score: 9.40±3.19 vs. 5.72±2.35, REMS score: 12.64±4.46 vs. 7.97±3.28, APACHE II score: 26.64±6.92 vs. 16.19±5.48, all P < 0.01). With the increase of NEWS, REMS and APACHE II score, the 28-day mortality of patients gradually increased [28-day mortality of NEWS < 5, 5-6, ≥ 7 was 3.03% (1/34), 13.33% (4/34), 64.25% (20/51); 28-day mortality of REMS < 12, 12-16, ≥ 17 was 10.99% (10/91), 50.00% (11/22), 66.67% (4/6); 28-day mortality of APACHE II < 15, 15-24, ≥ 25 was 2.33% (1/43), 15.09% (8/59), 69.57% (16/23), respectively, all P < 0.01]. The ROC curve analysis showed that the areas under the ROC curve (AUC) of NEWS, REMS and APACHE II score for predicting the prognosis of emergency critically ill patients were 0.830 [95% confidence interval (95%CI) = 0.737-0.923], 0.782 (95%CI = 0.671-0.892) and 0.878 (95%CI = 0.800-0.956), respectively (all P = 0.000), and the accuracy of prediction was 57.4%, 48.6%, 65.4%, respectively. The scores of NEWS, REMS and APACHE II were useful in predicting prognosis of critically ill patients, with the highest accuracy of APACHE II forecast, followed by NEWS, and the lowest of REMS. After comprehensive consideration of cost-effectiveness, NEWS is more reliable in ED.

The value of presepsin(sCD-14) combined with NEWS for predicting the prognosis of patients with sepsis

Objective To investigate the value of serum soluble leukocyte differentiation antigen 14 subtype (sCD14-ST, presepsin) combined with national early warning score (NEWS) for predicting the prognosis of emergency patients with sepsis. Methods To select 119 patients who came to the emergency department of Beijing Hospital with sepsis from September 2009 to July 2015 as the objects of the study. The serum samples were collected immediately as they came, the presepsin was measured, and the NEWS scorescalculated. Patients were divided into survival group (81 cases) and death group (38 cases) according to the 30-day prognosis, and the value of the presepsin, NEWS score and presepsin + NEWS score in the assessment of prognosis were compared. Results Presepsin and NEWS scores both were higher in the death group than the survival group.Presepsin and NEWS were the independent risk factors of the 30-day mortality of patients with sepsis.Under the ROC curve area (AUC) of presepsin and NEWS were 0.842 and 0.823; the combination of Presepsin and NEWS was 0.906. When presepsin> 927.5 pg / mL and NEWS> 6.5 points, it can significantly improve the efficacy of predicting prognosis. Conclusions Serum presepsin is a good indicator to judge the prognosis of patients with sepsis, and the combination with NEWS can improve the ability to predict the risk of septic death. Key words: Sepsis; Presepsin; NEWS; Prognosis

Can the prehospital National Early Warning Score identify patients most at risk from subsequent deterioration?

IntroductionThe National Early Warning Score (NEWS) aids the early recognition of those at risk of becoming critically ill. NEWS has been recommended for use by ambulance services, but very little...

The National Early Warning Score (NEWS) for outcome prediction in emergency department patients with community-acquired pneumonia: results from a 6-year prospective cohort study.

ObjectiveTo investigate the accuracy of the National Early Warning Score (NEWS) to predict mortality and adverse clinical outcomes for patients with community-acquired pneumonia (CAP) compared to standard risk scores such as the pneumonia severity index (PSI) and CURB-65.DesignSecondary analysis of patients included in a previous randomised-controlled trial with a median follow-up of 6.1 years.SettingsPatients with CAP included on admission to the emergency departments (ED) of 6 tertiary care hospitals in Switzerland.ParticipantsA total of 925 patients with confirmed CAP were included. NEWS, PSI and CURB-65 scores were calculated on admission to the ED based on admission data.Main outcome measureOur primary outcome was all-cause mortality within 6 years of follow-up. Secondary outcomes were adverse clinical outcome defined as intensive care unit (ICU) admission, empyema and unplanned hospital readmission all occurring within 30 days after admission. We used regression models to study associations of baseline risk scores and outcomes with the area under the receiver operating curve (AUC) as a measure of discrimination.Results6-year overall mortality was 45.1% (n=417) with a stepwise increase with higher NEWS categories. For 30 day and 6-year mortality prediction, NEWS showed only low discrimination (AUC 0.65 and 0.60) inferior compared to PSI and CURB-65. For prediction of ICU admission, NEWS showed moderate discrimination (AUC 0.73) and improved the prognostic accuracy of a regression model, including PSI (AUC from 0.66 to 0.74, p=0.001) and CURB-65 (AUC from 0.64 to 0.73, p=0.015). NEWS was also superior to PSI and CURB-65 for prediction of empyema, but did not well predict rehospitalisation.ConclusionsNEWS provides additional prognostic information with regard to risk of ICU admission and complications and thereby improves traditional clinical-risk scores in the management of patients with CAP in the ED setting.Trial registration numberISRCTN95122877; Post-results.

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

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. 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. 1 950 emergency elderly patients with critical illness were enrolled, with 78 cases (4.0％) dead within 30 days 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％,x 2 =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 (x 2 =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. 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.

A single-centre observational cohort study of admission National Early Warning Score (NEWS)

IntroductionEarly warning scores are commonly used in hospitals to identify patients at risk of deterioration. The National Early Warning Score (NEWS) has recently been introduced to UK practice. However, it is not yet widely implemented. We aimed to compare NEWS to the early warning score currently used in our hospital – the Patient at Risk Score (PARS). MethodsWe conducted a prospective observational cohort study of all adult general medical patients admitted to a single hospital over a 20-day period. Physiological data and early warning scores recorded in bedside charts were collected on admission and a NEWS score was retrospectively calculated. The patient notes were reviewed at 48h after admission. The primary outcome was a composite of critical care admission or death within 2 days of admission. The secondary outcome was hospital length of stay. ResultsNEWS was more strongly associated with the primary outcome than PARS (odds ratio 1.54, p<0.001 compared to 1.42, p=0.056). A NEWS of 3 or more was associated with the primary outcome (odds ratio 7.03, p=0.003). Neither score was correlated with hospital length of stay. ConclusionNEWS on admission is superior to PARS for identifying patients at risk of death or critical care admission within the first 2days of hospital stay. Current guidelines advocate a threshold of 5 for triggering a clinical review. However, since a score of 3 or more was associated with a poor outcome, this recommendation should be reviewed. Both scores were poor predictors of hospital length of stay.

Factors affecting response to National Early Warning Score (NEWS)

IntroductionThe NEWS is a physiological score, which prescribes an appropriate response for the deteriorating patient in need of urgent medical care. However, it has been suggested that compliance with early warning scoring systems for identifying patient deterioration may vary out of hours. We aimed to (1) assess the scoring accuracy and the adequacy of the prescribed clinical responses to NEWS and (2) assess whether responses were affected by time of day, day of week and score severity. MethodsWe performed a prospective observational study of 370 adult patients admitted to an acute medical ward in a London District General Hospital. Patient characteristics, NEW score, time of day, day of week and clinical response data were collected for the first 24h of admission. Patients with less than a 12h hospital stay were excluded. We analysed data with univariate and multivariate logistic regression. ResultsIn 70 patients (18.9%) the NEW score was calculated incorrectly. There was a worsening of the clinical response with increasing NEW score. An appropriate clinical response to the NEWS was observed in 274 patients (74.1%). Patients admitted on the weekend were more likely to receive an inadequate response, compared to patients admitted during the week (p<0.0001). After adjusting for confounders, increasing NEWS score remained significantly associated with an inadequate clinical response. Furthermore, our results demonstrate a small increase in inadequate NEWS responses at night, however this was not clinically or statistically significant. ConclusionThe high rate of incorrectly calculated NEW scores has implications for the prescribed actions. Clinical response to NEWS score triggers is significantly worse at weekends, highlighting an important patient safety concern.

Validation of the National Early Warning Score in the prehospital setting

BackgroundEarly intervention and response to deranged physiological parameters in the critically ill patient improves outcomes. A National Early Warning Score (NEWS) based on physiological observations has been developed for use throughout the National Health Service (NHS) in the UK. Although a good predictor of mortality and deterioration in inpatients, its performance in the prehospital setting is largely untested. This study aimed to assess the validity of the NEWS in unselected prehospital patients. MethodsAll clinical observations taken by emergency ambulance crews transporting patients to a single hospital were collated along with information relating to hospital outcome over a two month period. The performance of the NEWS in identifying the endpoints of 48h and 30 day mortality, intensive care unit (ICU) admission, and a combined endpoint of 48h mortality or ICU admission was analysed. Results1684 patients were analysed. All three of the primary endpoints and the combined endpoint were associated with higher NEWS scores (p<0.01 for each). The medium-risk NEWS group was associated with a statistically significant increase in ICU admission (RR=2.466, 95% CI 1.0–6.09), but not in-hospital mortality relative to the low risk group. The high risk NEWS group had significant increases in 48h mortality (RR 35.32 [10.08–123.7]), 30 day mortality (RR 6.7 [3.79–11.88]), and ICU admission (5.43 [2.29–12.89]). Similar results were noted when trauma and non-trauma patients were analysed separately. ConclusionsElevated NEWS among unselected prehospital patients is associated with a higher incidence of adverse outcomes. Calculation of prehospital NEWS may facilitate earlier recognition of deteriorating patients, early involvement of senior Emergency Department staff and appropriate critical care.

Aggregate National Early Warning Score (NEWS) values are more important than high scores for a single vital signs parameter for discriminating the risk of adverse outcomes

IntroductionThe Royal College of Physicians (RCPL) National Early Warning Score (NEWS) escalates care to a doctor at NEWS values of ≥5 and when the score for any single vital sign is 3. MethodsWe calculated the 24-h risk of serious clinical outcomes for vital signs observation sets with NEWS values of 3, 4 and 5, separately determining risks when the score did/did not include a single score of 3. We compared workloads generated by the RCPL's escalation protocol and for aggregate NEWS value alone. ResultsAggregate NEWS values of 3 or 4 (n=142,282) formed 15.1% of all vital signs sets measured; those containing a single vital sign scoring 3 (n=36,207) constituted 3.8% of all sets. Aggregate NEWS values of either 3 or 4 with a component score of 3 have significantly lower risks (OR: 0.26 and 0.53) than an aggregate value of 5 (OR: 1.0). Escalating care to a doctor when any single component of NEWS scores 3 compared to when aggregate NEWS values ≥5, would have increased doctors’ workload by 40% with only a small increase in detected adverse outcomes from 2.99 to 3.08 per day (a 3% improvement in detection). ConclusionsThe recommended NEWS escalation protocol produces additional work for the bedside nurse and responding doctor, disproportionate to a modest benefit in increased detection of adverse outcomes. It may have significant ramifications for efficient staff resource allocation, distort patient safety focus and risk alarm fatigue. Our findings suggest that the RCPL escalation guidance warrants review.