National Early Warning Score Values Research Articles

Application of national early warning score in assessing postoperative illness severity in elderly patients with gastrointestinal illnesses.

Population aging is a social problem that is being faced in most countries. To apply the National Early Warning Score (NEWS) for an early warning on the vital signs and consciousness of elderly patients who are hospitalized in the gastrointestinal surgical department and to provide a reference for early detection of changes in illness severity in elderly patients by studying the correlation between NEWS value and changes in illness severity. We enrolled 528 elderly patients who were hospitalized in the gastrointestinal surgical department of a tertiary grade A hospital in Guizhou Province between June 2020 and May 2021, to analyze how NEWS max value correlates with illness severity and obtain the optimal NEWS cutoff value for both potentially critically ill and critically ill elderly patients using the receiver operating characteristic (ROC) curve. There were statistically significant differences in NEWS values between elderly patients with various illness severities (P< 0.05). NEWS values correlated positively with illness severity (r= 0.605, P< 0.001). Based on the ROC curve, early warning trigger values for NEWS to identify potentially critically ill, critically ill and terminally ill elderly patients were 6, 7 and 8, respectively. The area under the curve (AUC) for potentially critically ill, critically ill and terminally ill elderly patients was 0.907, 0.921 and 0.939, respectively. NEWS performed better in detecting patient illness severity than Modified Early Warning Score (MEWS) in AUC, sensitivity, specificity, and Youden's index, with statistically significant differences (P< 0.05). An early warning on the vital signs and consciousness of hospitalized elderly patients using NEWS can facilitate advanced detection of changes in illness severity of elderly patients by medical staff and enable timely treatment, thus significantly lowering the risks of illness deterioration.

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.

Comparison of National Early Warning Score with shock index in patients with necrotizing fasciitis.

Shock index (SI) and national early warning score (NEWS) are more frequently used as assessment tools in acute illnesses, patient disposition and early identification of critical condition. Both they are consisted of common vital signs and parameters including heart rate, systolic blood pressure, respiratory rate, oxygen saturation and level of conscious, which made it easy to evaluate in medical facilities. Its ability to predict mortality in patients with necrotizing fasciitis (NF) in the emergency department remains unclear. This study was conducted to compare the predictive capability of the risk scores among NF patients. A retrospective cohort study of hospitalized patients with NF was conducted in 2 tertiary teaching hospitals in Taiwan between January 2013 and March 2015. We investigated the association of NEWS and SI with mortality in NF patients. Of the 395 NF patients, 32 (8.1%) died in the hospital. For mortality, the area under the receiver curve value of NEWS (0.81, 95% confidence interval 0.76-0.86) was significantly higher than SI (0.76, 95% confidence interval 0.73-0.79, P = .016). The sensitivities of NEWS of 3, 4, and 5 for mortality were 98.1%, 95.6%, and 92.3%. On the contrast, the sensitivities of SI of 0.5, 0.6, and 0.7 for mortality were 87.8%, 84.7%, and 81.5%. NEWS had advantage in better discriminative performance of mortality in NF patients. The NEWS may be used to identify relative low risk patients among NF patients.

National Early Warning Score Deployment in a Veterans Affairs Facility: A Quality Improvement Initiative and Analysis.

Early warning scores are algorithms designed to identify clinical deterioration. Current literature is predominantly in non-Veteran populations. Studies in Veterans are lacking. This study was a prospective quality improvement project deploying and assessing the National Early Warning Score (NEWS) at Kansas City VA Medical Center. Performance of NEWS was assessed as follows: discrimination for predicting a composite outcome of intensive care unit transfer or mortality within 24 hours via area under the receiver operating curve. A total of 4781 Veterans with 142 375 NEWS values were included. The NEWS area under the receiver operating curve for the composite outcome was 0.72 (95% CI, 0.71-0.74), indicating acceptable predictive accuracy. A NEWS of ≥7 was more likely associated with the composite outcome versus <7 (13.6% vs 0.8%; P < 0.001). This is one of the first studies to demonstrate successful deployment of NEWS in a Veteran population, with resultant important implications across the Veterans Health Administration.

The predictive value of warning scores for intensive care unit admission in coronavirus disease 2019 patients

To evaluate the predictive value of early warning scores for intensive care unit (ICU) admission in patients with coronavirus disease 2019 (COVID-19). For COVID-19 patients who were admitted to Shijiazhuang People's Hospital from January 2021 to February 2021, national early warning score (NEWS), national early warning score 2 (NEWS2), rapid emergency medicine score (REMS), quick sepsis-related organ failure (qSOFA), altered consciousness, blood urea nitrogen, respiratory rate, blood pressure, and age-65 (CURB-65) were used to evaluate the inpatient condition and the predictive value for ICU admission. A total of 368 patients were included, and 32 patients (8.7%) were transferred to the ICU. The median age was 49.0 (34.0,61.0) years. The scores of NEWS, NEWS2, REMS, and CURB-65 were 1 (0, 2), 1 (0, 2), 4 (2, 6) and 0 (0, 1), respectively. The receiver operating characteristic (ROC) cure (AUC) was used to evaluate the predictive value in detecting patients who are at risk of being transferred to the ICU. Area under the ROC AUC of NEWS was 0.756, sensitivity 65.6%, and specificity 71.3%. ROC AUC of NEWS2 was 0.732, sensitivity 62.5%, and specificity 61.3%. ROC AUC of REMS was 0.787, sensitivity 84.4%, and specificity 64.6%. ROC AUC of CURB-65 was 0.814, sensitivity 81.3%, and specificity 76.8%. The predictive value of NEWS and NEWS2 combined with age were significantly improved. The ROC AUC of NEWS combined with age was 0.885, sensitivity 85.1%, and specificity 75.0%. The ROC AUC of NEWS2 combined with age was 0.883, sensitivity 84.2%, and specificity 75.0%. NEWS and NEWS2 combined with age can be used as a predictive tool for whether COVID-19 patients will be admitted to the ICU.

The use of the news in predicting the clinical status of copd patients presenting to the emergency department with a the complaint of dyspnea

Aim: COPD (Chronic Obstructive Pulmonary Disease) is a lung disease that causes impairment in quality of life. NEWS (National Early Warning Score) is a scoring system that evaluates patients' general condition and mortality. We examined the utility of NEWS in predicting the clinical status of COPD patients. Materials and methods: COPD patients admitted to the emergency department were included in the study. Age, gender, comorbid diseases, occupational exposure status, smoking/tobacco intake, hematological and radiological examinations, vital values, and continuous drug use status of the patients were evaluated. The GCS (Glasgow Coma Scale), CCI (Charlson Comorbidity Index), and NEWS values of the patients were calculated. Chi-square, Fisher's exact, unpaired t-test, or Mann-Whitney U tests were applied according to the normal distribution. Values of p&lt;0.05 were considered statistically significant. Results: Of the patients, 82% (n=205) were male, and 18% (n=45) were female. Of the patients, 67% had comorbid diseases. Coronary artery disease was the most common comorbid disease (n=68, 27%). Low saturation, pH, mean blood pressure, low hemoglobin, high CO2, creatinine, urea, CRP, and INR levels were associated with mortality. In non-survival patients, the GCS was low, whereas the CCI and NEWS were high. Conclusions: The NEWS value should be considered in order to determine the clinical status of patients presenting with a COPD attack, to make the decision for hospitalization, and to predict their mortality. Keywords : Emergency department,COPD exacerbation,NEWS,mortality

National Early Warning Score (NEWS) Outperforms Quick Sepsis-Related Organ Failure (qSOFA) Score for Early Detection of Sepsis in the Emergency Department.

Prompt recognition of sepsis is critical to improving patients' outcomes. We compared the performance of NEWS and qSOFA scores as sepsis detection tools in patients admitted to the emergency department (ED) with suspicion of sepsis. A single-center 12-month retrospective study comparing NEWS using the recommended cut-off of ≥5 and qSOFA as sepsis screening tools in a cohort of patients transported by emergency medical services (EMS) to the Lausanne University Hospital (LUH). We used the Sepsis-3 consensus definition. The primary study endpoint was the detection of sepsis. Secondary endpoints were ICU admission and 28-day all-cause mortality. Among 886 patients admitted to ED by EMS for suspected infection, 556 (63%) had a complete set of vital parameters panel enabling the calculation of NEWS and qSOFA scores, of whom 300 (54%) had sepsis. For the detection of sepsis, the sensitivity of NEWS &gt; 5 was 86% and that of qSOFA ≥ 2 was 34%. Likewise, the sensitivities of NEWS ≥ 5 for predicting ICU admission and 28-day mortality were higher than those of qSOFA ≥ 2 (82% versus 33% and 88% versus 37%). Conversely, the specificity of qSOFA ≥ 2 for sepsis detection was higher than that of NEWS ≥ 5 (90% versus 55%). The negative predictive value of NEWS &gt; 5 was higher than that of qSOFA ≥ 2 (77% versus 54%), while the positive predictive value of qSOFA ≥ 2 was higher than that of NEWS ≥ 5 (80% versus 69%). Finally, the accuracy of NEWS ≥ 5 was higher than that of qSOFA ≥ 2 (72% versus 60%). The sensitivity of NEWS ≥ 5 was superior to that of qSOFA ≥ 2 to identify patients with sepsis in the ED and predict ICU admission and 28-day mortality. In contrast, qSOFA ≥ 2 had higher specificity and positive predictive values than NEWS ≥ 5 for these three endpoints.

Prognostic value of National Early Warning Score and Modified Early Warning Score on intensive care unit readmission and mortality: A prospective observational study.

BackgroundModified Early Warning Score (MEWS) and National Early Warning Score (NEWS) are widely used in predicting the mortality and intensive care unit (ICU) admission of critically ill patients. This study was conducted to evaluate and compare the prognostic value of NEWS and MEWS for predicting ICU readmission, mortality, and related outcomes in critically ill patients at the time of ICU discharge.MethodsThis multicenter, prospective, observational study was conducted over a year, from April 2019 to March 2020, in the general ICUs of two university-affiliated hospitals in Northwest Iran. MEWS and NEWS were compared based on the patients’ outcomes (including mortality, ICU readmission, time to readmission, discharge type, mechanical ventilation (MV), MV duration, and multiple organ failure after readmission) using the univariable and multivariable binary logistic regression. The receiver operating characteristic (ROC) curve was used to determine the outcome predictability of MEWS and NEWS.ResultsA total of 410 ICU patients were enrolled in this study. According to multivariable logistic regression analysis, both MEWS and NEWS were predictors of ICU readmission, time to readmission, MV status after readmission, MV duration, and multiple organ failure after readmission. The area under the ROC curve (AUC) for predicting mortality was 0.91 (95% CI = 0.88–0.94, P < 0.0001) for the NEWS and 0.88 (95% CI = 0.84–0.91, P < 0.0001) for the MEWS. There was no significant difference between the AUC of the NEWS and the MEWS for predicting mortality (P = 0.082). However, for ICU readmission (0.84 vs. 0.71), time to readmission (0.82 vs. 0.67), MV after readmission (0.83 vs. 0.72), MV duration (0.81 vs. 0.67), and multiple organ failure (0.833 vs. 0.710), the AUCs of MEWS were significantly greater (P < 0.001).ConclusionNational Early Warning Score and MEWS values of >4 demonstrated high sensitivity and specificity in identifying the risk of mortality for the patients’ discharge from ICU. However, we found that the MEWS showed superiority over the NEWS score in predicting other outcomes. Eventually, MEWS could be considered an efficient prediction score for morbidity and mortality of critically ill patients.

New Early Warning Score: EMS Off-Label Use in Out-of-Hospital Patients.

Background: The National Early Warning Score (NEWS) is an assessment scale of in-hospital patients’ conditions. The purpose of this study was to assess the appropriateness of a potential off-label use of NEWS by the emergency medical system (EMS) to facilitate the identification of critical patients and to trigger appropriate care in the pre-hospital setting. Methods: A single centre, longitudinal, prospective study was carried out between July and August 2020 in the EMS service of Bologna. Home patients with age ≥ 18 years old were included in the study. The exclusion criterion was the impossibility to collect all the parameters needed to measure NEWS. Results: A total of 654 patients were enrolled in the study. The recorded NEWS values increased along with the severity of dispatch priority code, the EMS return code, the emergency department triage code, and with patients’ age (r = 0.135; p = 0.001). The aggregated value of NEWS was associated with an increased risk of hospitalization (OR = 1.30 (1.17; 1.34); p < 0.0001). Conclusion: This study showed that the use of NEWS in the urgent and emergency care services can help patient assessment while not affecting EMS crew operation and might assist decision making in terms of severity-code assignment and resources utilization.

The effect of azoximer bromide (Polyoxidonium®) in patients hospitalized with coronavirus disease (COVID-19): an open-label, multicentre, interventional clinical study.

A clinical need for aetiotropic coronavirus disease (COVID-19) treatments is required. The immune modulator azoximer bromide (AZB; Polyoxidonium®) is indicated in Russia for use against acute viral infections and during remission. In this study, adults hospitalized with COVID-19 (n=32) received AZB and standard of care in an open-label, multicentre, interventional study. All patients were symptomatic; 22 had severe disease (National Early Warning Score ≥5) and required mechanical ventilation or respiratory support and 19 patients had co-morbidities. Patients received AZB 12 mg intravenously once daily for 3 days, then intramuscularly every other day (approximately ten injections) until discharge. The primary endpoint was the patient’s clinical status (7-point Ordinal Scale; OS) on day 15 versus that at baseline. The mean duration of hospitalization was 20 days. All patients were alive and discharged with normal oxygen saturation (SpO2) with no secondary infections or delayed mortality reported by the end-of-study visit (on day 28–72). A decrease in the mean OS and National Early Warning Score values was observed following treatment with AZB. A decrease in OS score was marked in patients identified as severe. Both sets of patients achieved similar scores, which can be classified as an improvement by day 9–10; SpO2 levels trended to normalization over time. By day 11–12, all patients had a normal body temperature. Serum C-reactive protein levels decreased in patients with severe and mild disease. Most patients had signs of pneumonia at baseline (n=27), with the majority recovering by days 10–12. No major toxicities were observed. AZB was safe and well tolerated when administered in addition to standard of care treatment for COVID-19. Further randomized, placebo-controlled studies are needed to elucidate any potential therapeutic effect in COVID-19.

National early warning score to predict intensive care unit transfer and mortality in COVID-19 in a French cohort.

BackgroundNo risk stratification tool has been validated in hospitalised patients with coronavirus disease 2019 (COVID‐19), despite a high rate of intensive care requirement and in‐hospital mortality. We aimed to determine whether the National Early Warning Score (NEWS) at admission can accurately predict in‐hospital mortality and ICU transfer.MethodsThis was a retrospective cohort study from January 24 to April 16, 2020, at Lille University Hospital. All consecutive adult patients with laboratory‐confirmed COVID‐19 who were initially admitted to non‐ICU wards were included. The primary outcome was a composite criterion consisting of ICU transfer or in‐hospital mortality. We evaluated the prognostic performance of NEWS by calculating the area under (AUC) the receiver operating characteristic curve, the optimal threshold value of NEWS, and its association with the primary outcome.ResultsOf the 202 COVID‐19 patients, the median age was 65 (interquartile range 52‐78), 38.6% were women and 136 had at least one comorbidity. The median NEWS was 4 (2‐6). A total of 65 patients were transferred to the ICU or died in the hospital. Compared with patients with favourable outcome, these patients were significantly older, had more comorbidities and higher NEWS. The AUC for NEWS was 0.68 (0.60‐0.77) and the best cutoff value was 6. Adjusted odds ratio for NEWS ≥ 6 as an independent predictor was 3.78 (1.94‐7.09).ConclusionsIn hospitalised COVID‐19 patients, NEWS was an independent predictor of ICU transfer and in‐hospital death. In daily practice, NEWS ≥ 6 at admission may help to identify patients who are at risk to deteriorate.

If early warning systems are used, would it be possible to estimate early clinical deterioration risk and prevent readmission to intensive care?

Although the intensive care unit (ICU) admission criteria are specified clearly, it is difficult to make the decision of discharge from ICU. The purpose of this study is to test whether or not early warning scores will allow us to estimate early clinical deterioration within 24 hours and predict readmission to intensive care. A total of 1330 patients were included in the retrospective study. All the patients' age, gender, ICU hospitalization reasons and Acute Physiological and Chronic Health Evaluation (APACHE II) scores were recorded. National Early Warning Score (NEWS) and VitalpacTM early warning score (VIEWS) scores were calculated using the physiological and neurological examination records. Discharge NEWS and VIEWS values of the patients who were readmitted to intensive care 24 hours after discharge were compared with the patients who were not readmitted to intensive care. The statistical analysis was performed using the IBM SPSS version 21 package software. Age average of all the patients was 64.3 ± 20.8 years. The number of the patients who were readmitted to intensive care was 118 (8.87%). When examining the factors that affect early clinical deterioration, it was found that advanced age, high APACHE II scores, higher NEWS and VIEWS scores, lower DAP values and the patient's transfer from the ward were significantly predictive (P < 0.05). In this study, high NEWS and VIEWS are strong scoring systems that can be used in estimating early clinical deterioration risk and are easy-to-use and less time consuming.

The optimal threshold for prompt clinical review: An external validation study of the national early warning score.

The aim of this study was to determine the optimal threshold for national early warning score in clinical practice. The national early warning score is an aggregate early warning score aiming to predict patient mortality. Studies validating national early warning score did not use standardised patient outcomes or did not always include clinical workload in their results. Since all patients with a positive national early warning score require a clinical workup, it is crucial to determine the optimal threshold to limit false-positive alerts. An external validation study using retrospectively collected data of patient admissions in six Belgian hospitals. We adhered to the STARD guideline for reporting. Two sample groups were selected: the cross-sectional sample (admitted patients, 1day every 4months) and the serious adverse event sample (all patients with unexpected death, cardiac arrest and unplanned admission to the intensive care unit). The maximum registered national early warning score value was collected in both groups. Predictive values were used as estimates for clinical workload. We collected 1,523 in the cross-sectional sample and 390 patients in the serious adverse event sample. A national early warning score ≥5 had a predictive value of 6.8% and a negative predictive value of 99.5% to predict unexpected death, cardiac arrest with cardiopulmonary resuscitation or unplanned admission to intensive care (AUROC 0.841). The performance of national early warning score differed between outcome measures. Considering the predictive value, the optimal threshold for national early warning score is ≥5. We validated national early warning score to be applied in general hospital wards and confirmed the optimal threshold (≥5). When a patient has a national early warning score <5, we may assume that in the next 24hr this patient is less likely to die unexpectedly, receive cardiopulmonary resuscitation or be transferred to the ICU. Because of the significant number of false positives when national early warning score is ≥5, hospitals should create workable guidelines for clinical practice.

Implementation of the National Early Warning Score in UK care homes: a qualitative evaluation.

The National Early Warning Score (NEWS) is a tool for identifying and responding to acute illness. When used in care homes, staff measure residents' vital signs and record them on a tablet computer, which calculates a NEWS to share with health services. This article outlines an evaluation of NEWS implementation in care homes across one clinical commissioning group area in northern England. To identify challenges to implementation of NEWS in care homes. Qualitative analysis of interviews conducted with 15 staff members from six care homes, five health professionals, and one clinical commissioning group employee. Interviews were intended to capture people's attitudes and experiences of using the intervention. Following an inductive thematic analysis, data were considered deductively against normalisation process theory constructs to identify the challenges and successes of implementing NEWS in care homes. Care home staff and other stakeholders acknowledged that NEWS could enhance the response to acute illness, improve communication with the NHS, and increase the confidence of care home staff. However, the implementation did not account for the complexity of either the intervention or the care home setting. Challenges to engagement included competing priorities, insufficient training, and shortcomings in communication. This evaluation highlights the need to involve care home staff and the primary care services that support them when developing and implementing interventions in care homes. The appropriateness and value of NEWS in non-acute settings requires ongoing monitoring.

Association between National Early Warning Scores in primary care and clinical outcomes: an observational study in UK primary and secondary care.

BackgroundNHS England has mandated use of the National Early Warning Score (NEWS), more recently NEWS2, in acute settings, and suggested its use in primary care. However, there is reluctance from GPs to adopt NEWS/NEWS2.AimTo assess whether NEWS calculated at the point of GP referral into hospital is associated with outcomes in secondary care.Design and settingAn observational study using routinely collected data from primary and secondary care.MethodNEWS values were prospectively collected for 13 047 GP referrals into acute care between July 2017 and December 2018. NEWS values were examined and multivariate linear and logistic regression used to assess associations with process measures and clinical outcomes.ResultsHigher NEWS values were associated with faster conveyance for patients travelling by ambulance, for example, median 94 minutes (interquartile range [IQR] 69–139) for NEWS ≥7; median 132 minutes, (IQR 84–236) for NEWS = 0 to 2); faster time from hospital arrival to medical review (54 minutes [IQR 25–114] for NEWS ≥7; 78 minutes [IQR 34–158] for NEWS = 0 to 2); as well as increased length of stay (5 days [IQR 2–11] versus 1 day [IQR 0–5]); intensive care unit admissions (2.0% versus 0.5%); sepsis diagnosis (11.7% versus 2.5%); and mortality, for example, 30-day mortality 12.0% versus 4.1% for NEWS ≥7 versus NEWS = 0 to 2, respectively. On average, for patients referred without a NEWS value (NEWS = NR), most clinical outcomes were comparable with patients with NEWS = 3 to 4, but ambulance conveyance time and time to medical review were comparable with patients with NEWS = 0 to 2.ConclusionThis study has demonstrated that higher NEWS values calculated at GP referral into hospital are associated with a faster medical review and poorer clinical outcomes.

The association between nurse staffing levels and a failure to respond to patients with deranged physiology: A retrospective observational study in the UK

BackgroundResponding to abnormalities in patients’ vital signs is a fundamental aspect of nursing. However, failure to respond to patient deterioration is common and often leads to adverse patient outcomes. This study aimed to determine the association between Registered Nurse (RN) and Nursing Assistant (NA) staffing levels and the failure to respond promptly to patients’ abnormal physiology. MethodsThis retrospective, observational study used routinely collected patients’ vital signs and administrative data, including nursing staffing, from 32 general wards of an acute hospital in England between April 2012 and March 2015. Mixed-effects binomial regression was used to model the relationship between nurse staffing, measured as ‘Hours per Patient Day’ (HPPD), and a composite primary outcome representing failure to respond for patients with National Early Warning Score (NEWS) values ≥ 6 and ≥ 7. ResultsThere were 189,123 NEWS values ≥ 6 and 114,504 NEWS values ≥ 7, affecting 28,098 patients. For patients with NEWS values ≥ 7, failure to respond was significantly associated with levels of RN HPPD ((IRR 0.98, 95% CI 0.96–0.99, p = 0.0001) but not NA HPPD (((IRR 0.99, 95%CI 0.96–1.01, p = 0.238). For patients with NEWS values ≥ 6, no such relationship existed. ConclusionsRN, but not NA, staffing levels influence the rates of failure to respond for patients with the most abnormal vital signs (NEWS values ≥ 7). These findings offer a possible explanation for the increasingly reported association between low RN staffing and an increased risk of patient death during a hospital admission.

The effectiveness of a national early warning score as a triage tool for activating a rapid response system in an outpatient setting: A retrospective cohort study.

Rapid response system (RRS) efficacy and national early warning score (NEWS) performances have largely been reported in inpatient settings, with few such reports undertaken in outpatient settings.This study aimed to investigate NEWS validity in predicting poor clinical outcomes among outpatients who had activated the RRS using single-parameter criteria.A single-center retrospective cohort studyFrom April 1, 2014 to November 30, 2017 in an urban 350-bed referral hospital in JapanWe collected patient characteristics such as activation triggers, interventions, arrival times, dispositions, final diagnoses, and patient outcomes. Poor clinical outcomes were defined as unplanned intensive care unit transfers or deaths within 24 hours. Correlations between the NEWS and clinical outcomes at the time of deterioration and disposition were analyzed.Among 31 outpatients, the NEWS value decreased significantly after a medical emergency team intervention (median, 8 vs 4, P < .001). The difference in the NEWS at the time of deterioration and at disposition was significantly less in patients with poor clinical outcomes (median 3 vs 1.5, P = .03). The area under the curve (AUC) for the NEWS high-risk patient group at the time of deterioration for predicting hospital admission was 0.85 (95% confidence interval [CI], 0.67-1.0), while the AUC for the NEWS high-risk patient group at disposition for predicting poor clinical outcomes was 0.83 (95% CI, 0.62-1.0).The difference between the NEWS at the time of deterioration and at disposition might usefully predict admissions and poor clinical outcomes in RRS outpatient settings.

Biomarkers and clinical scores to identify patient populations at risk of delayed antibiotic administration or intensive care admission

BackgroundThe performance of blood biomarkers (mid-regional proadrenomedullin (MR-proADM), procalcitonin (PCT), C-reactive protein (CRP), and lactate) and clinical scores (Sequential Organ Failure Assessment (SOFA), National Early Warning Score (NEWS), and quick SOFA) was compared to identify patient populations at risk of delayed treatment initiation and disease progression after presenting to the emergency department (ED) with a suspected infection.MethodsA prospective observational study across three EDs. Biomarker and clinical score values were calculated upon presentation and 72 h, and logistic and Cox regression used to assess the strength of association. Primary outcomes comprised of 28-day mortality prediction and delayed antibiotic administration or intensive care (ICU) admission, whilst secondary outcomes identified subsequent disease progression.ResultsSix hundred eighty-four patients were enrolled with hospitalisation, ICU admission, and infection-related 28-day mortality rates of 72.8%, 3.4%, and 4.4%, respectively. MR-proADM and NEWS had the strongest association with hospitalisation and the requirement for antibiotic administration, whereas MR-proADM alone had the strongest association with ICU admission (OR [95% CI]: 5.8 [3.1 - 10.8]) and mortality (HR [95% CI]: 3.8 [2.2 - 6.5]). Patient subgroups with high MR-proADM concentrations (≥ 1.77 nmol/L) and low NEWS (< 5 points) values had significantly higher rates of ICU admission (8.1% vs 1.6%; p < 0.001), hospital readmission (18.9% vs. 5.9%; p < 0.001), infection-related mortality (13.5% vs. 0.2%; p < 0.001), and disease progression (29.7% vs. 4.9%; p < 0.001) than corresponding patients with low MR-proADM concentrations. ICU admission was delayed by 1.5 [0.25 – 5.0] days in patients with high MR-proADM and low NEWS values compared to corresponding patients with high NEWS values, despite similar 28-day mortality rates (13.5% vs. 16.5%). Antibiotics were withheld in 17.4% of patients with high MR-proADM and low NEWS values, with higher subsequent rates of ICU admission (27.3% vs. 4.8%) and infection-related hospital readmission (54.5% vs. 14.3%) compared to those administered antibiotics during ED treatment.ConclusionsPatients with low severity signs of infection but high MR-proADM concentrations had an increased likelihood of subsequent disease progression, delayed antibiotic administration or ICU admission. Appropriate triage decisions and the rapid use of antibiotics in patients with high MR-proADM concentrations may constitute initial steps in escalating or intensifying early treatment strategies.

Use of National Early Warning Score for observation for increased risk for clinical deterioration during post-ICU care at a surgical ward.

PurposePatients transferred from an intensive care unit (ICU) to a general ward are at risk for clinical deterioration. The aim of the study was to determine if an increase in National Early Warning Score (NEWS) value predicted worse outcomes in surgical ward patients previously treated in the ICU.Patients and methodsA retrospective observational study was conducted in a cohort of gastrointestinal surgery patients after transfer from an ICU/high dependency unit (HDU). NEWS values were collected throughout the ward admission. Clinical deterioration was defined by ICU readmission or death. The ability of NEWS to predict clinical deterioration was determined using a linear mixed effect model.ResultsWe included 124 patients, age 65.9±14.5, 60% males with an ICU Simplified Acute Physiology Score II 33.8±12.7. No patients died unexpectedly at the ward and 20 were readmitted to an ICU/HDU. The NEWS values increased by a mean of 0.15 points per hour (intercept 3.7, P<0.001) before ICU/HDU readmission according to the linear mixed effect model. NEWS at transfer from ICU was the only factor that predicted readmission (OR 1.32; 95% CI 1.01–1.72; P=0.04) at the time of admission to the ward.ConclusionClinical deterioration of surgical patients was preceded by an increase in NEWS.

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.