NEWS2 Score Research Articles

NEWS-2 Accuracy in Predicting Mortality and Severe Morbidity Among Hospitalized COVID-19 Patients: A Prospective Cohort Study

Background: Early risk stratification tools for COVID-19 patients have been indicated yet there are few data about their ability to effectively detect clinical deterioration among COVID-19 patients. Objectives: To evaluate the NEWS-2 to predict severe morbidity and mortality for COVID-19 patients admitted to hospitals. Methods: We conducted a prospective cohort study among adult COVID-19 patients with a confirmed diagnosis who were admitted to the inpatient units at COVID-19 Martyrs Medical Military Complex Hospital, from 1 March 2022, until 29 February 2023. NEWS-2 scores were measured at admission and 6, 12, 24, and 48 h after their admission to the hospital using receiver operating characteristic (ROC) curves. Results: Overall, 192 adult COVID-19 patients aged 25–94 years (mean = 62.1, SD = 13.9) were enrolled. Of those, 49.0% were males, 47.4% were vaccinated, and 53.6% had diabetes. The 192 enrolled patients were classified into NEWS-2 score categories, with almost 13% (12.5%) falling into the high-risk category already upon admission. The mean NEWS-2 scores were excellent predictors of mechanical ventilation, admission to the ICU, and mortality, as indicated by an AUROC of 0.94 (95% CI: 0.88–1.00, p < 0.001), 0.91 (95% CI: 0.87–0.96, p < 0.001), and 0.96 (95% CI: 0.92–1.00, p < 0.001), respectively. Significant differences in mean NEWS-2 scores were found between the participating patients, both with and without comorbidity in the course of the patient’s stay in the ICU, and mortality (p = 0.004, p = 0.043, respectively). Positive correlations of the high NEWS-2 scores were revealed using a multiple linear regression model, indicating the necessity of administering non-invasive ventilatory assistance (p = 0.013), hospitalization for a minimum of six days (p = 0.013), and admission to the ICU (p = 0.006). Nonetheless, there was a negative association between mortality and the NEWS-2 score (p < 0.001). Conclusions: The NEWS-2 had moderate sensitivity and specificity in predicting the deterioration of patients with COVID-19 whereas there was high sensitivity and specificity in predicting the mortality for patients with COVID-19, both with and without comorbidity. Our findings support the utility of NEWS-2 monitoring as a sensitive approach for initially assessing COVID-19 patients. It could be helpful to enhance the accuracy of predictive performance by supplementing the score parameters by adding biological parameters in addition to clinical judgment.

The rate and predictors of violence against EMS personnel

BackgroundViolence against Emergency Medical Services (EMS) personnel vary between studies. Current studies are mainly based on self-reporting, thus other designs are needed to provide more perspective. The purpose of this study was to explore the rate and predictors of violent behavior targeted at EMS personnel by exploring the Electronic patient care records (ePCR) documentation by EMS personnel.MethodsThis was a retrospective cohort study of EMS patients in Finland. The data were collected from three regions between 1st June and 30th November 2018. Text mining and manual evaluation were used to identify and explore predictors of violence targeted at EMS personnel from the ePCR narratives. Multivariable logistic regressions were used to determine factors that were independently associated with violent behavior. The results are presented with odds ratios (ORs) with 95% confidence intervals (CIs).ResultsThe EMS personnel reported experiences of violence in a total of 297 identified missions (0.7%) of all EMS missions (n = 40,263). The violence was mostly verbal (62.3%) and the most common violence perpetrator was the patient (98.0%). The police were alarmed to many missions where violence was reported (40.7%). Sometimes violence occurred suddenly although the police were present. The multivariable logistic regression model indicates that violence occurred typically in urban areas (OR 1.699; 95% CI 1.283 to 2.248), at weekend nights (OR 1.357; 95% CI 1.043 to 1.765), by male (OR 1.501; 95% CI 1.160 to 1.942), and patients influenced by alcohol (OR 3.464; 95% CI 2.644 to 4.538). A NEWS2 score of 3 in any parameter (vs. score 0–4, OR 2.386; 95% CI: 1.788 to 3.185) and ALS unit type (vs. BLS, OR 1.373; 95% CI: 1.009 to 1.866) increased the likelihood as well.ConclusionsThe documentation in ePCRs show low rates of violence targeted at EMS personnel. However, violence is a multidimensional phenomenon connected to unfamiliar patients, rushed situations, and an uncontrolled environment. This means that the EMS personnels’ safety cannot be ensured in all situations. Therefore, a balance between safety margins and treating patients needs to be considered.

Early Warning Scores With and Without Artificial Intelligence

Early warning decision support tools to identify clinical deterioration in the hospital are widely used, but there is little information on their comparative performance. To compare 3 proprietary artificial intelligence (AI) early warning scores and 3 publicly available simple aggregated weighted scores. This retrospective cohort study was performed at 7 hospitals in the Yale New Haven Health System. All consecutive adult medical-surgical ward hospital encounters between March 9, 2019, and November 9, 2023, were included. Simultaneous Epic Deterioration Index (EDI), Rothman Index (RI), eCARTv5 (eCART), Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), and NEWS2 scores. Clinical deterioration, defined as a transfer from ward to intensive care unit or death within 24 hours of an observation. Of the 362 926 patient encounters (median patient age, 64 [IQR, 47-77] years; 200 642 [55.3%] female), 16 693 (4.6%) experienced a clinical deterioration event. eCART had the highest area under the receiver operating characteristic curve at 0.895 (95% CI, 0.891-0.900), followed by NEWS2 at 0.831 (95% CI, 0.826-0.836), NEWS at 0.829 (95% CI, 0.824-0.835), RI at 0.828 (95% CI, 0.823-0.834), EDI at 0.808 (95% CI, 0.802-0.812), and MEWS at 0.757 (95% CI, 0.750-0.764). After matching scores at the moderate-risk sensitivity level for a NEWS score of 5, overall positive predictive values (PPVs) ranged from a low of 6.3% (95% CI, 6.1%-6.4%) for an EDI score of 41 to a high of 17.3% (95% CI, 16.9%-17.8%) for an eCART score of 94. Matching scores at the high-risk specificity of a NEWS score of 7 yielded overall PPVs ranging from a low of 14.5% (95% CI, 14.0%-15.2%) for an EDI score of 54 to a high of 23.3% (95% CI, 22.7%-24.2%) for an eCART score of 97. The moderate-risk thresholds provided a median of at least 20 hours of lead time for all the scores. Median lead time at the high-risk threshold was 11 (IQR, 0-69) hours for eCART, 8 (IQR, 0-63) hours for NEWS, 6 (IQR, 0-62) hours for NEWS2, 5 (IQR, 0-56) hours for MEWS, 1 (IQR, 0-39) hour for EDI, and 0 (IQR, 0-42) hours for RI. In this cohort study of inpatient encounters, eCART outperformed the other AI and non-AI scores, identifying more deteriorating patients with fewer false alarms and sufficient time to intervene. NEWS, a non-AI, publicly available early warning score, significantly outperformed EDI. Given the wide variation in accuracy, additional transparency and oversight of early warning tools may be warranted.

Acute kidney injury and mortality in patients with critical COVID-19 in Mexico: case-control study.

We aimed to test the association between acute kidney injury (AKI) and mortality in critically ill patients with Coronavirus disease 2019 (COVID-19). We conducted a single-center case-control study at the intensive care unit (ICU) of a second-level hospital in Mexico. We included 100 patients with critical COVID-19 from January to December 2021, and collected demographic characteristics, comorbidities, APACHE II, SOFA, NEWS2, and CO-RADS scores at admission, incidence of intrahospital complications, length of hospital and ICU stay, and duration of mechanical ventilation, among others. The median survival of deceased patients was 20 days. After multivariable logistic regression, the following variables were significantly associated to mortality: AKI (adjusted odds ratio [AOR] 6.64, 95% confidence intervals [CI] = 2.1-20.6, p = 0.001), age > 55 years (AOR 5.3, 95% CI = 1.5-18.1, p = 0.007), and arrhythmias (AOR 5.15, 95% CI = 1.3-19.2, p = 0.015). Median survival was shorter in patients with AKI (15 vs. 22 days, p = 0.043), as well as in patients with overweight/obesity (15 vs. 25 days, p = 0.026). Our findings show that the development of AKI was the main risk factor associated with mortality in critical COVID-19 patients, while other factors such as older age and cardiac arrhythmias were also associated with this outcome. The management of patients with COVID-19 should include renal function screening and staging on admission to the Emergency Department.

NEWS, NEWS2, and qSOFA accuracy in predicting sepsis-related mortality in acute myeloid leukemia: a retrospective single-center analysis.

Acute myeloid leukemia (AML) treated with intensive chemotherapy carries a high risk of severe infection. The development of reliable assessment tools to promptly identify patients at risk of developing critical illness is essential to prevent delays in intensive care unit (ICU) admission. This study evaluated the accuracy of quick Sequential Organ Failure Assessment (qSOFA) score, National Early Warning Score (NEWS), and NEWS2 score in predicting ICU admission and sepsis-related mortality in this population. A retrospective analysis was conducted, including 365 episodes of febrile neutropenia in 126 patients. The results showed that all three scores-qSOFA, NEWS, and NEWS2-demonstrated good accuracy for all outcomes, with area under the receiver-operating characteristic curve values for sepsis-related mortality of 0.812, 0.858, and 0.848, respectively. In addition, the scores exhibited excellent accuracy in predicting ICU admission and the composite outcome of ICU admission or sepsis-related mortality. To our knowledge, this is the first study to evaluate the accuracy of NEWS in a population of patients with AML who did not undergo stem cell transplantation. These findings suggest that NEWS and NEWS2 are effective tools for identifying patients with AML at high risk of clinical deterioration during febrile neutropenia, supporting their use in clinical practice.

Evaluating the Utility of Clinical Scores APACHE, CURB, SOFA, and NEWS2 at Admission and 5-Days after Symptom Onset in Predicting Severe COVID-19 in Patients with Diabetes.

The elevated risk of severe COVID-19 outcomes in patients with diabetes underscores the need for effective predictive tools. This study aimed to assess the predictive accuracy of APACHE II, CURB-65, SOFA, and NEWS2 scores at critical time points in diabetic patients diagnosed with COVID-19, aiming to guide early and potentially life-saving interventions. In a prospective cohort study conducted from January 2021 to December 2023, adult patients with type 1 or type 2 diabetes and confirmed SARS-CoV-2 infection were evaluated. Clinical scores were calculated at admission and five days post-symptom onset, with data analyzed using receiver operating characteristic (ROC) curves and logistic regression to determine areas under the curve (AUC) and hazard ratios (HR) for severe outcomes. Among the 141 diabetic patients studied, ROC analysis revealed high AUC values for SOFA (0.771 at admission, 0.873 at day five) and NEWS2 (0.892 at admission, 0.729 at day five), indicating strong predictive accuracy for these scores. The APACHE II score's AUC improved from 0.698 at admission to 0.806 on day five, reflecting worsening patient conditions. Regression analysis showed significant HRs associated with exceeding threshold scores: The SOFA score HR at day five was 3.07 (95% CI: 2.29-4.12, p < 0.001), indicating a threefold risk of severe outcomes. Similarly, the APACHE II score showed an HR of 2.96 (95% CI: 2.21-3.96, p < 0.001) at day five, highlighting its utility in predicting severe disease progression. The SOFA and NEWS2 scores demonstrated excellent early predictive accuracy for severe COVID-19 outcomes in diabetic patients, with significant AUC and HR findings. Continuous score monitoring, especially of APACHE II and SOFA, is crucial for managing and potentially mitigating severe complications in this vulnerable population. These tools can effectively assist in the timely escalation of care, thus potentially reducing morbidity and mortality among diabetic patients during the COVID-19 pandemic.

2198 Evidence of systematic missingness in frailty data: a European cohort study

Abstract Introduction Emergency department (ED) frailty screening is recommended in guidelines for its potential to trigger earlier and more appropriate comprehensive evaluation and intervention for the most vulnerable patients. Post-implementation studies of the Clinical Frailty Scale (CFS) typically observe around 50% concordance with screening. Little is known regarding the characteristics of those people omitted. Methods The Frailty in European Emergency Departments (FEED) cohort study observed prevalence of frailty, administering the CFS to consecutive attenders over twenty-four hours. Retrospective ‘normal day’ data from two weeks prior were also collected, where sites used retrievable electronic health records. Age, sex, ethnic group, mode and time of arrival and departure, NEWS2 score, and use of resuscitation areas were recorded. CFS missingness was assessed for distribution and dependency with other variables using chi-squared tests. The frailty distributions in prospective and retrospective data were compared with the Kruskal-Wallis test. Results Only five of sixty-two sites collected CFS scores in retrievable electronic records. The cohorts included 368 individuals prospectively and 399 retrospectively. At these sites, 14% prospective and 55% retrospective CFS observations were missing. CFS entries were more frequently missing in people with non-white ethnic group (p = 0.007) and self-presentation (p &amp;lt; 0.001). The distributions of CFS differed significantly (p = 0.009); on the retrospective day, no individuals were assigned CFS scores 1 or 9, and CFS scores 4 and 6 were over-represented. Conclusion Acknowledging the limited participation and use of snapshot data, these findings alert the presence of systematic, non-random missing data in routine CFS screening. Systematic missingness in frailty data has critical implications for research in geriatric emergency medicine, presenting real limitations in validity where studies seek to analyse routinely collected data to reach representative inferences. Screening practices and retrievability of data warrant further study and improvement.

PROGNOSTIC FACTORS FOR THE DEVELOPMENT OF SEPSIS IN POSTPARTUM WOMEN WHO HAVE SUFFERED CRITICAL OBSTETRICAL CONDITIONS

The aim of the research. To identify prognostic factors for the development of sepsis in postpartum women who have suffered critical obstetric conditions (CAC). Materials and methods. We retrospectively examined 39 postpartum women after CAC, who were divided into groups: A – main group, with advanced sepsis (n = 18), B – control group without sepsis (n = 21). An analysis of clinical data upon admission was carried out. The results were processed using Statistica 12.0, Microsoft Excel and in the R environment. Results. Statistically significantly more often, patients in the main group gave birth before the 34th week of pregnancy, p = 0.04. About 50% of the subjects gave birth in first-level maternity facility. Preeclampsia and obstetric hemorrhage were the main causes of CAC development. Hemorrhagic shock occurred in 84,6% of subjects. All women underwent total hysterectomy. Sepsis developed on day 9 (4; 9) after delivery. It was shown that the chance of developing obstetric sepsis is 28 times more often in the case of artifical ventilation and at AVPU, 10 times – in case of adult respiratory distress syndrom, 7 times – in case of developed kidney failure, 6 times – in case of cerebral edema. When assessing the condition of postpartum women using the integral scales APACHE II, APACHE III, SOFA, NEWS2, a statistically significant OR in the development of sepsis remains only for the NEWS2 index; with a score of 4 points, the resulting model predicts the development of sepsis. The risk of developing obstetric sepsis is associated with MNO ≥ 1,13, CVP ≥ 6 and ASAT ≥ 45; in the presence of at least one of these factors, it increases by 7-8 times in terms of odds ratio (OR). Conclusion. The risk of developing obstetric sepsis in critical obstetric conditions is associated with the presence of mechanical ventilation and AVPU, adult RDS, renal failure, cerebral edema, a NEWS2 score of 4 or more points, MNO ≥ 1,13, CVP ≥ 6 and ASAT ≥ 45. The effectiveness of the developed prognostic model is: sensitivity – 94,5%, specificity – 90,5%.

Cross-cultural adaptation of National Early Warning Score 2 to Angolan Portuguese

ObjectiveTo make a cross-cultural adaptation of the National Early Warning Score 2 (NEWS 2) from English to Angolan Portuguese. MethodsA methodological research of cross-cultural adaptation was conducted, involving sequential stages of forward translation, translation synthesis, back-translation, and the application of the Delphi Panel methodology for analyzing semantic, idiomatic, experiential, and conceptual equivalence between the translated and the original versions. This process culminated in the development of a pre-final version, which subsequently underwent testing in a cohort of nurses (n = 37). The Intraclass Correlation Coefficient was calculated to assess inter-rater reliability of ratings. Cronbach's alpha was used for evaluating the internal consistency and reliability within the items of the NEWS 2 score. ResultsThe cross-cultural adaptation process allowed us to prepare the final version of this tool. The data collected during the testing phase facilitated the examination of inter-rater reliability of ratings and the internal consistency and reliability within the items of the NEWS2 score. The Intraclass Correlation Coefficient observed at this step was 0.992. The Cronbach's alpha was 0.993. ConclusionThe cross-cultural adaptation of the NEWS 2 scoring system to Angolan Portuguese was successful, providing healthcare professionals in Angola with the means to effectively use the tool.

Correlation Between I/T Ratio, S100B, Interleukin-10 Serum, and NEWS2 Score in Sepsis

Immature/total neutrophils (I/T) ratio is a simple and inexpensive method used as an early sign of bacterial infection. Meanwhile, the S100B protein is found in glial cells and functions as a neuroprotection. Then, the interleukin-10 cytokine acts as an anti-inflammatory cytokine during infection. In addition, the NEWS2 score is used to see the early and fast changes in patients with sepsis. The purpose of the study was to prove the correlation between the I/T ratio, S100B, IL-10, and NEWS2 score in patients with sepsis. A cross-sectional study was conducted on 34 patients with sepsis from September 2020 to February 2021. I/T ratio was calculated in 100 leukocytes from microscopic blood smear preparation. Levels of S100B and IL-10 serum were measured using the ELISA method. Pearson correlation test was used for normally distributed data, and the Spearman correlation test was utilized for abnormally distributed data. Correlation test between I/T ratio, S100B, and IL-10 with NEWS2 score respectively showed values of r=0.58; P=0.01, r=0.36; P=0.03, and r=0.39; P=0.02, in which P&lt;0.05. There was a moderate positive correlation between I/T ratio and NEWS2 score, a weak positive correlation between S100B and NEWS2 score, and a weak positive correlation between IL-10 and NEWS2 score.

External validation of two clinical prediction models for mortality in COVID-19 patients (4C and NEWS2), in three centers in Medellín, Colombia: Assessing the impact of vaccination over time

ObjectivesExternal validation of the 4C and NEWS2 scores for the prediction of in-hospital mortality in COVID-19 patients, and evaluation of its operational performance in two time periods: before and after the start of the vaccination program in Colombia. MethodsRetrospective cohort in three high complexity hospitals in the city of Medellín, Colombia, between June 2020 and April 2022. ResultsThe areas under the ROC curve (AUC) for the 4C mortality risk score and the NEWS2 were 0.75 (95% CI 0.73–0.78) and 0.68 (95% CI 0.66–0.71), respectively. For the 4C score, the AUC for the first and second periods was 0.77 (95% CI 0.74–0.80) and 0.75 (95% CI 0.71–0.78); whilst for the NEWS2 score, it was 0.68 (95% CI 0.65–0.71) and 0.69 (95% CI 0.64–0.73). The calibration for both scores was adequate, albeit with reduced performance during the second period. ConclusionsThe 4C mortality risk score proved to be the more adequate predictor of in-hospital mortality in COVID-19 patients in this Latin American population. The operational performance during both time periods remained similar, which shows its utility notwithstanding major changes, including vaccination, as the pandemic evolved.

Clinical Characteristics and Microorganisms Isolated in Community-Acquired Pneumonia in the COVID-19 Period.

Community-acquired pneumonia is a leading cause of mortality and hospital admissions. The aetiology remains unknown in 30-65% of the cases. Molecular tests are available for multiple pathogen detection and are under research to improve the causal diagnosis. We carried out a prospective study to describe the clinical characteristics and aetiology of community-acquired pneumonia during the COVID-19 pandemic and to assess the diagnostic effectivity of the microbiological tests, including a molecular test of respiratory pathogens (FilmArray™ bioMérieux). From the 1st of February 2021 until the 31st of March 2022, 225 patients were included. Failure in microorganism identification occurred in approximately 70% of patients. Streptococcus pneumoniae was the most common isolate. There were 5 cases of viral pneumonia. The tested FilmArray exhibited a low positivity rate of 7% and mainly aided in the diagnosis of viral coinfections. Despite our extensive diagnostic protocol, there is still a low rate of microorganism identification. We have observed a reduction in influenza and other viral pneumoniae during the COVID-19 pandemic. Having a high NEWS2 score on arrival at the emergency department, an active oncohematological disease or chronic neurological conditions and a positive microbiological test result were related to worse outcomes. Further research is needed to determine the role of molecular tests in the microbiological diagnosis of pneumonia.

Simulation to improve healthcare pathway and inequities for people with disabilities.

Introduction: The Convention on the Rights of People with Disabilities (1) reported that people with disabilities do not have equitable access to health services. People with intellectual disabilities, especially the ageing, are more susceptible to somatic disease and other lifestyle diseases than the general population (2, 3, 4, 5, 6). &#x0D; General practitioners' (GP) competence in the field of intellectual disability is largely experience-based, not systematic and research-based (7). In municipalities, approximately half of healthcare workers (HCWs) at municipal housing for people with intellectual disabilities are unskilled. These HCWs have experienced not being taken seriously when calling either their patients’ GP or accident and emergency (A&amp;E) department to report that the resident is 'not well', resulting in residents receiving inadequate healthcare. Municipal leaders and educators decided to address the inadequate clinical observation and communication skills among HCWs with a simulation-based training program (SBTP), to improve competence and treatment of residents when escalating levels of care.&#x0D; Methods: Based on national recommendations about ""Early detection of deteriorating condition"" and the urgency of the covid-pandemic, the SBTP was quickly rolled out to all HCW. The SBTP consisted of both theoretical teaching and e-learning in ABCDE, training in the tool NEWS2, as well as the communication technique ISBAR. Baseline NEWS2 scores were established for all residents.&#x0D; Based on positive experience with SBTP in donning and doffing of personal protection equipment (8) in the municipality early in the pandemic, and uncertainty about safer care for sick corona patients in residential homes, leaders requested continued use SMTP to improve observational skills.&#x0D; Results &amp; Discussion: Evidence of improved competency at work and resulting improved escalation of care came fast.&#x0D; One example was of a resident with backpain whose relatives’ recommended painkillers. HCWs performed NEWS2 scoring, discovered pathological changes, contacted A&amp;E, received treatment advice, continually followed up on NEWS2 measurements, secured ambulance help &amp; reaction based on baseline NEWS2, and admission where sepsis was discovered. Similarly, another group of HCWs performed NEWS2 scoring on a patient with presenting manic symptoms, discovered clinical signs of somatic illness, which lead to a completely different medication than expected. These cases were seen as post-SBTP improvements in HCWs behavior, and patient safety.&#x0D; &#x0D; SBTP to improve observational skills in the municipality has led to better differential diagnosis in the early stage, more precise communication with GP and A&amp;E which in turn has led to better healthcare pathways for a vulnerable patient group.&#x0D; Keywords: simulation, observational competence, competence, health rights&#x0D;

Do patients with acute diverticulitis need to be in the hospital? - Implementation of an @Home treatment pathway to reduce admissions

Abstract Aims Acute complicated diverticulitis is often treated as an in-patient, despite few needing intervention. Virtual wards are designed to treat patients at home. The aim was to develop an NHS@Home service for acute diverticulitis to reduce hospital admissions. Methods A retrospective review of patients with diverticulitis examined daily WCC &amp; CRP, analgesia and IV antibiotic requirements, NEWS2 &amp; pain scores. This was used to develop an @Home treatment protocol. In this, patients with CT-confirmed diverticulitis +/- localized perforation &amp;lt;3cm, NEWS2 &amp;lt;2, Pain score &amp;lt;5, and CRP &amp;lt;200 were given one dose of IV antibiotics, then oral antibiotics at home with thrice-a-day observations and daily bloods. Discharge was nurse-led on day 2 or 3 with criteria for re-admission. Results Of 42 admissions, mean WCC was 12.7, mean CRP was 171 if perforated, and 85 if not. All NEWS2 scores were &amp;lt;2 and mean pain score was 3. 65% of patients (28/42) had no perforation on CT. Most patients (60.5%) did not require opioid analgesia, mean IV antibiotic treatment duration was 2.5 days and mean LOS was 3.75 days. Only 6/42 patients (14.28%) had a collection. In all patients, WCC was static or reduced during admission but CRP increased in a third. 35 patients were treated on the Diverticulitis@Home Pathway in the first 4 months with one readmission. The pathway was used to standardize colonic imaging according to guidelines. As a result, 60% (36/61) of endoluminal imaging previously ordered by clinicians was canceled. Conclusion An @home diverticulitis pathway is safe, effective and saves bed days.

Automated audit of hospital oxygen use devised during the COVID-19 pandemic

BackgroundThe British Thoracic Society (BTS) has organised intermittent audits of hospital oxygen use in UK hospitals since 2008. Manual audits are time-consuming and subject to human errors. Oxygen prescribing and...

Risk stratification of hemodynamically stable patients with acute pulmonary embolism: external validation and comparison of different strategies

Abstract Background Risk stratification for adverse outcome in hemodynamically stable patients with acute pulmonary embolism (PE) remains an issue. We aimed at validating and comparing currently available tools for risk stratification in this setting. Methods Hemodynamically stable patients (n= 5,036) from a prospective, multicentre study of adult patients with acute, symptomatic, objectively diagnosed PE (COPE) were included in this study. Study outcomes were in-hospital death, death at 30 days, PE-related death and the composite of clinical deterioration or death at 30 days. We assessed and compared the accuracy of ESC-2014, ESC-2019, PEITHO, Bova, TELOS, FAST and NEWS2 models to predict study outcome events by AUC statistics, negative and positive predictive values. Results Patient distribution in risk categories highly varied across different models (low-risk class: from 14.4% in ESC-2019 to 70.1% in FAST; highest risk class: from 16.4% in BOVA to 43.7% in ESC 2014). When the 3,544 patients with echocardiography performed and troponin assessed were considered, ESC-2014, PEITHO, TELOS and NEWS-2 had i) the best discriminatory powers for study outcome events, ii) the best performances for all study outcome events (ROC curves for death or clinical deterioration reported in the Figure) and iii) negative predictive values for PE-related death above 99%. Negative predictive values for death or clinical deterioration were above 98% for all the models except for FAST; positive predictive values were all below 10% except for TELOS. TELOS score had the best performance; NEWS2 score was very good by including clinical variables only (no instrumental/laboratory items). Conclusions The majority of available models for risk stratification of patients with acute PE have good accuracy for the identification of low-risk patients; their positive predictive values in hemodynamically stable patients remain modest, the best being that of TELOS score. These data are essential to inform management studies.

COVID-19: An evaluation of predictive scoring systems in South Africa

Background| The Coronavirus Disease 2019 (COVID-19) pandemic, caused by SARS-CoV-2, has resulted in more than 700 million cases worldwide. Sepsis and pneumonia severity scores assist in risk assessment of critical outcomes in patients with COVID-19. This allows healthcare workers to triage patients, by using clinical parameters and limited special investigations, thus offering the most appropriate level of care. Methods| A retrospective cohort study of 605 adult patients hospitalised with moderate to severe COVID-19, at a tertiary state hospital in South Africa. Evaluating the utility of the CURB65, NEWS2 and ISARIC-4C Mortality Score, in predicting critical outcomes, using clinical characteristics on admission. Outcomes included in-hospital mortality, invasive mechanical ventilation, and intensive care unit admission (ICU). Performance of severity scores and risk factors was assessed by area under the receiver operator characteristics (AUROC) analysis and logistic regression. Findings |A total of 605 records were used, 129 (21 %) non-survivors, 101 (17 %) ICU admissions and 77 (13 %) requiring invasive ventilation. Greater odds of mortality was associated with moderate and severe risk groups of the CURB65, ISARIC-4C and NEWS2 score. Mortality AUROC curve analysis for the CURB65 score was 0·76 (95 % CI: 0·71–0·8), 0·77 (95 % CI: 0·73–0·81) for the ISARIC-4C and 0·77 (95 % CI: 0·73–0·82) for the NEWS2 score. The CURB65 score had a sensitivity of 86 % with 12·8 % mortality, ISARIC-4C score a sensitivity of 87·6 % with 8 % mortality and NEWS2 score a sensitivity of 92·2 % with 8·6 % mortality. Interpretation |In 605 hospitalised patients with moderate to severe COVID-19, predominantly infected by the ancestral strain, good performance of the NEWS2 and ISARIC-4C score in predicting in-hospital mortality was noted. The CURB65 score had a high mortality rate in its low-risk group suggesting unexplained risk factors, not accounted for in the score, thus limiting its utility in the South African setting.

Critically deviating vital signs among patients with non-specific diagnoses-A register-based historic cohort study.

One third of ambulance patients receive non-specific diagnoses in hospital. Mortality is 3-4%, however due to the high patient volume this group accounts for 20% of all deaths at day 30. Non-specific diagnoses do not provide much information on causes for death. Vital signs at first contact with ambulance personnel can act as a proxy for the patient's condition. Thus, we aimed to describe the prevalence of abnormal vital signs, as determined by a modified NEWS2, in ambulance patients who received a non-specific hospital diagnosis. Secondly, we examined the association between vital signs, NEWS2 scores, type of non-specific diagnosis, and mortality among these patients. Register-based historic cohort study of ambulance patients aged 16+ in the North Denmark Region during 2012-2016, who received a non-specific diagnosis (ICD-10 chapters R or Z) at hospital. We used NEWS2 scores to determine if first vital signs were normal or deviating (including critical). Mortality was estimated with the Kaplan-Meier estimator. Association between vital signs and mortality was evaluated by logistic regression. We included 41,539 patients, 20.9% (N = 8,691) had normal vital signs, 16.3% (N = 6,766) had incomplete vital sign registration, 62.8% (N = 26,082) had deviating vital signs, and of these 6.8% (N = 1,779) were critical. If vital signs were incompletely registered or deviating, mortality was higher compared to normal vital signs. Patients with critical vital signs displayed the highest crude 48-hour and 30-day mortality (7.0% (5.9-8.3) and 13.4% (11.9-15.1)). Adjusting for age, sex, and comorbidity did not change that pattern. Across all vital sign groups, despite severity, the most frequent diagnosis assigned was Z039 observation for suspected disease or condition unspecified. Most ambulance patients with non-specific diagnoses had normal or non-critical deviating vital signs and low mortality. Around 4% had critical vital signs and high mortality, not explained by age or comorbidity.

Comparison of the clinical characteristics of SARS-CoV-2 Delta (B.1.617.2) and Omicron (B.1.1.529) infected patients from a single hospitalist service

BackgroundWhile existing evidence suggests less severe clinical manifestations and lower mortality are associated with the Omicron variant as compared to the Delta variant. However, these studies fail to control for differences in health systems facilities and providers. By comparing patients hospitalized on a single medical service during the Delta and Omicron surges we were able to conduct a more accurate comparison of the two varaints’ clinical manifestations and outcomes.MethodsWe conducted a prospective study of 364 Omicron (BA.1) infected patients on a single hospitalist service and compared these findings to a retrospective analysis of 241 Delta variant infected patients managed on the same service. We examined differences in symptoms, laboratory measures, and clinical severity between the two variants and assessed potential risk drivers for case mortality.FindingsPatients infected with Omicron were older and had more underlying medical conditions increasing their risk of death. Although they were less severely ill and required less supplemental oxygen and dexamethasone, in-hospital mortality was similar to Delta cases, 7.14% vs. 4.98% for Delta (q-value = 0.38). Patients older than 60 years or with immunocompromised conditions had much higher risk of death during hospitalization, with estimated odds ratios of 17.46 (95% CI: 5.05, 110.51) and 2.80 (1.03, 7.08) respectively. Neither vaccine history nor variant type played a significant role in case fatality. The Rothman score, NEWS-2 score, level of neutrophils, level of care, age, and creatinine level at admission were highly predictive of in-hospital death.InterpretationIn hospitalized patients, the Omicron variant is less virulent than the Delta variant but is associated with a comparable mortality. Clinical and laboratory features at admission are informative about the risk of death.

Association between SARS-CoV-2 viral kinetics and clinical score evolution in hospitalized patients.

The role of antiviral treatment in coronavirus disease 2019 hospitalized patients is controversial. To address this question, we analyzed simultaneously nasopharyngeal viral load and the National Early Warning Score 2 (NEWS-2) using an effect compartment model to relate viral dynamics and the evolution of clinical severity. The model is applied to 664 hospitalized patients included in the DisCoVeRy trial (NCT04315948; EudraCT 2020-000936-23) randomly assigned to either standard of care (SoC) or SoC + remdesivir. Then we use the model to simulate the impact of antiviral treatments on the time to clinical improvement, defined by a NEWS-2 score lower than 3 (in patients with NEWS-2 <7 at hospitalization) or 5 (in patients with NEWS-2 ≥7 at hospitalization), distinguishing between patients with low or high viral load at hospitalization. The model can fit well the different observed patients trajectories, showing that clinical evolution is associated with viral dynamics, albeit with large interindividual variability. Remdesivir antiviral activity was 22% and 78% in patients with low or high viral loads, respectively, which is not sufficient to generate a meaningful effect on NEWS-2. However, simulations predicted that antiviral activity greater than 99% could reduce by 2 days the time to clinical improvement in patients with high viral load, irrespective of the NEWS-2 score at hospitalization, whereas no meaningful effect was predicted in patients with low viral loads. Our results demonstrate that time to clinical improvement is associated with time to viral clearance and that highly effective antiviral drugs could hasten clinical improvement in hospitalized patients with high viral loads.