Evaluation of the efficacy of the National Early Warning Score in predicting in-hospital mortality via the risk stratification

ObjectivesAlthough the National Early Warning Score (NEWS) and its latest version NEWS2 are recommended for monitoring deterioration in patients admitted to hospital, little is known about their performance in COVID-19 patients. We aimed to compare the performance of the NEWS and NEWS2 in patients with COVID-19 versus those without during the first phase of the pandemic.DesignA retrospective cross-sectional study.SettingTwo acute hospitals (Scarborough and York) are combined into a single dataset and analysed collectively.ParticipantsAdult (≥18 years) non-elective admissions discharged between 11 March 2020 and 13 June 2020 with an index or on-admission NEWS2 electronically recorded within ±24 hours of admission to predict mortality at four time points (in-hospital, 24 hours, 48 hours and 72 hours) in COVID-19 versus non-COVID-19 admissions.ResultsOut of 6480 non-elective admissions, 620 (9.6%) had a diagnosis of COVID-19. They were older (73.3 vs 67.7 years), more often male (54.7% vs 50.1%), had higher index NEWS (4 vs 2.5) and NEWS2 (4.6 vs 2.8) scores and higher in-hospital mortality (32.1% vs 5.8%). The c-statistics for predicting in-hospital mortality in COVID-19 admissions was significantly lower using NEWS (0.64 vs 0.74) or NEWS2 (0.64 vs 0.74), however, these differences reduced at 72hours (NEWS: 0.75 vs 0.81; NEWS2: 0.71 vs 0.81), 48 hours (NEWS: 0.78 vs 0.81; NEWS2: 0.76 vs 0.82) and 24hours (NEWS: 0.84 vs 0.84; NEWS2: 0.86 vs 0.84). Increasing NEWS2 values reflected increased mortality, but for any given value the absolute risk was on average 24% higher (eg, NEWS2=5: 36% vs 9%).ConclusionsThe index or on-admission NEWS and NEWS2 offers lower discrimination for COVID-19 admissions versus non-COVID-19 admissions. The index NEWS2 was not proven to be better than the index NEWS. For each value of the index NEWS/NEWS2, COVID-19 admissions had a substantially higher risk of mortality than non-COVID-19 admissions which reflects the increased baseline mortality risk of COVID-19.

Download Full-text

Peer review report 2 on “Pre-hospital national early warning score (NEWS) is associated with in-hospital mortality and critical care unit admission: A cohort study”

Annals of Medicine and Surgery ◽

10.1016/j.amsu.2018.03.039 ◽

2018 ◽

Vol 25 ◽

pp. 50

Keyword(s):

Critical Care ◽

Cohort Study ◽

Hospital Mortality ◽

Peer Review ◽

Early Warning ◽

Critical Care Unit ◽

Early Warning Score ◽

National Early Warning Score

Download Full-text

Predicting In-hospital Mortality Using the National Early Warning Score in Older Adults Admitted to the Emergency Department

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2020.07.054 ◽

2020 ◽

Vol 59 (5) ◽

pp. 755-757

Author(s):

I.Y. Kim ◽

C.S. Youn

Keyword(s):

Older Adults ◽

Emergency Department ◽

Hospital Mortality ◽

Early Warning ◽

Early Warning Score ◽

National Early Warning Score

Download Full-text

Evaluation and Improvement of the National Early Warning Score (NEWS2) for COVID-19: a multi-hospital study

10.1101/2020.04.24.20078006 ◽

2020 ◽

Cited By ~ 8

Author(s):

Ewan Carr ◽

Rebecca Bendayan ◽

Daniel Bean ◽

Matt Stammers ◽

Wenjuan Wang ◽

...

Keyword(s):

Risk Stratification ◽

Early Warning ◽

External Validation ◽

Early Warning Score ◽

Minimal Set ◽

Estimated Gfr ◽

Risk Stratification Model ◽

Risk Scoring ◽

National Early Warning Score ◽

The Uk

AbstractObjectivesTo evaluate the National Early Warning Score (NEWS2), currently recommended in the UK for risk-stratification of severe COVID-19 outcomes, and subsequently identify and validate a minimal set of common parameters taken at hospital admission that improve the score.DesignRetrospective observational cohort with internal and multi-hospital external validation.SettingSecondary care.InterventionsNot applicable.ParticipantsMain outcome measuresResultsTraining and temporal external validation cohorts comprised 1464 patients admitted to King’s College Hospital NHS Foundation Trust (KCH) with COVID-19 disease from 1st March to 30th April 2020. External validation cohorts included 3869 patients from two UK NHS Trusts (Guys and St Thomas’ Hospitals, GSTT and University Hospitals Southampton, UHS) and two hospitals in Wuhan, China (Wuhan Sixth Hospital and Taikang Tongji Hospital).The primary outcome was patient status at 14 days after symptom onset categorised as severe disease (transferred to intensive care unit or death). Age, physiological measures, blood biomarkers, sex, ethnicity and comorbidities (hypertension, diabetes, cardiovascular, respiratory and kidney diseases) were included.ConclusionsNEWS2 score on admission was a weak predictor of severe COVID-19 infection (AUC = 0.628). Adding age and common blood tests (CRP, neutrophil count, estimated GFR and albumin) provided substantial improvements to a risk stratification model, particularly in relation to sensitivity, but performance was only moderate (AUC = 0.753). Improvement over NEWS2 remained robust and generalisable in GSTT (AUC = 0.817), UHS (AUC = 0.835) and Wuhan hospitals (AUC = 0.918).Adding age and a minimal set of blood parameters to NEWS2 improves the detection of patients likely to develop severe COVID-19 outcomes. This finding was replicated across NHS and non-UK hospitals. Adding a few common parameters to a pre-existing acuity score allows rapid and easy implementation of this risk-scoring system.Key MessagesThe National Early Warning Score (NEWS2), currently recommended for severe COVID-19 disease in the UK shows overall poor discrimination for severe outcomes (transfer to ICU or death). It can be improved by the addition of a small number of blood and physiological parameters routinely measured at hospital admission.The addition of age and a minimal set of common blood tests (C-reactive protein, neutrophil count, estimated GFR and albumin) provided substantial improvements in a risk stratification model.Although predictive performance varied from hospital to hospital, the improvement over NEWS2 alone was consistent across different patient cohorts.The proposed addition of a limited number of dichotomised parameters is easily derived from a pre-existing acuity score would be substantially easier to implement in a short-time scale compared to novel high-dimensional risk-scoring systems.

Download Full-text

The National Early Warning Score (NEWS2) systematically underestimates the risk of in-hospital mortality in unplanned COVID-19 admissions to hospital

10.1101/2020.07.13.20144907 ◽

2020 ◽

Author(s):

Donald Richardson ◽

Muhammad Faisal ◽

Massimo Fiori ◽

Kevin Beatson ◽

Mohammed A Mohammed

Keyword(s):

Hospital Mortality ◽

Mortality Risk ◽

Early Warning ◽

Absolute Risk ◽

Clinical Staff ◽

Early Warning Score ◽

Time Points ◽

Valid Predictor ◽

National Early Warning Score ◽

The Absolute

AbstractBackgroundAlthough the National Early Warning Score (NEWS) and its latest version NEWS2 are recommended for monitoring for deterioration in patients admitted to hospital, little is known about their performance in COVID-19 patients. We analysed the performance of National Early Warning Score (NEWS2) during the first phase of the COVID-19 pandemic.MethodsAdult non-elective admissions discharged between 11-March-2020 to 13-June-2020 with an index NEWS2 electronically recorded within ±24 hours of admission are used to predict mortality at four time points (in-hospital, 24hours, 48hours, and 72hours) in COVID-19 versus non-COVID-19 admissions.ResultsOut of 6480 non-elective admissions, 620 (9.6%) had a diagnosis of COVID-19. They were older (73.3 vs 67.7yrs), more often male (54.7% vs 50.1%), had higher index NEWS (4 vs 2.5) and NEWS2 (4.6 vs 2.8) scores and higher in-hospital mortality (32.1% vs 5.8%). The c-statistics for predicting in-hospital mortality in COVID-19 admissions was significantly lower using NEWS (0.64 vs 0.74) or NEWS2 (0.64 vs 0.74), however these differences reduced at 72hours (NEWS: 0.75 vs 0.81; NEWS2: 0.71 vs 0.81), 48 hours (NEWS: 0.78 vs 0.81; NEWS2: 0.76 vs 0.82) and 24hours (NEWS: 0.84 vs 0.84; NEWS2: 0.86 vs 0.84). Increasing NEWS2 values reflected increased mortality, but for any given value the absolute risk was on average 24% higher (e.g.NEWS2=5: 36% vs 9%).InterpretationNEWS2 is a valid predictor of the mortality risk but substantially underestimates the absolute mortality risk in COVID-19 patients. Clinical staff and escalation protocols based on NEWS2 need to make note of this finding.

Download Full-text

Comparison of the National Early Warning Score (NEWS) and the Modified Early Warning Score (MEWS) for predicting admission and in-hospital mortality in elderly patients in the pre-hospital setting and in the emergency department

PeerJ ◽

10.7717/peerj.6947 ◽

2019 ◽

Vol 7 ◽

pp. e6947 ◽

Cited By ~ 7

Author(s):

Toshiya Mitsunaga ◽

Izumu Hasegawa ◽

Masahiko Uzura ◽

Kenji Okuno ◽

Kei Otani ◽

...

Keyword(s):

Elderly Patients ◽

Hospital Mortality ◽

Early Warning ◽

Pressure Pulse ◽

Vital Signs ◽

Early Warning Score ◽

Single Centre ◽

Peripheral Oxygen Saturation ◽

Significant Difference ◽

National Early Warning Score

The aim of this study is to evaluate the usefulness of the pre-hospital National Early Warning Score (pNEWS) and the pre-hospital Modified Early Warning Score (pMEWS) for predicting admission and in-hospital mortality in elderly patients presenting to the emergency department (ED). We also compare the value of the pNEWS with that of the ED NEWS (eNEWS) and ED MEWS (eMEWS) for predicting admission and in-hospital mortality. This retrospective, single-centre observational study was carried out in the ED of Jikei University Kashiwa Hospital, in Chiba, Japan, from 1st April 2017 to 31st March 2018. All patients aged 65 years or older were included in this study. The pNEWS/eNEWS were derived from seven common physiological vital signs: respiratory rate, peripheral oxygen saturation, the presence of inhaled oxygen parameters, body temperature, systolic blood pressure, pulse rate and Alert, responds to Voice, responds to Pain, Unresponsive (AVPU) score, whereas the pMEWS/eMEWS were derived from six common physiological vital signs: respiratory rate, peripheral oxygen saturation, body temperature, systolic blood pressure, pulse rate and AVPU score. Discrimination was assessed by plotting the receiver operating characteristic (ROC) curve and calculating the area under the ROC curve (AUC). The median pNEWS, pMEWS, eNEWS and eMEWS were significantly higher at admission than at discharge (p < 0.001). The median pNEWS, pMEWS, eNEWS and eMEWS of non-survivors were significantly higher than those of the survivors (p < 0.001). The AUC for predicting admission was 0.559 for the pNEWS and 0.547 for the pMEWS. There was no significant difference between the AUCs of the pNEWS and the pMEWS for predicting admission (p = 0.102). The AUCs for predicting in-hospital mortality were 0.678 for the pNEWS and 0.652 for the pMEWS. There was no significant difference between the AUCs of the pNEWS and the pMEWS for predicting in-hospital mortality (p = 0.081). The AUC for predicting admission was 0.628 for the eNEWS and 0.591 for the eMEWS. The AUC of the eNEWS was significantly greater than that of the eMEWS for predicting admission (p < 0.001). The AUC for predicting in-hospital mortality was 0.789 for the eNEWS and 0.720 for the eMEWS. The AUC of the eNEWS was significantly greater than that of the eMEWS for predicting in-hospital mortality (p < 0.001). For admission and in-hospital mortality, the AUC of the eNEWS was significantly greater than that of the pNEWS (p < 0.001, p < 0.001), and the AUC of the eMEWS was significantly greater than that of the pMEWS (p < 0.01, p < 0.05). Our single-centre study has demonstrated the low utility of the pNEWS and the pMEWS as predictors of admission and in-hospital mortality in elderly patients, whereas the eNEWS and the eMEWS predicted admission and in-hospital mortality more accurately. Evidence from multicentre studies is needed before introducing pre-hospital versions of risk-scoring systems.

Download Full-text

Impact of Intensive Care Unit Readmissions on Patient Outcomes and the Evaluation of the National Early Warning Score to Prevent Readmissions: Literature Review

JMIR Perioperative Medicine ◽

10.2196/13782 ◽

2020 ◽

Vol 3 (1) ◽

pp. e13782

Author(s):

Heidi Mcneill ◽

Saif Khairat

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Literature Review ◽

Hospital Mortality ◽

Patient Outcomes ◽

Early Warning ◽

Early Warning Score ◽

Risk Stratification Tool ◽

National Early Warning Score ◽

The Impact

Background Intensive care unit (ICU) readmissions have been shown to increase a patient’s in-hospital mortality and length of stay (LOS). Despite this, no methods have been set in place to prevent readmissions from occurring. Objective The aim of this literature review was to evaluate the impact of ICU readmission on patient outcomes and to evaluate the effect of using a risk stratification tool, the National Early Warning Score (NEWS), on ICU readmissions. Methods A database search was performed on PubMed, Cumulative Index of Nursing and Allied Health Literature, Google Scholar, and ProQuest. In the initial search, 2028 articles were retrieved; after inclusion and exclusion criteria were applied, 12 articles were ultimately used in this literature review. Results This literature review found that patients readmitted to the ICU have an increased mortality rate and LOS at the hospital. The sample sizes in the reviewed studies ranged from 158 to 745,187 patients. Readmissions were most commonly associated with respiratory issues about 18% to 59% of the time. The NEWS has been shown to detect early clinical deterioration in a patient within 24 hours of transfer, with a 95% CI of 0.89 to 0.94 (P<.001), a sensitivity of 93.6% , and a specificity of 82.2%. Conclusions ICU readmissions are associated with worse patient outcomes, including hospital mortality and increased LOS. Without the use of an objective screening tool, the provider has been solely responsible for the decision of patient transfer. Assessment with the NEWS could be helpful in decreasing the frequency of inappropriate transfers and ultimately ICU readmission.

Download Full-text

Impact of Intensive Care Unit Readmissions on Patient Outcomes and the Evaluation of the National Early Warning Score to Prevent Readmissions: Literature Review (Preprint)

10.2196/preprints.13782 ◽

2019 ◽

Author(s):

Heidi Mcneill ◽

Saif Khairat

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Literature Review ◽

Hospital Mortality ◽

Patient Outcomes ◽

Early Warning ◽

Early Warning Score ◽

Risk Stratification Tool ◽

National Early Warning Score ◽

The Impact

BACKGROUND Intensive care unit (ICU) readmissions have been shown to increase a patient’s in-hospital mortality and length of stay (LOS). Despite this, no methods have been set in place to prevent readmissions from occurring. OBJECTIVE The aim of this literature review was to evaluate the impact of ICU readmission on patient outcomes and to evaluate the effect of using a risk stratification tool, the National Early Warning Score (NEWS), on ICU readmissions. METHODS A database search was performed on PubMed, Cumulative Index of Nursing and Allied Health Literature, Google Scholar, and ProQuest. In the initial search, 2028 articles were retrieved; after inclusion and exclusion criteria were applied, 12 articles were ultimately used in this literature review. RESULTS This literature review found that patients readmitted to the ICU have an increased mortality rate and LOS at the hospital. The sample sizes in the reviewed studies ranged from 158 to 745,187 patients. Readmissions were most commonly associated with respiratory issues about 18% to 59% of the time. The NEWS has been shown to detect early clinical deterioration in a patient within 24 hours of transfer, with a 95% CI of 0.89 to 0.94 (<i>P</i><.001), a sensitivity of 93.6% , and a specificity of 82.2%. CONCLUSIONS ICU readmissions are associated with worse patient outcomes, including hospital mortality and increased LOS. Without the use of an objective screening tool, the provider has been solely responsible for the decision of patient transfer. Assessment with the NEWS could be helpful in decreasing the frequency of inappropriate transfers and ultimately ICU readmission.

Download Full-text

How to follow the NEWS

Acute Medicine Journal ◽

10.52964/amja.0356 ◽

2014 ◽

Vol 13 (3) ◽

pp. 104-107

Author(s):

John Kellett ◽

◽

Alan Murray ◽

Keyword(s):

Hospital Mortality ◽

Early Warning ◽

Fold Increase ◽

Early Warning Score ◽

Published Data ◽

Initial Value ◽

Early Warning Scores ◽

Average Patient ◽

Prognostic Importance ◽

National Early Warning Score

Background: it is not known how best to respond to changes in the National Early Warning Score (NEWS) after hospital admission. This report manipulates and extrapolates previously published data on the trajectories of the abbreviated early warning score (AbEWS i.e. NEWS that does not include mental status). Methods: trajectories of averaged AbEWS for patients for their first 5 days in hospital and their last 5 days in hospital were combined to obtain an approximation of what happens to the average patient while in hospital. Results: the trajectories of patients admitted with a low score are different from those admitted with a high score. Patients should be observed for 12 to 24 hours before their outcome can be predicted. The score of most patients who die in hospital trends upward on the second or third day after admission. Patients admitted with a score of 0-2 who raise their score to >=3 have a ten-fold increase in-hospital mortality. Conclusions: the trajectories of early warning scores after admission are of prognostic importance, and escalation protocols should relate changes in the score to its initial value on admission.

Download Full-text

National Early Warning Score 2 (NEWS2) to predict poor outcome in hospitalised COVID-19 patients in India

PLoS ONE ◽

10.1371/journal.pone.0261376 ◽

2021 ◽

Vol 16 (12) ◽

pp. e0261376

Author(s):

Pugazhvannan CR ◽

Ilavarasi Vanidassane ◽

Dhivya Pownraj ◽

Ravichandran Kandasamy ◽

Aneesh Basheer

Keyword(s):

Risk Stratification ◽

Early Warning ◽

Area Under The Curve ◽

Clinical Score ◽

Supplemental Oxygen ◽

Early Warning Score ◽

National Early Warning Score ◽

Poor Outcomes ◽

Indian Setting ◽

Sensitivity Specificity

Background While several parameters have emerged as predictors of prognosis of COVID-19, a simple clinical score at baseline might help early risk stratification. We determined the ability of National Early Warning Score 2 (NEWS2) to predict poor outcomes among adults with COVID-19. Methods A prospective study was conducted on 399 hospitalised adults with confirmed SARS-CoV-2 infection between August and December 2020. Baseline NEWS2 score was determined. Primary outcome was poor outcomes defined as need for mechanical ventilation or death within 28 days. The sensitivity, specificity and Area under the curve were determined for NEWS2 scores of 5 and 6. Results Mean age of patients was 55.5 ± 14.8 years and 275 of 399 (68.9%) were male. Overall mortality was 3.8% and 7.5% had poor outcomes. Median (interquartile range) NEWS2 score at admission was 2 (0–6). Sensitivity and specificity of NEWS 2 of 5 or more in predicting poor outcomes was 93.3% (95% CI: 76.5–98.8) and 70.7% (95% CI: 65.7–75.3) respectively [area under curve 0.88 (95% CI: 0.847–0.927)]. Age, baseline pulse rate, baseline oxygen saturation, need for supplemental oxygen and ARDS on chest X ray were independently associated with poor outcomes. Conclusions NEWS2 score of 5 or more at admission predicts poor outcomes in patients with COVID-19 with good sensitivity and can easily be applied for risk stratification at baseline. Further studies are needed in the Indian setting to validate this simple score and recommend widespread use.

Download Full-text