Examining the utility of the Hamilton early warning scores (HEWS) at triage: Retrospective pilot study in a Canadian emergency department

ABSTRACTObjectivesEarly warning scores use vital signs to identify patients at risk of critical illness. The current study examines the Hamilton Early Warning Score (HEWS) at emergency department (ED) triage among patients who experienced a critical event during their hospitalization. HEWS was also evaluated as a predictor of sepsis.MethodsThe study population included admissions to two hospitals over a 6-month period. Cases experienced a critical event defined by unplanned intensive care unit admission, cardiopulmonary resuscitation, or death. Controls were randomly selected from the database in a 2-to-1 ratio to match cases on the burden of comorbid illness. Receiver operating characteristic (ROC) curves were used to evaluate HEWS as a predictor of the likelihood of critical deterioration and sepsis.ResultsThe sample included 845 patients, of whom 270 experienced a critical event; 89 patients were excluded because of missing vitals. An ROC analysis indicated that HEWS at ED triage had poor discriminative ability for predicting the likelihood of experiencing a critical event 0.62 (95% CI 0.58-0.66). HEWS had a fair discriminative ability for meeting criteria for sepsis 0.77 (95% CI 0.72-0.82) and good discriminative ability for predicting the occurrence of a critical event among septic patients 0.82 (95% CI 0.75-0.90).ConclusionThis study indicates that HEWS at ED triage has limited utility for identifying patients at risk of experiencing a critical event. However, HEWS may allow earlier identification of septic patients. Prospective studies are needed to further delineate the utility of the HEWS to identify septic patients in the ED.

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P120: Exploring the utility of the Hamilton early warning score at triage: pilot study in a Canadian emergency department

CJEM ◽

10.1017/cem.2016.295 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S118-S118

Author(s):

S. Skitch ◽

L. McInnis ◽

A. Vu ◽

B. Tam ◽

M. Xu ◽

...

Keyword(s):

At Risk ◽

Emergency Department ◽

Early Warning ◽

Tertiary Care ◽

Vital Signs ◽

Early Warning Score ◽

Critical Event ◽

Likelihood Ratios ◽

Discriminative Ability ◽

Patients At Risk

Introduction: Early warning scores (EWS) use vital signs to identify patients at risk of critical events as defined by unplanned intensive care unit (ICU) admission, cardiopulmonary resuscitation (CPR), or death. Systems that combine an EWS with a ICU outreach team can improve hospital survival and cardiac arrest rates. Although initially developed for use in ward patients, evidence suggests that EWS are useful in emergency department (ED) patients and may aid in the earlier identification of sepsis. The Hamilton Early Warning Score (HEWS) was recently developed as part of quality improvement process in our health system. The current study examined HEWS at ED triage among a cohort of patients who experienced a critical event during their hospitalization. HEWS were also evaluated as a predictor of sepsis. Methods: Patient were selected from a database of patients admitted to a medical or surgical ward at two tertiary care hospitals over a six-month period. Cases were patients who experienced a critical event during admission and were admitted via the ED. Controls were randomly selected from the database in a two-to-one ratio using an algorithm to match cases based upon burden of comorbid illness. Receiver operator curves (ROC) and likelihood ratios were used to evaluate HEWS at ED triage as a predictor of likelihood of critical deterioration and sepsis. Results: The sample included 845 patients of whom 267 experienced a critical event. The median time to occurrence of critical event from admission was 124 hours. ROC analysis indicated that HEWS at ED triage had poor discriminative ability for predicting likelihood of experiencing a critical event 0.63 [95%CI: 0.58-0.67]. HEWS had fair discriminative ability for predicting likelihood of meeting criteria for sepsis 0.75 [95%CI: 0.71-0.80], and good discriminative ability for predicting likelihood of experiencing a critical event among patients meeting criteria for sepsis 0.80 [95%CI: 0.74-0.86]. Conclusion: This retrospective study indicates that HEWS at ED triage has limited utility for identifying patients at risk of experiencing a critical event. This may be because deterioration commonly occurred days after admission. However, HEWS may have utility as tool for aiding earlier identification of critically ill septic patients. Prospective studies are needed to further delineate the utility of the HEWS in the ED.

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The Admission Hamilton Early Warning Score (HEWS) Predicts the Risk of Critical Event during Hospitalization

Canadian Journal of General Internal Medicine ◽

10.22374/cjgim.v11i4.190 ◽

2017 ◽

Vol 11 (4) ◽

Cited By ~ 3

Author(s):

Benjamin Tam BHSc MD ◽

Michael Xu BHSc ◽

Michelle Kwong BHSc Cand. ◽

Christine Wardell BHSc Cand. ◽

Andrew Kwong BHSc Cand. ◽

...

Keyword(s):

At Risk ◽

High Risk ◽

Early Warning ◽

Early Warning Score ◽

Surgical Patients ◽

Critical Event ◽

Critical Events ◽

Patients At Risk ◽

Icu Transfer ◽

Very High

Background: Early warning scores detect patients at risk of deterioration in hospital. Our objective was to first, demonstrate that the admission Hamilton Early Warning Score (HEWS) predicts critical events and second, estimate the workload required to identify critical events during hospitalization.Methods: We prospectively identified a consecutive cohort of medical/surgical patients for retrospective review. Critical events were defined as a composite of inpatient death, cardio-pulmonary arrest or ICU transfer. Likelihood of a critical event during hospitalization and the number needed to evaluate to detect a critical event was based on highest admission HEWS.Results: We found 506 critical events occurred in 7130 cases. HEWS identified graduated levels of risk at admission. We found 2.6 and 1.8 patients needed to be evaluated in the ‘high-risk’ and very ‘high-risk’ subgroups to detect a critical event.Conclusions: HEWS identified patients at risk for critical events during hospitalization at ward admission. Few patients with high HEWS required evaluation to detect a critical event.

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Glucose as an additional parameter to National Early Warning Score (NEWS) in prehospital setting enhances identification of patients at risk of death: an observational cohort study

Emergency Medicine Journal ◽

10.1136/emermed-2018-208309 ◽

2020 ◽

pp. emermed-2018-208309

Author(s):

Hanna Vihonen ◽

Mitja Lääperi ◽

Markku Kuisma ◽

Jussi Pirneskoski ◽

Jouni Nurmi

Keyword(s):

At Risk ◽

Blood Glucose ◽

Regression Model ◽

Early Warning ◽

Prehospital Setting ◽

Early Warning Score ◽

Calibration Model ◽

Risk Of Death ◽

Patients At Risk ◽

National Early Warning Score

BackgroundTo determine if prehospital blood glucose could be added to National Early Warning Score (NEWS) for improved identification of risk of short-term mortality.MethodsRetrospective observational study (2008–2015) of adult patients seen by emergency medical services in Helsinki metropolitan area for whom all variables for calculation of NEWS and a blood glucose value were available. Survival of 24 hours and 30 days were determined. The NEWS parameters and glucose were tested by multivariate logistic regression model. Based on ORs we formed NEWSgluc model with hypoglycaemia (≤3.0 mmol/L) 3, normoglycaemia 0 and hyperglycaemia (≥11.1 mmol/L) 1 points. The scores from NEWS and NEWSgluc were compared using discrimination (area under the curve), calibration (Hosmer-Lemeshow test), likelihood ratio tests and reclassification (continuous net reclassification index (cNRI)).ResultsData of 27 141 patients were included in the study. Multivariable regression model for NEWSgluc parameters revealed a strong association with glucose disturbances and 24-hour and 30-day mortality. Likelihood ratios (LRs) for mortality at 24 hours using a cut-off point of 15 were for NEWSgluc: LR+ 17.78 and LR− 0.96 and for NEWS: LR+ 13.50 and LR− 0.92. Results were similar at 30 days. Risks per score point estimation and calibration model showed glucose added benefit to NEWS at 24 hours and at 30 days. Although areas under the curve were similar, reclassification test (cNRI) showed overall improvement of classification of survivors and non-survivors at 24 days and 30 days with NEWSgluc.ConclusionsIncluding glucose in NEWS in the prehospital setting seems to improve identification of patients at risk of death.

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Using Modified Early Warning Scores to predict patients at risk of chorioamnionitis following preterm, prolonged rupture of membranes

Evidence Based Womenʼs Health Journal ◽

10.1097/01.ebx.0000438944.40772.8c ◽

2014 ◽

Vol 4 (2) ◽

pp. 63-65

Author(s):

Kurtis Tadeusz Zapasnik ◽

Imogen Ann Mitchell ◽

David Knight

Keyword(s):

At Risk ◽

Early Warning ◽

Early Warning Scores ◽

Patients At Risk

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Using modified early warning score to predict need of lifesaving intervention in adult non-trauma patients in a tertiary state hospital

Hong Kong Journal of Emergency Medicine ◽

10.1177/1024907917751980 ◽

2018 ◽

Vol 25 (3) ◽

pp. 146-151 ◽

Cited By ~ 1

Author(s):

Leong Shian Peng ◽

Azhana Hassan ◽

Aida Bustam ◽

Muhaimin Noor Azhar ◽

Rashidi Ahmad

Keyword(s):

Emergency Department ◽

Critically Ill ◽

Early Warning ◽

Demographic Data ◽

Vital Signs ◽

Multivariate Logistic Regression Analysis ◽

Early Warning Score ◽

Trauma Patients ◽

Multivariate Logistic Regression ◽

Level Of Consciousness

Background: Modified early warning score has been validated in many uses in the emergency department. We propose that the modified early warning score performs well in predicting the need of lifesaving interventions in the emergency department, as a predictor of patients who are critically ill. Objective: The study aims to evaluate the use of modified early warning score in sorting out critically ill patients in the emergency department. Methods: The patients’ demographic data and first vital signs (blood pressure, heart rate, temperature, respiratory rate, and level of consciousness) were collected prospectively. Individual modified early warning score was calculated. The outcome was a patient received one or more lifesaving interventions toward the end of stay in emergency department. Multivariate logistic regression analysis was utilized to assess the association between modified early warning score and other potential predictors with outcome. Results: There are a total of 259 patients enrolled into the study. The optimal modified early warning score in predicting lifesaving intervention was ≥4 with a sensitivity of 95% and specificity of 81%. Modified early warning score ≥4 (odds ratio = 96.97, 95% confidence interval = 11.82–795.23, p < 0.001) was found to significantly increase the risk of receiving lifesaving intervention in the emergency department. Conclusion: Modified early warning score is found to be a good predictor for patients in need of lifesaving intervention in the emergency department.

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Evaluation of the feasibility and performance of early warning scores to identify patients at risk of adverse outcomes in a low-middle income country setting

BMJ Open ◽

10.1136/bmjopen-2017-019387 ◽

2018 ◽

Vol 8 (4) ◽

pp. e019387 ◽

Cited By ~ 9

Author(s):

Abi Beane ◽

Ambepitiyawaduge Pubudu De Silva ◽

Nirodha De Silva ◽

Jayasingha A Sujeewa ◽

R M Dhanapala Rathnayake ◽

...

Keyword(s):

At Risk ◽

Early Warning ◽

Middle Income Country ◽

Adverse Outcomes ◽

Income Country ◽

Middle Income ◽

Early Warning Scores ◽

Patients At Risk ◽

And Performance

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Continuous monitoring in COVID-19 care; a retrospective study in time of crisis

JAMIA Open ◽

10.1093/jamiaopen/ooab030 ◽

2021 ◽

Author(s):

Roy de Ree ◽

Jorn Willemsen ◽

Gilbert te Grotenhuis ◽

Rick de Ree ◽

Joé Kolkert ◽

...

Keyword(s):

Adverse Events ◽

Respiratory Rate ◽

Nursing Staff ◽

Early Warning ◽

Wireless Sensors ◽

Continuous Monitoring ◽

Vital Signs ◽

Early Warning Score ◽

Monitoring Systems ◽

Patients At Risk

Abstract Background A new monitoring system was implemented to support nursing staff and physicians on the COVID-19 ward. This system was designed to remotely monitor vital signs, to calculate an automated Early Warning Score (aEWS) and to help identify patients at risk of deterioration. Methods Hospitalized patients who tested positive for SARS-CoV-2 were connected to two wireless sensors measuring vital signs. Patients were divided into two groups based on the occurrence of adverse events during hospitalization. Heart and respiratory rate were monitored continuously and an automated EWS was calculated every 5 minutes. Data were compared between groups. Results Prior to the occurrence of adverse events, significantly higher median heart and respiration rate and significantly lower median SPO2 values were observed. Mean and median automated EWS were significantly higher in patients with an adverse event. Conclusion Continuous monitoring systems might help to detect clinical deterioration in COVID-19 patients at an earlier stage. Lay Summary A new monitoring system was implemented to support nursing staff and physicians on the COVID-19 ward. This system was designed to remotely monitor vital signs, like respiratory rate, heart rate and the oxygen level in the blood. These parameters were used to calculate an automated early warning score which helps to identify patients at risk of deterioration. Hospitalized patients who tested positive for SARS-CoV-2 were connected to two wireless sensors. Heart and respiratory rate were monitored continuously and an automated EWS was calculated every 5 minutes. Data were compared between patients at the COVID-19 ward and patients who were transported to the ICU or died. COVID patients at the ICU or those who died had significantly higher median heart and respiration rate and significantly lower median oxygen levels. These findings showed that continuous monitoring systems might help to detect clinical deterioration in COVID-19 patients at an earlier stage.

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Pediatric Early Warning Score Systems, nurse’s perspective – a focus group study

Dansk Tidsskrift for Akutmedicin ◽

10.7146/akut.v2i3.112945 ◽

2019 ◽

Vol 2 (3) ◽

pp. 38

Author(s):

Claus Sixtus Jensen

Keyword(s):

Focus Group ◽

Early Warning ◽

Clinical Judgment ◽

Vital Signs ◽

Early Warning Score ◽

Focus Group Discussions ◽

Focus Group Study ◽

Group Discussions ◽

Patients At Risk ◽

Nurses Perceptions

Background: Pediatric early warning score (PEWS) systems are used to monitor pediatric patients’ vital signs and facilitate the treatment of patients at risk of deteriorating. The aim of this study was to gain knowledge about nurses’ experiences with PEWS and to highlight factors facilitating and impeding the use of PEWS tools in clinical practice we aim to obtain knowledge about nurses’ experiences with PEWS. Methods: An exploratory qualitative design was chosen using focus group discussions to gain a deeper understanding of nurses’ experiences with PEWS. A total of five focus group discussions were conducted at three hospitals, and the analyses performed were inspired by Kvale and Brinckman. Results: Seven themes were identified, including i) lack of interdisciplinary awareness, ii) clinical judgment and PEWS—a multi-faceted approach, iii) PEWS supports a professional language, iv) monitoring equipment—a challenge, v) PEWS helps to visualize the need for escalating care, vi) an inflexible and challenging tool, and vii) supportive tools enhance the nurses’ experiences of PEWS positively. Conclusions: Our findings suggest that attention should be given to nurses’ perceptions of how both clinical judgment and PEWS should be seen as essential in providing nurses with information about the patients’ conditions. If not, the risk of failing to recognize patients’ deteriorating conditions will remain. From the nurses’ perspective, medical doctors seemed unaware of their role in using PEWS.

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