Improving recognition of patients at risk in a Portuguese general hospital: results from a preliminary study on the 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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Examining the utility of the Hamilton early warning scores (HEWS) at triage: Retrospective pilot study in a Canadian emergency department

CJEM ◽

10.1017/cem.2017.21 ◽

2017 ◽

Vol 20 (2) ◽

pp. 266-274 ◽

Cited By ~ 6

Author(s):

Steven Skitch ◽

Benjamin Tam ◽

Michael Xu ◽

Laura McInnis ◽

Anthony Vu ◽

...

Keyword(s):

At Risk ◽

Emergency Department ◽

Early Warning ◽

Vital Signs ◽

Roc Curves ◽

Early Warning Score ◽

Critical Event ◽

Discriminative Ability ◽

Early Warning Scores ◽

Patients At Risk

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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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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Clinical and scientific letters: The national early warning score gives misleading scores for oxygen saturation in patients at risk of hypercapnia

Clinical Medicine ◽

10.7861/clinmedicine.15-1-98a ◽

2015 ◽

Vol 15 (1) ◽

pp. 98.2-98 ◽

Cited By ~ 1

Author(s):

B Ronan O’Driscoll ◽

Kirstie Grant ◽

Darren Green ◽

Simon Edeghere ◽

Nawar Diar Bakerly ◽

...

Keyword(s):

At Risk ◽

Oxygen Saturation ◽

Early Warning ◽

Early Warning Score ◽

Patients At Risk ◽

National Early Warning Score

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Implementation of a pediatric early warning score tool in a pediatric oncology Ward in Palestine

BMC Health Services Research ◽

10.1186/s12913-021-07157-x ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

David Mills ◽

Alexis Schmid ◽

Mohammad Najajreh ◽

Ahmad Al Nasser ◽

Yara Awwad ◽

...

Keyword(s):

At Risk ◽

Pediatric Oncology ◽

Early Warning ◽

Vital Sign ◽

Clinical Deterioration ◽

Early Warning Score ◽

Pdsa Cycle ◽

Oncology Ward ◽

Patients At Risk ◽

Scoring Tool

Abstract Background Pediatric Early Warning Scores (PEWS) are nurse-administered clinical assessment tools utilizing vital signs and patient signs and symptoms to screen for patients at risk for clinical deterioration.1–3 When utilizing a PEWS system, which consists of an escalation algorithm to alert physicians of high risk patients requiring a bedside evaluation and assessment, studies have demonstrated that PEWS systems can decrease pediatric intensive care (PICU) utilization, in-hospital cardiac arrests, and overall decreased mortality in high income settings. Yet, many hospital based settings in low and lower middle income countries (LMIC) lack systems in place for early identification of patients at risk for clinical deterioration. Methods A contextually adapted 16-h pediatric resuscitation program included training of a PEWS tool followed by implementation and integration of a PEWS system in a pediatric hematology/oncology ward in Beit Jala, Palestine. Four PDSA cycles were implemented post-implementation to improve uptake and scoring of PEWS which included PEWS tool integration into an existing electronic medical record (EMR), escalation algorithm and job aid implementation, data audits and ward feedback. Results Frequency of complete PEWS vital sign documentation reached a mean of 89.9%. The frequency and accuracy of PEWS scores steadily increased during the post-implementation period, consistently above 89% in both categories starting from data audit four and continuing thereafter. Accuracy of PEWS scoring was unable to be assessed during week 1 and 2 of data audits due to challenges with PEWS integration into the existing EMR (PDSA cycle 1) which were resolved by the 3rd week of data auditing (PDSA cycle 2). Conclusions Implementation of a PEWS scoring tool in an LMIC pediatric oncology inpatient unit is feasible and can improve frequency of vital sign collection and generate accurate PEWS scores. Contribution to the literature This study demonstrates how to effectively implement a PEWS scoring tool into an LMIC clinical setting. This study demonstrates how to utilize a robust feedback mechanism to ensure a quality program uptake. This study demonstrates an effective international partnership model that other institutions may utilize for implementation science.

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A comparison of the ability of the National Early Warning Score and the National Early Warning Score 2 to identify patients at risk of in-hospital mortality: A multi-centre database study

Resuscitation ◽

10.1016/j.resuscitation.2018.09.026 ◽

2019 ◽

Vol 134 ◽

pp. 147-156 ◽

Cited By ~ 32

Author(s):

Marco A.F. Pimentel ◽

Oliver C. Redfern ◽

Stephen Gerry ◽

Gary S. Collins ◽

James Malycha ◽

...

Keyword(s):

At Risk ◽

Hospital Mortality ◽

Early Warning ◽

Early Warning Score ◽

Database Study ◽

Centre Database ◽

Patients At Risk ◽

National Early Warning Score

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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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