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

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.

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

Journal of Critical Care ◽

10.1016/j.jcrc.2018.07.011 ◽

2018 ◽

Vol 47 ◽

pp. 222-226 ◽

Cited By ~ 7

Author(s):

Young Seok Lee ◽

Jae Woo Choi ◽

Yeon Hee Park ◽

Chaeuk Chung ◽

Dong Il Park ◽

...

Keyword(s):

Risk Stratification ◽

Hospital Mortality ◽

Early Warning ◽

Early Warning Score ◽

National Early Warning Score

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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.

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Development, Implementation, and Evaluation of an In-Hospital Optimized Early Warning Score for Patient Deterioration

MDM Policy & Practice ◽

10.1177/2381468319899663 ◽

2020 ◽

Vol 5 (1) ◽

pp. 238146831989966 ◽

Cited By ~ 4

Author(s):

Cara O’Brien ◽

Benjamin A. Goldstein ◽

Yueqi Shen ◽

Matthew Phelan ◽

Curtis Lambert ◽

...

Keyword(s):

Confidence Interval ◽

Early Warning ◽

Clinical Decision Making ◽

Risk Model ◽

Clinical Status ◽

Area Under The Curve ◽

Clinical Decision ◽

Early Warning Score ◽

Support Tool ◽

National Early Warning Score

Background. Identification of patients at risk of deteriorating during their hospitalization is an important concern. However, many off-shelf scores have poor in-center performance. In this article, we report our experience developing, implementing, and evaluating an in-hospital score for deterioration. Methods. We abstracted 3 years of data (2014–2016) and identified patients on medical wards that died or were transferred to the intensive care unit. We developed a time-varying risk model and then implemented the model over a 10-week period to assess prospective predictive performance. We compared performance to our currently used tool, National Early Warning Score. In order to aid clinical decision making, we transformed the quantitative score into a three-level clinical decision support tool. Results. The developed risk score had an average area under the curve of 0.814 (95% confidence interval = 0.79–0.83) versus 0.740 (95% confidence interval = 0.72–0.76) for the National Early Warning Score. We found the proposed score was able to respond to acute clinical changes in patients’ clinical status. Upon implementing the score, we were able to achieve the desired positive predictive value but needed to retune the thresholds to get the desired sensitivity. Discussion. This work illustrates the potential for academic medical centers to build, refine, and implement risk models that are targeted to their patient population and work flow.

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Early Warning Scores in Patients with Suspected COVID-19 Infection in Emergency Departments

Journal of Personalized Medicine ◽

10.3390/jpm11030170 ◽

2021 ◽

Vol 11 (3) ◽

pp. 170

Author(s):

Francisco Martín-Rodríguez ◽

José L. Martín-Conty ◽

Ancor Sanz-García ◽

Virginia Carbajosa Rodríguez ◽

Guillermo Ortega Rabbione ◽

...

Keyword(s):

Early Warning ◽

Emergency Departments ◽

Life Support ◽

Area Under The Curve ◽

Advanced Life Support ◽

Early Mortality ◽

Early Warning Score ◽

Mortality Data ◽

Early Warning Scores ◽

National Early Warning Score

Early warning scores (EWSs) help prevent and recognize and thereby act as the first signs of clinical and physiological deterioration. The objective of this study is to evaluate different EWSs (National Early Warning Score 2 (NEWS2), quick sequential organ failure assessment score (qSOFA), Modified Rapid Emergency Medicine Score (MREMS) and Rapid Acute Physiology Score (RAPS)) to predict mortality within the first 48 h in patients suspected to have Coronavirus disease 2019 (COVID-19). We conducted a retrospective observational study in patients over 18 years of age who were treated by the advanced life support units and transferred to the emergency departments between March and July of 2020. Each patient was followed for two days registering their final diagnosis and mortality data. A total of 663 patients were included in our study. Early mortality within the first 48 h affected 53 patients (8.3%). The scale with the best capacity to predict early mortality was the National Early Warning Score 2 (NEWS2), with an area under the curve of 0.825 (95% CI: 0.75–0.89). The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive patients presented an area under the curve (AUC) of 0.804 (95% CI: 0.71–0.89), and the negative ones with an AUC of 0.863 (95% CI: 0.76–0.95). Among the EWSs, NEWS2 presented the best predictive power, even when it was separately applied to patients who tested positive and negative for SARS-CoV-2.

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Combination of the National Early Warning Score (NEWS) and inflammatory biomarkers for early risk stratification in emergency department patients: results of a multinational, observational study

BMJ Open ◽

10.1136/bmjopen-2018-024636 ◽

2019 ◽

Vol 9 (1) ◽

pp. e024636 ◽

Cited By ~ 3

Author(s):

Andreas Eckart ◽

Stephanie Isabelle Hauser ◽

Alexander Kutz ◽

Sebastian Haubitz ◽

Pierre Hausfater ◽

...

Keyword(s):

Emergency Department ◽

Observational Study ◽

Risk Stratification ◽

Early Warning ◽

Inflammatory Markers ◽

Early Warning Score ◽

Receiver Operating Curve ◽

Secondary Outcome ◽

Icu Admission ◽

National Early Warning Score

ObjectivesThe National Early Warning Score (NEWS) helps to estimate mortality risk in emergency department (ED) patients. This study aimed to investigate whether the prognostic value of the NEWS at ED admission could be further improved by adding inflammatory blood markers (ie, white cell count (WCC), procalcitonin (PCT) and midregional-proadrenomedullin (MR-proADM).DesignSecondary analysis of a multinational, observational study (TRIAGE study, March 2013–October 2014).SettingThree tertiary care centres in France, Switzerland and the USA.ParticipantsA total of 1303 adult medical patients with complete NEWS data seeking ED care were included in the final analysis. NEWS was calculated retrospectively based on admission data.Main outcome measuresThe primary outcome was all-cause 30-day mortality. Secondary outcome was intensive care unit (ICU) admission. We used multivariate regression analyses to investigate associations of NEWS and blood markers with outcomes and area under the receiver operating curve (AUC) as a measure of discrimination.ResultsOf the 1303 included patients, 54 (4.1%) died within 30 days. The NEWS alone showed fair prognostic accuracy for all-cause 30-day mortality (AUC 0.73), with a multivariate adjusted OR of 1.26 (95% CI 1.13 to 1.40, p<0.001). The AUCs for the prediction of mortality using the inflammatory markers WCC, PCT and MR-proADM were 0.64, 0.71 and 0.78, respectively. Combining NEWS with all three blood markers or only with MR-proADM clearly improved discrimination with an AUC of 0.82 (p=0.002). Combining the three inflammatory markers with NEWS improved prediction of ICU admission (AUC 0.70vs0.65 when using NEWS alone, p=0.006).ConclusionNEWS is helpful in risk stratification of ED patients and can be further improved by the addition of inflammatory blood markers. Future studies should investigate whether risk stratification by NEWS in addition to biomarkers improve site-of-care decision in this patient population.Trial registration numberNCT01768494; Post-results.

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Prehospital Point-Of-Care Lactate Increases the Prognostic Accuracy of National Early Warning Score 2 for Early Risk Stratification of Mortality: Results of a Multicenter, Observational Study

Journal of Clinical Medicine ◽

10.3390/jcm9041156 ◽

2020 ◽

Vol 9 (4) ◽

pp. 1156 ◽

Cited By ~ 1

Author(s):

Francisco Martín-Rodríguez ◽

Raúl López-Izquierdo ◽

Juan F. Delgado Benito ◽

Ancor Sanz-García ◽

Carlos del Pozo Vegas ◽

...

Keyword(s):

Risk Stratification ◽

Early Warning ◽

Life Support ◽

Low Risk ◽

Early Warning Score ◽

Multicenter Observational Study ◽

Risk Of Death ◽

Prognostic Accuracy ◽

Risk Of Mortality ◽

National Early Warning Score

The objective of this study was to assess whether the use of prehospital lactate (pLA) can increase the prognostic accuracy of the National Early Warning Score 2 (NEWS2) to detect the risk of death within 48 h. A prospective, multicenter study in adults treated consecutively by the emergency medical services (EMS) included six advanced life support (ALS) services and five hospitals. Patients were assigned to one of four groups according to their risk of mortality (low, low-medium, medium, and high), as determined by the NEWS2 score. For each group, the validity of pLA in our cohort was assessed by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. In this study, 3081 participants with a median age of 69 years (Interquartile range (IQR): 54–81) were included. The two-day mortality was 4.4% (137 cases). The scale derived from the implementation of the pLA improved the capacity of the NEWS2 to discriminate low risk of mortality, with an AUC of 0.910 (95% CI: 0.87–0.94; p < 0.001). The risk stratification provided by the NEWS2 can be improved by incorporating pLA measurement to more accurately predict the risk of mortality in patients with low risk.

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

BMC Medicine ◽

10.1186/s12916-020-01893-3 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Ewan Carr ◽

Rebecca Bendayan ◽

Daniel Bean ◽

Matt Stammers ◽

Wenjuan Wang ◽

...

Keyword(s):

Risk Stratification ◽

Hospital Admission ◽

Early Warning ◽

Kidney Diseases ◽

Physiological Parameters ◽

Early Warning Score ◽

Brier Score ◽

University Hospitals ◽

Medium Term ◽

National Early Warning Score

Abstract Background The National Early Warning Score (NEWS2) is currently recommended in the UK for the risk stratification of COVID-19 patients, but little is known about its ability to detect severe cases. We aimed to evaluate NEWS2 for the prediction of severe COVID-19 outcome and identify and validate a set of blood and physiological parameters routinely collected at hospital admission to improve upon the use of NEWS2 alone for medium-term risk stratification. Methods Training cohorts comprised 1276 patients admitted to King’s College Hospital National Health Service (NHS) Foundation Trust with COVID-19 disease from 1 March to 30 April 2020. External validation cohorts included 6237 patients from five UK NHS Trusts (Guy’s and St Thomas’ Hospitals, University Hospitals Southampton, University Hospitals Bristol and Weston NHS Foundation Trust, University College London Hospitals, University Hospitals Birmingham), one hospital in Norway (Oslo University Hospital), and two hospitals in Wuhan, China (Wuhan Sixth Hospital and Taikang Tongji Hospital). The outcome was severe COVID-19 disease (transfer to intensive care unit (ICU) or death) at 14 days after hospital admission. Age, physiological measures, blood biomarkers, sex, ethnicity, and comorbidities (hypertension, diabetes, cardiovascular, respiratory and kidney diseases) measured at hospital admission were considered in the models. Results A baseline model of ‘NEWS2 + age’ had poor-to-moderate discrimination for severe COVID-19 infection at 14 days (area under receiver operating characteristic curve (AUC) in training cohort = 0.700, 95% confidence interval (CI) 0.680, 0.722; Brier score = 0.192, 95% CI 0.186, 0.197). A supplemented model adding eight routinely collected blood and physiological parameters (supplemental oxygen flow rate, urea, age, oxygen saturation, C-reactive protein, estimated glomerular filtration rate, neutrophil count, neutrophil/lymphocyte ratio) improved discrimination (AUC = 0.735; 95% CI 0.715, 0.757), and these improvements were replicated across seven UK and non-UK sites. However, there was evidence of miscalibration with the model tending to underestimate risks in most sites. Conclusions NEWS2 score had poor-to-moderate discrimination for medium-term COVID-19 outcome which raises questions about its use as a screening tool at hospital admission. Risk stratification was improved by including readily available blood and physiological parameters measured at hospital admission, but there was evidence of miscalibration in external sites. This highlights the need for a better understanding of the use of early warning scores for COVID.

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The Prognostic Accuracy of National Early Warning Score 2 on Predicting Clinical Deterioration for Patients With COVID-19: A Systematic Review and Meta-Analysis

Frontiers in Medicine ◽

10.3389/fmed.2021.699880 ◽

2021 ◽

Vol 8 ◽

Author(s):

Kai Zhang ◽

Xing Zhang ◽

Wenyun Ding ◽

Nanxia Xuan ◽

Baoping Tian ◽

...

Keyword(s):

Early Warning ◽

Clinical Deterioration ◽

Early Warning Score ◽

Cochrane Library ◽

Hospital Death ◽

Likelihood Ratios ◽

Prognostic Accuracy ◽

National Early Warning Score ◽

Sensitivity Specificity ◽

Sensitive Method

Background: During the coronavirus disease 2019 (COVID-19) pandemic, the National Early Warning Score 2 (NEWS2) is recommended for the risk stratification of COVID-19 patients, but little is known about its ability to detect severe cases. Therefore, our purpose is to assess the prognostic accuracy of NEWS2 on predicting clinical deterioration for patients with COVID-19.Methods: We searched PubMed, Embase, Scopus, and the Cochrane Library from December 2019 to March 2021. Clinical deterioration was defined as the need for intensive respiratory support, admission to the intensive care unit, or in-hospital death. Sensitivity, specificity, and likelihood ratios were pooled by using the bivariate random-effects model. Overall prognostic performance was summarized by using the area under the curve (AUC). We performed subgroup analyses to assess the prognostic accuracy of NEWS2 in different conditions.Results: Eighteen studies with 6,922 participants were included. The NEWS2 of five or more was commonly used for predicting clinical deterioration. The pooled sensitivity, specificity, and AUC were 0.82, 0.67, and 0.82, respectively. Benefitting from adding a new SpO2 scoring scale for patients with hypercapnic respiratory failure, the NEWS2 showed better sensitivity (0.82 vs. 0.75) and discrimination (0.82 vs. 0.76) than the original NEWS. In addition, the NEWS2 was a sensitive method (sensitivity: 0.88) for predicting short-term deterioration within 72 h.Conclusions: The NEWS2 had moderate sensitivity and specificity in predicting the deterioration of patients with COVID-19. Our results support the use of NEWS2 monitoring as a sensitive method to initially assess COVID-19 patients at hospital admission, although it has a relatively high false-trigger rate. Our findings indicated that the development of enhanced or modified NEWS may be necessary.

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Use of the National Early Warning Score in community nursing: a scoping review

British Journal of Community Nursing ◽

10.12968/bjcn.2021.26.8.396 ◽

2021 ◽

Vol 26 (8) ◽

pp. 396-404

Author(s):

Anne-Marie Phillips

Keyword(s):

Scoping Review ◽

Early Warning ◽

Early Warning Score ◽

Current Evidence ◽

Community Nursing ◽

Community Settings ◽

National Early Warning Score ◽

Barriers To Use ◽

Poor Outcomes ◽

The Uk

People in the UK are living longer and with multi-morbidities, increasing the size, complexity and acuity of Community Nursing caseloads. Nurses visiting infrequently and inconsistently on a task-focused basis need an objective method by which to identify / quantify physical deterioration for early treatment avoiding crisis and hospital admission. The National Early Warning Score (NEWS), is the most recognised tool for identification of deterioration in acute settings but is not validated for community use. Using published frameworks for scoping review and evaluation, this study aims to explore the current evidence for use of NEWS in community settings. Although there is work to be done, particularly in terms of frequency of scoring and response, this study identifies benefits in communication and prioritisation of care as well as sensitivity, particularly in predicting poor outcomes. The identified barriers to use include integration into practice and perceived dissonance with clinical judgement.

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Experiences of a National Early Warning Score (NEWS) intervention in care homes during the COVID-19 pandemic: a qualitative interview study

BMJ Open ◽

10.1136/bmjopen-2020-045469 ◽

2021 ◽

Vol 11 (7) ◽

pp. e045469

Author(s):

Rachel Stocker ◽

Siân Russell ◽

Jennifer Liddle ◽

Robert O Barker ◽

Adam Remmer ◽

...

Keyword(s):

Early Warning ◽

Healthcare Professionals ◽

Care Home ◽

Qualitative Interview ◽

Interview Study ◽

Care Homes ◽

Early Warning Score ◽

Service Utilisation ◽

Qualitative Interview Study ◽

National Early Warning Score

BackgroundThe COVID-19 pandemic has taken a heavy toll on the care home sector, with residents accounting for up to half of all deaths in Europe. The response to acute illness in care homes plays a particularly important role in the care of residents during a pandemic. Digital recording of a National Early Warning Score (NEWS), which involves the measurement of physical observations, started in care homes in one area of England in 2016. Implementation of a NEWS intervention (including equipment, training and support) was accelerated early in the pandemic, despite limited evidence for its use in the care home setting.ObjectivesTo understand how a NEWS intervention has been used in care homes in one area of North-East England during the COVID-19 pandemic, and how it has influenced resident care, from the perspective of stakeholders involved in care delivery and commissioning.MethodsA qualitative interview study with care home (n=10) and National Health Service (n=7) staff. Data were analysed using thematic analysis.ResultsUse of the NEWS intervention in care homes in this area accelerated during the COVID-19 pandemic. Stakeholders felt that NEWS, and its associated education and support package, improved the response of care homes and healthcare professionals to deterioration in residents’ health during the pandemic. Healthcare professionals valued the ability to remotely monitor resident observations, which facilitated triage and treatment decisions. Care home staff felt empowered by NEWS, providing a common clinical language to communicate concerns with external services, acting as an adjunct to staff intuition of resident deterioration.ConclusionsThe NEWS intervention formed an important part of the care home response to COVID-19 in the study area. Positive staff perceptions now need to be supplemented with data on the impact on resident health and well-being, workload, and service utilisation, during the pandemic and beyond.

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