Early Warning Score

BackgroundThere is a need for validated clinical risk scores to identify patients at risk of severe disease and to guide decision-making during the covid-19 pandemic. The National Early Warning Score 2 (NEWS2) is widely used in emergency medicine, but so far, no studies have evaluated its use in patients with covid-19. We aimed to study the performance of NEWS2 and compare commonly used clinical risk stratification tools at admission to predict risk of severe disease and in-hospital mortality in patients with covid-19.MethodsThis was a prospective cohort study in a public non-university general hospital in the Oslo area, Norway, including a cohort of all 66 patients hospitalised with confirmed SARS-CoV-2 infection from the start of the pandemic; 13 who died during hospital stay and 53 who were discharged alive. Data were collected consecutively from March 9th to April 27th 2020. The main outcome was the ability of the NEWS2 score and other clinical risk scores at emergency department admission to predict severe disease and in-hospital mortality in covid-19 patients. We calculated sensitivity and specificity with 95% confidence intervals (CIs) for NEWS2 scores ≥5 and ≥ 6, quick Sequential Organ Failure Assessment (qSOFA) score ≥ 2, ≥2 Systemic Inflammatory Response Syndrome (SIRS) criteria, and CRB-65 score ≥ 2. Areas under the curve (AUCs) for the clinical risk scores were compared using DeLong's test.ResultsIn total, 66 patients (mean age 67.9 years) were included. Of these, 23% developed severe disease. In-hospital mortality was 20%. Tachypnoea, hypoxemia and confusion at admission were more common in patients developing severe disease. A NEWS2 score ≥ 6 at admission predicted severe disease with 80.0% sensitivity and 84.3% specificity (Area Under the Curve (AUC) 0.822, 95% CI 0.690-0.953). NEWS2 was superior to qSOFA score ≥ 2 (AUC 0.624, 95% CI 0.446-0.810, p ConclusionNEWS2 score at hospital admission predicted severe disease and in-hospital mortality, and was superior to other widely used clinical risk scores in patients with covid-19.

ImportanceRisk scores used in early warning systems exist for general inpatients and patients with suspected infection outside the intensive care unit (ICU), but their relative performance is incompletely characterized.ObjectiveTo compare the performance of tools used to determine points-based risk scores among all hospitalized patients, including those with and without suspected infection, for identifying those at risk for death and/or ICU transfer.Design, setting, and participantsIn a cohort design, a retrospective analysis of prospectively collected data was conducted in 21 California and 7 Illinois hospitals between 2006 and 2018 among adult inpatients outside the ICU using points-based scores from 5 commonly used tools: National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), Between the Flags (BTF), Quick Sequential Sepsis-Related Organ Failure Assessment (qSOFA), and Systemic Inflammatory Response Syndrome (SIRS). Data analysis was conducted from February 2019 to January 2020.Main outcomes and measuresRisk model discrimination was assessed in each state for predicting in-hospital mortality and the combined outcome of ICU transfer or mortality with area under the receiver operating characteristic curves (AUCs). Stratified analyses were also conducted based on suspected infection.ResultsThe study included 773 477 hospitalized patients in California (mean [SD] age, 65.1 [17.6] years; 416 605 women [53.9%]) and 713 786 hospitalized patients in Illinois (mean [SD] age, 61.3 [19.9] years; 384 830 women [53.9%]). The NEWS exhibited the highest discrimination for mortality (AUC, 0.87; 95% CI, 0.87-0.87 in California vs AUC, 0.86; 95% CI, 0.85-0.86 in Illinois), followed by the MEWS (AUC, 0.83; 95% CI, 0.83-0.84 in California vs AUC, 0.84; 95% CI, 0.84-0.85 in Illinois), qSOFA (AUC, 0.78; 95% CI, 0.78-0.79 in California vs AUC, 0.78; 95% CI, 0.77-0.78 in Illinois), SIRS (AUC, 0.76; 95% CI, 0.76-0.76 in California vs AUC, 0.76; 95% CI, 0.75-0.76 in Illinois), and BTF (AUC, 0.73; 95% CI, 0.73-0.73 in California vs AUC, 0.74; 95% CI, 0.73-0.74 in Illinois). At specific decision thresholds, the NEWS outperformed the SIRS and qSOFA at all 28 hospitals either by reducing the percentage of at-risk patients who need to be screened by 5% to 20% or increasing the percentage of adverse outcomes identified by 3% to 25%.Conclusions and relevanceIn all hospitalized patients evaluated in this study, including those meeting criteria for suspected infection, the NEWS appeared to display the highest discrimination. Our results suggest that, among commonly used points-based scoring systems, determining the NEWS for inpatient risk stratification could identify patients with and without infection at high risk of mortality.

AimsTo compare the ability of the National Early Warning Score (NEWS) and the National Early Warning Score 2 (NEWS2) to identify patients at risk of in-hospital mortality and other adverse outcomes.MethodsWe undertook a multi-centre retrospective observational study at five acute hospitals from two UK NHS Trusts. Data were obtained from completed adult admissions who were not fit enough to be discharged alive on the day of admission. Diagnostic coding and oxygen prescriptions were used to identify patients with type II respiratory failure (T2RF). The primary outcome was in-hospital mortality within 24 h of a vital signs observation. Secondary outcomes included unanticipated intensive care unit admission or cardiac arrest within 24 h of a vital signs observation. Discrimination was assessed using the c-statistic.ResultsAmong 251,266 adult admissions, 48,898 were identified to be at risk of T2RF by diagnostic coding. In this group, NEWS2 showed statistically significant lower discrimination (c-statistic, 95% CI) for identifying in-hospital mortality within 24 h (0.860, 0.857-0.864) than NEWS (0.881, 0.878-0.884). For 1394 admissions with documented T2RF, discrimination was similar for both systems: NEWS2 (0.841, 0.827-0.855), NEWS (0.862, 0.848-0.875). For all secondary endpoints, NEWS2 showed no improvements in discrimination.ConclusionsNEWS2 modifications to NEWS do not improve discrimination of adverse outcomes in patients with documented T2RF and decrease discrimination in patients at risk of T2RF. Further evaluation of the relationship between SpO2 values, oxygen therapy and risk should be investigated further before wide-scale adoption of NEWS2.

BackgroundThe National Early Warning Score (NEWS), and updated NEWS2, is used to detect all-cause deterioration, based on clinical observations. Many studies have validated the prognostic accuracy of NEWS/NEWS2, but few have investigated whether its use improves patient outcomes. This systematic review aims to bring together all evidence evaluating the effectiveness of using NEWS/NEWS2, compared to not using NEWS/NEWS2, on patient outcomes.MethodsWe searched Embase, MEDLINE, CINAHL, The Cochrane Library, and international trial registries from January 2012 (when NEWS was developed) to October 2024, for all records which mentioned NEWS/NEWS2 in their title or abstract. All comparative studies with interventions which included NEWS/NEWS2, and comparator areas, regions, organisations, time points, or settings which did not, were included. The target population was all non-maternity patients aged 16+ years treated in healthcare settings. Where possible, studies were synthesised by outcome using random-effects meta-analyses. Risk of bias was assessed using ROB2 and ROBINS-I v2; certainty of evidence was assessed using GRADE. PROSPERO registration CRD42023442061.ResultsWe screened 2814 records and included 20 studies (in 32 records), with 18 presenting data for our outcomes. Sample sizes ranged from 66 to 13,059,865 participants. There was low certainty evidence that using NEWS/NEWS2 reduced in-hospital mortality (summary odds ratio [OR] from eleven studies 0.79, 95% confidence interval [CI] 0.66 to 0.94). There was also a little low certainty evidence of a reduction in hospital length of stay (two of four studies) and cardiac arrests (three of seven studies), and a potential reduction in intensive care admissions (summary OR from seven studies 0.63, 95% CI 0.36 to 1.09). Most included studies had a serious/high (12/18; 67%) or moderate (5/18; 28%) risk of bias.ConclusionsThis review highlights a lack of large scale, high-quality studies exploring the effectiveness of NEWS/NEWS2. No included studies reported negative clinical impacts of using NEWS/NEWS2 on any outcomes presented in this review. However, there is still further work required to ascertain whether the use of NEWS/NEWS2 improves patient outcomes.Systematic review registrationPROSPERO CRD42023442061.