Summary NHS England recently mandated that the National Early Warning Score of vital signs be used in all acute hospital trusts in the UK despite limited validation in the postoperative setting. We undertook a multicentre UK study of 13,631 patients discharged from intensive care after risk‐stratified cardiac surgery in four centres, all of which used VitalPACTM to electronically collect postoperative National Early Warning Score vital signs. We analysed 540,127 sets of vital signs to generate a logistic score, the discrimination of which we compared with the national additive score for the composite outcome of: in‐hospital death; cardiac arrest; or unplanned intensive care admission. There were 578 patients (4.2%) with an outcome that followed 4300 sets of observations (0.8%) in the preceding 24 h: 499 out of 578 (86%) patients had unplanned re‐admissions to intensive care. Discrimination by the logistic score was significantly better than the additive score. Respective areas (95%CI) under the receiver‐operating characteristic curve with 24‐h and 6‐h vital signs were: 0.779 (0.771–0.786) vs. 0.754 (0.746–0.761), p < 0.001; and 0.841 (0.829–0.853) vs. 0.813 (0.800–0.825), p < 0.001, respectively. Our proposed logistic Early Warning Score was better than the current National Early Warning Score at discriminating patients who had an event after cardiac surgery from those who did not.

Aims: International early warning scores (EWS) including the additive National Early Warning Score (NEWS) and logistic EWS currently utilise physiological snapshots to predict clinical deterioration. We hypothesised that a dynamic score including vital sign trajectory would improve discriminatory power. Methods: Multicentre retrospective analysis of electronic health record data from postoperative patients admitted to cardiac surgical wards in four UK hospitals. Least absolute shrinkage and selection operator-type regression (LASSO) was used to develop a dynamic model (DyniEWS) to predict a composite adverse event of cardiac arrest, unplanned intensive care re-admission or in-hospital death within 24 h. Results: A total of 13,319 postoperative adult cardiac patients contributed 442,461 observations of which 4234 (0.96%) adverse events in 24 h were recorded. The new dynamic model (AUC = 0.80 [95% CI 0.78À0.83], AUPRC = 0.12 [0.10À0.14]) outperforms both an updated snapshot logistic model (AUC = 0.76 [0.73À0.79], AUPRC = 0.08 [0.60À0.10]) and the additive National Early Warning Score (AUC = 0.73 [0.70À0.76], AUPRC = 0.05 [0.02 À0.08]). Controlling for the false alarm rates to be at current levels using NEWS cutoffs of 5 and 7, DyniEWS delivers a 7% improvement in balanced accuracy and increased sensitivities from 41% to 54% at NEWS 5 and 18%À30% at NEWS 7. Conclusions: Using an advanced statistical approach, we created a model that can detect dynamic changes in risk of unplanned readmission to intensive care, cardiac arrest or in-hospital mortality and can be used in real time to risk-prioritise clinical workload.

Summary An endobronchial tube (Macintosh‐Leatherdale) was used to secure the airway for a tracheal resection and end‐to‐end anastomosis. This lung separation device enabled insertion of both a fibreoptic bronchoscope and a tube exchange catheter. These were required after the trachea was transected and re‐anastomosis proved surgically difficult. The airway exchange catheter allowed for jet ventilation and later a tube change when an emergency occurred. Options and management issues for tracheal surgery and lung separators are discussed. A case is made for a re‐evaluation of endobronchial tubes both as a useful conduit for modern airway instruments and as an alternative to small double‐lumen tubes for the increasing population of obese patients weighing > 100 kg, requiring thoracic surgery.

Editor -I read with interest the rapid report on contact tracing for SARS-CoV-2. 1 The authors refer to the potential for a much larger network of potentially secondarily infected contacts, but don't address how this could be solved other than by prompt contact tracing. One addition to the current system which may help would be testing of all identified contacts. This is standard practice in the given examples of sexually transmitted infections and tuberculosis, and recommended for SARS-CoV-2, yet remains curiously absent from the NHS Test and Trace programme unless contacts develop symptoms. 2,3 Testing of all contacts, regardless of symptoms, would ensure any secondarily infected contacts (including those who are asymptomatic or presymptomatic) are identified early, enabling their own contact tracing processes to be started promptly. It could also aid compliance to self-isolation for those with positive tests. This would need to be offset by clear messaging and incentives to reinforce the need for ongoing isolation in those with negative tests; one potential solution would be to offer tests at multiple timepoints during the isolation period, to ensure continued compliance and to confirm negativity prior to release from isolation.The test, trace and isolate (TTI) modelling group published a report in November advising that daily test of contacts could offer an improvement over the current strategy; consideration should be given to implementing testing for all traced contacts at the earliest opportunity. 4 ■

No abstract