Can early warning scores identify deteriorating patients in pre-hospital settings? A systematic review

Patel, Rita; Nugawela, Manjula D; Edwards, Hannah B; Richards, Alison; Roux, Hein le; Pullyblank, Anne; Whiting, Penny

doi:10.1016/j.resuscitation.2018.08.028

Cited by 89 publications

(81 citation statements)

References 22 publications

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“…This generated a very homogeneous cohort since all the cases were assessed by the physician at the ALS and the purpose of selecting cases was to detect those cases with a risk of deterioration. Secondly, early mortality (within 48 hours) was determined as one of the result outcomes but we are aware that this time limitation in the inclusion of cases is partial and it may be very interesting to study mortality rates after seven or 30 days, or even in the longer term, but the objective of this study is to analyze the influence of the procedures carried out by the EMS at the scene or en route, such that mortality after two days does not seem to be an adequate solution and this is in line with similar publications [27,55,56].…”

Section: Limitationssupporting

confidence: 52%

Identification of Serious Adverse Events in Patients with Traumatic Brain Injuries, from Prehospital Care to Intensive-Care Unit, Using Early Warning Scores

Martin-Rodríguez

López-Izquierdo

Mohedano-Moriano

et al. 2020

IJERPH

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Traumatic brain injuries are complex situations in which the emergency medical services must quickly determine the risk of deterioration using minimal diagnostic methods. The aim of this study is to analyze whether the use of early warning scores can help with decision-making in these dynamic situations by determining the patients who need the intensive care unit. A prospective, multicentric cohort study without intervention was carried out on traumatic brain injury patients aged over 18 given advanced life support and taken to the hospital. Our study included a total of 209 cases. The total number of intensive-care unit admissions was 50 cases (23.9%). Of the scores analyzed, the National Early Warning Score2 was the best result presented with an area under the curve of 0.888 (0.81–0.94; p < 0.001) and an odds ratio of 25.4 (95% confidence interval (CI):11.2–57.5). The use of early warning scores (and specifically National Early Warning Score2) can help the emergency medical services to differentiate traumatic brain injury patients with a high risk of deterioration. The emergency medical services should use the early warning scores routinely in all cases for the early detection of high-risk situations.

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Section: Limitationssupporting

confidence: 52%

Identification of Serious Adverse Events in Patients with Traumatic Brain Injuries, from Prehospital Care to Intensive-Care Unit, Using Early Warning Scores

Martin-Rodríguez

López-Izquierdo

Mohedano-Moriano

et al. 2020

IJERPH

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“…Scores are calculated from physiological observations, with higher scores indicating poorer health. Though developed for hospitals, studies of EWS in pre-hospital settings have been shown to predict outcomes such as hospital stay and mortality; [2][3][4][5][6] however, those studies were mostly in ambulance and non-UK settings.…”

Section: Introductionmentioning

confidence: 99%

“…However, there is reluctance from GPs to adopt NEWS/NEWS2 for a number of reasons, such as a preference for observing symptoms, clinical instinct, and a lack of validated studies conducted in primary care; GPs also report time restraints restricting the appropriateness of a full set of observations. 16,17 There is currently little evidence about how NEWS in these settings influences patient outcomes, 4 though some is beginning to emerge. [2][3][4][5]13,16,18 The objective of this study was to investigate whether NEWS calculated at the point of GP referral to hospital affects timely process of care, that is, sicker patients seen faster, and to investigate clinical outcomes in hospital.…”

Section: Introductionmentioning

confidence: 99%

Association between National Early Warning Scores in primary care and clinical outcomes: an observational study in UK primary and secondary care

et al. 2020

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BackgroundNHS England has mandated use of the National Early Warning Score (NEWS), more recently NEWS2, in acute settings, and suggested its use in primary care. However, there is reluctance from GPs to adopt NEWS/NEWS2.AimTo assess whether NEWS calculated at the point of GP referral into hospital is associated with outcomes in secondary care.Design and settingAn observational study using routinely collected data from primary and secondary care.MethodNEWS values were prospectively collected for 13 047 GP referrals into acute care between July 2017 and December 2018. NEWS values were examined and multivariate linear and logistic regression used to assess associations with process measures and clinical outcomes.ResultsHigher NEWS values were associated with faster conveyance for patients travelling by ambulance, for example, median 94 minutes (interquartile range [IQR] 69–139) for NEWS ≥7; median 132 minutes, (IQR 84–236) for NEWS = 0 to 2); faster time from hospital arrival to medical review (54 minutes [IQR 25–114] for NEWS ≥7; 78 minutes [IQR 34–158] for NEWS = 0 to 2); as well as increased length of stay (5 days [IQR 2–11] versus 1 day [IQR 0–5]); intensive care unit admissions (2.0% versus 0.5%); sepsis diagnosis (11.7% versus 2.5%); and mortality, for example, 30-day mortality 12.0% versus 4.1% for NEWS ≥7 versus NEWS = 0 to 2, respectively. On average, for patients referred without a NEWS value (NEWS = NR), most clinical outcomes were comparable with patients with NEWS = 3 to 4, but ambulance conveyance time and time to medical review were comparable with patients with NEWS = 0 to 2.ConclusionThis study has demonstrated that higher NEWS values calculated at GP referral into hospital are associated with a faster medical review and poorer clinical outcomes.

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“…Studies indicate that EWS in pre-hospital settings could identify patients at risk of deterioration and in need of hospitalisation, with patients at low risk of deterioration safely managed at home [29].…”

Section: Formal Home Care Servicementioning

confidence: 99%

“…RNs experienced that identification of potentially life-threatening conditions for elderly patients, such as infections and sepsis, were identified and treated earlier with EWS [29,34].…”

Section: The Implementation Of Mews Has Improved Practicementioning

confidence: 99%

Applying the Modified Early Warning Score (MEWS) to assess geriatric patients in home care settings: A qualitative study of nurses’ and general practitioners’ experiences

Jeppestøl¹,

Kirkevold

Bragstad

2020

Preprint

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Background: Acute functional decline is a common clinical syndrome in geriatric health care that is typically characterised by nonspecific symptoms and presents with a mix of physical, psychological, social and functional manifestations.Early warning score (EWS) systems are widely implemented in nursing homes and home care to detect clinical deterioration. The effects of EWS systems have been thoroughly evaluated in hospital care settings, but few studies have evaluated these systems in community health care.The purpose of this study is to describe the experiences of registered nurses (RNs) and general practitioners (GPs) when using the Modified Early Warning Score (MEWS) to support clinical reasoning and decision-making with geriatric home care patients who suffer from acute functional decline.Method: A qualitative methodology was used with a descriptive exploratory design. Data were collected from seven focus group interviews. GPs and RNs were purposively sampled from large, medium and small municipalities in Norway. Data were analysed using an inductive content analysis method.Results: MEWS was used as an additional decision-making tool with elderly home care patients when acute functional decline was detected. RNs and GPs emphasised that MEWS supported the clinical reasoning and decision-making process. Additionally, those applying MEWS required comprehensive reasoning skills and specific knowledge of the patients. RNs identified the need for contextual adjustments to the use of MEWS in home care settings. Implementing MEWS has improved the collaboration and clinical practice of RNs and GPs. The adherence to MEWS follow-up recommendations was adjusted to the home care setting, accounting for potentially limited medical availability.Conclusion: MEWS supported RNs and GPs in conducting comprehensive clinical assessments and reasoning when acute functional decline was detected. Interdisciplinary communication and collaboration appeared to be strengthened, and GPs’ work was streamlined. Several limitations were identified with the use of MEWS reference values with geriatric patients, which could lead to ambiguity and misjudgements. MEWS trigger recommendations were experienced as inappropriate in the home care context. This study identifies the need for a modified, evidence-based EWS adjusted for geriatric patients in home care.

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Can early warning scores identify deteriorating patients in pre-hospital settings? A systematic review

Cited by 89 publications

References 22 publications

Identification of Serious Adverse Events in Patients with Traumatic Brain Injuries, from Prehospital Care to Intensive-Care Unit, Using Early Warning Scores

Identification of Serious Adverse Events in Patients with Traumatic Brain Injuries, from Prehospital Care to Intensive-Care Unit, Using Early Warning Scores

Association between National Early Warning Scores in primary care and clinical outcomes: an observational study in UK primary and secondary care

Applying the Modified Early Warning Score (MEWS) to assess geriatric patients in home care settings: A qualitative study of nurses’ and general practitioners’ experiences

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