Early warning score adjusted for age to predict the composite outcome of mortality, cardiac arrest or unplanned intensive care unit admission using observational vital-sign data: a multicentre development and validation

Abstract

ObjectivesEarly warning scores (EWS) alerting for in-hospital deterioration are commonly developed using routinely collected vital-sign data from the whole in-hospital population. As these in-hospital populations are dominated by those over the age of 45 years, resultant scores may perform less well in younger age groups. We developed and validated an age-specific early warning score (ASEWS) derived from statistical distributions of vital signs.DesignObservational cohort study.SettingOxford University Hospitals (OUH) July 2013 to March 2018 and Portsmouth Hospitals (PH) NHS Trust January 2010 to March 2017 within the Hospital Alerting Via Electronic Noticeboard database.ParticipantsHospitalised patients with electronically documented vital-sign observationsOutcomeComposite outcome of unplanned intensive care unit admission, mortality and cardiac arrest.Methods and resultsStatistical distributions of vital signs were used to develop an ASEWS to predict the composite outcome within 24 hours. The OUH development set consisted of 2 538 099 vital-sign observation sets from 142 806 admissions (mean age (SD): 59.8 (20.3)). We compared the performance of ASEWS to the National Early Warning Score (NEWS) and our previous EWS (MCEWS) on an OUH validation set consisting of 581 571 observation sets from 25 407 emergency admissions (mean age (SD): 63.0 (21.4)) and a PH validation set consisting of 5 865 997 observation sets from 233 632 emergency admissions (mean age (SD): 64.3 (21.1)). ASEWS performed better in the 16–45 years age group in the OUH validation set (AUROC 0.820 (95% CI 0.815 to 0.824)) and PH validation set (AUROC 0.840 (95% CI 0.839 to 0.841)) than NEWS (AUROC 0.763 (95% CI 0.758 to 0.768) and AUROC 0.836 (95% CI 0.835 to 0.838) respectively) and MCEWS (AUROC 0.808 (95% CI 0.803 to 0.812) and AUROC 0.833 (95% CI 0.831 to 0.834) respectively). Differences in performance were not consistent in the elder age group.ConclusionsAccounting for age-related vital sign changes can more accurately detect deterioration in younger patients.

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“…• GCS [15]: evaluation of eye, speech, and motor functions; • NEWS [16]: seven routinely collected vital signs, including respiratory rate, oxygen saturation, temperature, blood pressure, pulse and AVPU response; • PEWS [17]; three routinely collected vital signs including capillary refill, behavior and respiration rate.…”

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“…6 7 However, studies have shown contradictory results regarding the added value of the EWS in relation to patient outcomes. [8][9][10] Alternatively, clinical evaluation by nurses can be augmented by devices that allow the continuous monitoring of vital signs. Towards this end, Philips General Care Solutions proposed an automated Modified Early Warning Score monitoring system, the Philips IntelliVue Guardian Solution (Guardian), 11 and concerning wearable vital sign monitoring devices, Weenk et al showed that the ViSi Mobile and the HealthPatch give more frequent alerts than do nurses.…”

Development and Validation of Early Warning Score Systems for COVID-19 Patients

“…EWS systems that are currently used in practice are based on routinely measured physiological variables, including vital signs, consciousness level (AVPU), oxygen support, and different laboratory markers [4,3,5,6,7]. Common examples of these tools include the National Early Warning Score (NEWS) [7], Centile-Based Early Warning Score (CEWS) [3], Manual Centile-Based Early Warning Score (MCEWS) [4], Age-Based Early Warning Score (AEWS) [8], Laboratory Decision Tree Early Warning Score (LDTEWS) [9], and LDTEWS:NEWS [5] (which combines both NEWS and LDTEWS), among others. The scores evaluate physiological parameters (NEWS, CEWS, MCEWS and AEWS), laboratory parameters (LDTEWS) and a combination of physiological and laboratory parameters (LDTEWS:NEWS) (Supplementary A: Table S6) [7,3,4,8,9,5].…”

“…Common examples of these tools include the National Early Warning Score (NEWS) [7], Centile-Based Early Warning Score (CEWS) [3], Manual Centile-Based Early Warning Score (MCEWS) [4], Age-Based Early Warning Score (AEWS) [8], Laboratory Decision Tree Early Warning Score (LDTEWS) [9], and LDTEWS:NEWS [5] (which combines both NEWS and LDTEWS), among others. The scores evaluate physiological parameters (NEWS, CEWS, MCEWS and AEWS), laboratory parameters (LDTEWS) and a combination of physiological and laboratory parameters (LDTEWS:NEWS) (Supplementary A: Table S6) [7,3,4,8,9,5]. They have also been validated for different outcomes, including ICU admission, mortality, and cardiac arrest, usually within 24 hours from the time of collecting the vital-sign measurements or obtaining the laboratory test results (Supplementary A: Table S6).…”