Modified early warning score-based clinical decision support: cost impact and clinical outcomes in sepsis

Horton, Devin; Graves, Kevin G.; Kukhareva, Polina; Johnson, Stacy A.; Cedillo, Maribel; Sanford, Matthew; Dunson, William A.; White, Michael A.; Roach, Dave; Arego, John J; Kawamoto, Kensaku

doi:10.1093/jamiaopen/ooaa014

Cited by 18 publications

(24 citation statements)

References 22 publications

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“…The median time before the first normal saline bolus administration to the patients in the pre-EAS group was 107 (37,218) minutes compared to 30 (11,112) minutes for those in the post-EAS group (p < 0.001). The median time before the first dose of antimicrobials administration was 170.5 (66,320) minutes for the pre-EAS group, with 131 (53,279) minutes for the post-EAS group (p 0.042).…”

Section: Resultsmentioning

confidence: 89%

“…EAS electronic alert system, SD standard deviation. The p-value was calculated using the indicated statistics: www.nature.com/scientificreports/ Many challenges and limitations can be encountered during electronic alert development, including differences in adult and pediatric parameters, the presentation timing, and the variable phenotypes of sepsis and the underpinning genomics subgroups 33,[36][37][38][39] . For instance, compared to adults, pediatric sepsis recognition is challenging due to the low specificity of tachycardia and tachypnea and the relatively late manifestation of hypotension 38 .…”

Section: Discussionmentioning

confidence: 99%

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Impact of an electronic alert system for pediatric sepsis screening a tertiary hospital experience

Alturki

Al‐Eyadhy

Alfayez

et al. 2022

Sci Rep

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This study aimed to assess the potential impact of implementing an electronic alert system (EAS) for systemic inflammatory syndrome (SIRS) and sepsis in pediatric patients mortality. This retrospective study had a pre and post design. We enrolled patients aged ≤ 14 years who were diagnosed with sepsis/severe sepsis upon admission to the pediatric intensive care unit (PICU) of our tertiary hospital from January 2014 to December 2018. We implemented an EAS for the patients with SIRS/sepsis. The patients who met the inclusion criteria pre-EAS implementation comprised the control group, and the group post-EAS implementation was the experimental group. Mortality was the primary outcome, while length of stay (LOS) and mechanical ventilation in the first hour were the secondary outcomes. Of the 308 enrolled patients, 147 were in the pre-EAS group and 161 in the post-EAS group. In terms of mortality, 44 patients in the pre-EAS group and 28 in the post-EAS group died (p 0.011). The average LOS in the PICU was 7.9 days for the pre-EAS group and 6.8 days for the post-EAS group (p 0.442). Considering the EAS initiation time as the “zero time”, early recognition of SIRS and sepsis via the EAS led to faster treatment interventions in post-EAS group, which included fluid boluses with median (25th, 75th percentile) time of 107 (37, 218) min vs. 30 (11,112) min, p < 0.001) and time to initiate antimicrobial therapy median (25th, 75th percentile) of 170.5 (66,320) min vs. 131 (53,279) min, p 0.042). The difference in mechanical ventilation in the first hour of admission was not significant between the groups (25.17% vs. 24.22%, p 0.895). The implementation of the EAS resulted in a statistically significant reduction in the mortality rate among the patients admitted to the PICU in our study. An EAS can play an important role in saving lives and subsequent reduction in healthcare costs. Further enhancement of systematic screening is therefore highly recommended to improve the prognosis of pediatric SIRS and sepsis. The implementation of the EAS, warrants further validation in multicenter or national studies.

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Section: Resultsmentioning

confidence: 89%

Section: Discussionmentioning

confidence: 99%

Impact of an electronic alert system for pediatric sepsis screening a tertiary hospital experience

Alturki

Al‐Eyadhy

Alfayez

et al. 2022

Sci Rep

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“…From time series analysis, we interpreted a positive change in NEWS2 recording and formed completion post dashboards intervention and potential for a further improvement as quality is monitored. In the current integration of EWS into EHRS, displaying the real-time score and generating alerts of EWS, like Modified Early Warning Score (MEWS), Paediatric EWS (PEWS), and NEWS, has shown several advantages in different care settings (39)(40)(41). It allowed for a real-time prediction of critical events associated with reduced hospitalisation costs and, more importantly, is believed to be a keystone for safe practice.…”

Section: Discussionmentioning

confidence: 99%

Evaluating a novel, integrative dashboard for health professionals’ performance in managing deteriorating patients:quality improvement project

Alhmoud

Melley

Khan

et al. 2022

Preprint

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Background: The quality of recording and documentation of deteriorating patient management by health professionals has been challenged at health system level during the COVID-19 pandemic. Non-adherence to monitoring and escalation guidelines and poor documentation increases risk of serious adverse events. Electronic health record (EHR)-integrated dashboards are real-time auditing tools of patients status and clinicians performance, but neither the views nor the performance of health professionals have been assessed, relating to management of deteriorating patients . Objective: To develop and evaluate a real-time dashboard of deteriorating patients assessment, referral, and therapy by examining the perception of the dashboard and the performance of nurses and physicians. Settings: Five academic hospitals in the largest NHS trust in the UK (Barts Health NHS Trust). Intervention: The dashboard was developed from EHR data to investigate patients with NEWS2>5, assessment, and escalation of deteriorating patients. We adopted the Plan, Do, Study, Act model and followed the SQUIRE framework to evaluate the dashboard. Design: Mixed methods: (i) Virtual, face-to-face, key informant interviews and (ii) Retrospective descriptive EHR data analysis to measure performance change over time. Results: We interviewed 3 nurses (2 quality and safety and 1 informatics specialists). Key themes were: (1) participants perceived the dashboard as a facilitator for auditing NEWS2 recording and escalation of care to improve clinicians practice; (2) There is a need for guiding clinicians and adjusting data sources and metrics which could enhance the functionality and usability. From EHR (2019 to 2022) data analysis showed: (1) NEWS2 recording has gradually improved in the implementation and evaluation phases (May 2021 to Apr 2022) from 64% to 83%; (2) Referral and nurses' assessment forms completion increased (n: 170 to 6800 & 23 to 540, respectively). Conclusion: The deterioration dashboard is an effective real time data- driven method for improving the quality of managing deteriorating patients. Improving the dashboard by integrating multiple health systems, a wider analysis of further NEWS2 and escalation of care metrics, clinicians learning of digital solutions will enhance functionality and experience, potentially boosting its value. There is a need to examine the generalizability of the dashboard through further validation and quality improvement studies.

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“…6,7 Current in-hospital early warning systems for sepsis (Modified Early Warning System [MEWS]) are used to alert health-care providers to the possibility of sepsis. 8 In many cases, the decision to initiate sepsis resuscitation bundles and more intensive management is an empiric decision made by the health-care provider at the bedside, prior to documentary evidence of microbial infection, organ injury or immunological dyscrasia. Existing clinical scores such as the Acute Physiology and Chronic Health Evaluation II (APACHE II) and sequential organ failure assessment (SOFA) score require 24 hours to properly calculate, making them impractical for immediate clinical decision-making.…”

Section: Introductionmentioning

confidence: 99%

A Transcriptomic Severity Metric that Predicts Clinical Outcomes in Critically Ill Surgical Sepsis Patients

Brakenridge

Starostik

Ghita

et al. 2021

Preprint

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Purpose: Prognostic metrics for the rapid and accurate prediction of sepsis severity that could elicit a meaningful change in clinical practice are currently lacking. Here, we evaluated a whole blood, multiplex host mRNA expression metric, Inflammatix-Severity-2 (IMX-SEV-2), for identifying septic, hospitalized patients for 30-day mortality, development of chronic critical illness (CCI), discharge disposition, and/or secondary infections. Methods: This is a retrospective, validation cohort analysis of a prospectively enrolled 335 patient study with surgical sepsis treated in the surgical intensive care unit. Whole blood collected in PAXgene Blood RNA collection tubes at 24 hours post sepsis diagnosis was analyzed using a custom 29-mRNA classifier (IMX-SEV-2) in a CLIA-CAP-accredited diagnostic laboratory using the NanoString FLEX profiler. Results: Among patients meeting Sepsis-3 criteria, the IMX-SEV-2 severity score was significantly better (p<0.05) at predicting secondary infections (AUROC 0.71) and adverse clinical outcomes (AUROC 0.75) than C-reactive protein (CRP), absolute lymphocyte counts (ALC), total white blood cell (WBC) count, age and Charlson comorbidity index (and better, albeit nonsignificantly, than IL-6 and APACHE II). Using multivariate logistic regression analysis, only combining the Charlson comorbidity index (AUROC 0.80) or APACHE II (AUROC 0.81) with the IMX-SEV-2 significantly improved prediction of adverse clinical outcomes, and combining with the Charlson comorbidity index for predicting 30-day mortality (AUROC 0.79). Conclusions: The IMX-SEV-2 severity score was superior at predicting secondary infections and overall adverse clinical outcomes versus other common metrics. Importantly, combining a rapidly measured transcriptomic metric with clinical or physiologic indices has sufficient precision to optimize resource utilization and allow adjustments to patient management that may improve outcomes in surgical sepsis. Hospitalized patients who are septic and present with an elevated IMX-SEV2 severity score and pre-existing comorbidities would be strong candidates for clinical interventions aimed at reducing the risk of secondary infections and adverse clinical outcomes.

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Modified early warning score-based clinical decision support: cost impact and clinical outcomes in sepsis

Cited by 18 publications

References 22 publications

Impact of an electronic alert system for pediatric sepsis screening a tertiary hospital experience

Impact of an electronic alert system for pediatric sepsis screening a tertiary hospital experience

Evaluating a novel, integrative dashboard for health professionals’ performance in managing deteriorating patients:quality improvement project

A Transcriptomic Severity Metric that Predicts Clinical Outcomes in Critically Ill Surgical Sepsis Patients

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