Modified Early Warning Score (MEWS) Identifies Critical Illness among Ward Patients in a Resource Restricted Setting in Kampala, Uganda: A Prospective Observational Study

Abstract

IntroductionProviding optimal critical care in developing countries is limited by lack of recognition of critical illness and lack of essential resources. The Modified Early Warning Score (MEWS), based on physiological parameters, is validated in adult medical and surgical patients as a predictor of mortality. The objective of this study performed in Uganda was to determine the prevalence of critical illness on the wards as defined by the MEWS, to evaluate the MEWS as a predictor of death, and to describe additional risk factors for mortality.MethodsWe conducted a prospective observational study at Mulago National Referral Teaching Hospital in Uganda. We included medical and surgical ward patients over 18 years old, excluding patients discharged the day of enrolment, obstetrical patients, and patients who self-discharged prior to study completion. Over a 72-hour study period, we collected demographic and vital signs, and calculated MEWS; at 7-days we measured outcomes. Patients discharged prior to 7 days were assumed to be alive at study completion. Descriptive and inferential statistical analyses were performed.ResultsOf 452 patients, the median age was 40.5 (IQR 29–54) years, 53.3% were male, 24.3% were HIV positive, and 45.1% had medical diagnoses. MEWS ranged from 0 to 9, with higher scores representing hemodynamic instability. The median MEWS was 2 [IQR 1–3] and the median length of hospital stay was 9 days [IQR 4–24]. In-hospital mortality at 7-days was 5.5%; 41.4% of patients were discharged and 53.1% remained on the ward. Mortality was independently associated with medical admission (OR: 7.17; 95% CI: 2.064–24.930; p = 0.002) and the MEWS ≥ 5 (OR: 5.82; 95% CI: 2.420–13.987; p<0.0001) in the multivariable analysis.ConclusionThere is a significant burden of critical illness at Mulago Hospital, Uganda. Implementation of the MEWS could provide a useful triage tool to identify patients at greatest risk of death. Future research should include refinement of MEWS for low-resource settings, and development of appropriate interventions for patients identified to be at high risk of death based on early warning scores.

Derivation and validation of a universal vital assessment (UVA) score: a tool for predicting mortality in adult hospitalised patients in sub-Saharan Africa

“…30 31 However, we found that the UVA score performed better than MEWS perhaps due to differences BMJ Global Health in age, chronic illness, respiratory compromise and HIV prevalence between the derivation cohorts. The importance of severity of illness scores in patients with infection was recently highlighted by the new consensus sepsis-3 definitions that incorporated mortality risk scores including qSOFA that were derived from large data sets from North America and Europe.…”

Global Critical Care: Moving Forward in Resource-Limited Settings

“…Mortality prediction scores to risk-adjust in research and quality improvement efforts must also be developed and validated in relevant populations [54,55]. Region-specific equations or adaptations for resource-limited settings can improve performance and facilitate implementation [55][56][57][58][59].…”

“…Region-specific equations or adaptations for resource-limited settings can improve performance and facilitate implementation [55][56][57][58][59]. Risk assessment tools, such as the Modified Early Warning Score, which might help triage critically patients and allocate resources [54] have shown conflicting results when applied in resource-limited settings and need additional modifications and validation [60,61].…”

The Niguarda MEWS, a new and refined tool to determine criticality and instability in Internal Medicine Ward and Emergency Medicine Unit

“…23 Some studies employ MEWS to classify internal medicine patients at admission, [24][25][26] but some others highlight the need for improvement and extension of parameters to better classify these patients. 23,27,28 Much effort has recently been put by the UK National Health Service (NHS) into a standardized scoring system and, as a result, the national early warning score (NEWS) has been introduced.…”