The use of Early Warning System Scores in Pre-Hospital and Emergency Department Settings to Predict Clinical Deterioration: s Systematic Review and Meta-Analysis

Abstract

Background: It is unclear which Early Warning System (EWS) score best predicts in-hospital deterioration when applied in the emergency department (ED) or pre-hospital setting. Methods: This systematic review and meta-analysis assessed the predictive abilities of five commonly used EWS scores: National Early Warning Score (NEWS) and its updated version NEWS2, Modified Early Warning Score (MEWS), Rapid Acute Physiological Score (RAPS) and Cardiac Arrest Risk Triage (CART). Outcomes of interest included admission to ICU, up-to-≥3-day and 30-day mortality. Pooled estimates were calculated using DerSimonian and Laird random-effects models, constructed by type of EWS score, cut-off points, outcomes, and study setting. Risk of bias was assessed using the Newcastle-Ottawa Scale. Meta-regressions investigated between study heterogeneity. Funnel plots tested for publication bias. Results: A total of 11,565 articles was identified, of which 15 were included. Eight and seven articles conducted in the ED and pre-hospital settings, respectively. In the ED, MEWS and NEWS at cut-off points of 3, 4, or 6 had similar pooled diagnostic odds ratios (DOR) to predict 30-day mortality, ranging from 4.05 (Confidence Interval (CI) 2.35–6.99) to 6.48 (95% CI 1.83–22.89), p = 0.757. The ability of MEWS (cut-off point ≥ 3) to predict ICU admission had a similar pooled DOR of 5.54 (95% CI 2.02–15.21). In the pre-hospital setting, EWS scores failed to predict 30-day mortality. Using high cut-off points of 5, 7, or 9, their predictability improved when assessing up-to-≥3-day mortality with DOR ranging from 11.60 (95%, CI 9.75–13.88) to 20.37 (95% CI 13.16–31.52).Publication bias was not detected. Participants’ age explained 92% of between-study variance. Conclusion: EWS scores’ predictability of clinical deterioration improves when applied on patient populations that are already in the ED or hospital. The high thresholds used and the scores’ failure to predict 30-day mortality make them less suited for use in the pre-hospital setting.