Background: Early warning scores (EWSs) are used to identify deteriorating patients for appropriate interventions. We performed a systematic review to examine the usefulness of EWSs in predicting inpatient mortality and morbidity (transfer to higher-level care and length of hospital stay) in older people admitted to acute medical units with sepsis, acute cardiovascular events, or pneumonia. Methods: A systematic review of published and unpublished databases was conducted. Cochrane′s tool for assessing Risk of Bias in Non-Randomised Studies—of Interventions (ROBINS-I) was used to appraise the evidence. A narrative synthesis was performed due to substantial heterogeneity. RESULTS: Five studies (n = 12,057) were eligible from 1033 citations. There was an overall “moderate” risk of bias for all studies. The predictive ability of EWSs regarding mortality was reported in one study (n = 274), suggesting EWSs were better at predicting survival, (negative predictive value >90% for all scores). Three studies (n = 1819) demonstrated a significant association between increasing modified EWSs (MEWSs) and increased risk of mortality. Hazards ratios for a composite death/intensive care (ICU) admission with MEWSs ≥5 were significant in one study (p = 0.003). Two studies (n = 1421) demonstrated that a MEWS ≥6 was associated with 21 times higher probability of mortality (95% Confidence Interval (CI): 2.71–170.57) compared with a MEWS ≤1. A MEWS of ≥5 was associated with 22 times higher probability of mortality (95% CI: 10.45–49.16). Conclusion: Increasing EWSs are strongly associated with mortality and ICU admission in older acutely unwell patients. Future research should be targeted at better understanding the usefulness of high and increasing EWSs for specific acute illnesses in older adults.
Background: To improve outcomes for patients who present to hospital with suspected sepsis, it is necessary to accurately identify those at high risk of adverse outcomes as early and swiftly as possible. To assess the prognostic accuracy of shock index (heart rate divided by systolic blood pressure) and its modifications in patients with sepsis or community-acquired pneumonia. Methods: An electronic search of MEDLINE, EMBASE, Allie and Complementary Medicine Database (AMED), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Open Grey, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (WHO ITRP) was conducted from conception to 26th March 2019. Eligible studies were required to assess the prognostic accuracy of shock index or its modifications for outcomes of death or requirement for organ support either in sepsis or pneumonia. The methodological appraisal was carried out using the Downs and Black checklist. Evidence was synthesised using a narrative approach due to heterogeneity. Results: Of 759 records screened, 15 studies (8697 patients) were included in this review. Shock index ≥ 1 at time of hospital presentation was a moderately accurate predictor of mortality in patients with sepsis or community-acquired pneumonia, with high specificity and low sensitivity. Only one study reported outcomes related to organ support. Conclusions: Elevated shock index at time of hospital presentation predicts mortality in sepsis with high specificity. Shock index may offer benefits over existing sepsis scoring systems due to its simplicity.
Rising antimicrobial volumes up to 2011 were mainly due to rising DDD per prescription. Trends in dispensed drug volumes do not readily translate into information on individual exposure, which is more relevant for adverse consequences including emergence of resistance.
The CV of ECFV/BSA in normal subjects is a useful indicator of the technical robustness with which GFR is measured and, in this study, indicated a wide variation in departmental performance.
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