Risk Stratification of Hospitalized Patients on the Wards

Abstract

Patients who suffer adverse events on the wards, such as cardiac arrest and death, often have vital sign abnormalities hours before the event. Early warning scores have been developed with the aim of identifying clinical deterioration early and have been recommended by the National Institute for Health and Clinical Excellence. In this review, we discuss recently developed and validated risk scores for use on the general inpatient wards. In addition, we compare newly developed systems with more established risk scores such as the Modified Early Warning Score and the criteria used in the Medical Early Response Intervention and Therapy (MERIT) trial in our database of > 59,000 ward admissions. In general we found the single-parameter systems, such as the MERIT criteria, to have the lowest predictive accuracy for adverse events, whereas the aggregate weighted scoring systems had the highest. The Cardiac Arrest Risk Triage (CART) score was best for predicting cardiac arrest, ICU transfer, and a composite outcome (area under the receiver operating characteristic curve [AUC], 0.83, 0.77, and 0.78, respectively), whereas the Standardized Early Warning Score, VitalPAC Early Warning Score, and CART score were similar for predicting mortality (AUC, 0.88). Selection of a risk score for a hospital or health-care system should be guided by available variables, calculation method, and system resources. Once implemented, ensuring high levels of adherence and tying them to specific levels of interventions, such as activation of a rapid response team, are necessary to allow for the greatest potential to improve patient outcomes.

Quick Sepsis-related Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and Early Warning Scores for Detecting Clinical Deterioration in Infected Patients outside the Intensive Care Unit

“…However, we used the same definition as the original qSOFA study and also included only IV medications, which should improve the validity of our results. Finally, we only studied 2 of the more than 100 published early warning scores in the literature (26). Because most of these scores are similar to the MEWS and NEWS, and these are two of the most highly cited scores in common use, we believed that these results would be of value for clinicians.…”

A Comparison of the Ability of the Physiologic Components of Medical Emergency Team Criteria and the U.K. National Early Warning Score to Discriminate Patients at Risk of a Range of Adverse Clinical Outcomes*

“…changes to vital signs monitoring frequency; involvement of more experienced ward staff; or calling a rapid response team (RRT). Many EWSS are in use, with marked variation in measured physiological variables, assigned weightings and outcome discrimination (3)(4)(5)(6)(7)(8). In 2012, the Royal College of Physicians of London (RCPL) recommended the use of a standardised EWSS in the National Health Service (NHS) -the National EWS (NEWS) (Supplementary Digital Content 1) (9).…”

Optymalizacja funkcji układu krążenia w okresie okołooperacyjnym u chorych poddawanych operacjom niekardiochirurgicznym — stanowisko Sekcji Kardiotorakoanestezjologii Polskiego Towarzystwa Anestezjologii i Intensywnej Terapii. Część 1

“…In the regular (surgical) ward, the role of enhanced nursing personnel surveillance is of particular importance. If providing direct postoperative supervision is difficult (1 nurse for up to 4-6 patients) [53], it is beneficial to monitor patients using available early warning systems (EWS) ( Table 7) [54][55][56]. A score of at least 4 by the Modified Early Warning Score (MEWS), 4 by the Standardized Early Warning Score (SEWS), or 8 by the VitalPAC Early Warning Score (ViEWS) should prompt the nurse to notify the physician of a patient's worsening condition and the risk of complications.…”