Scores for sepsis detection and risk stratification – construction of a novel score using a statistical approach and validation of RETTS

Mellhammar, Lisa; Linder, Adam; Tverring, Jonas; Christensson, Bértil; Boyd, John H.; Åkesson, Per; Kahn, Fredrik

doi:10.1371/journal.pone.0229210

Cited by 13 publications

(18 citation statements)

References 27 publications

(34 reference statements)

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“…Whereas, the NEWS, on the other hand, may have better capabilities to detect a deteriorating patient with a score of combined VS. This is also supported by other studies of sepsis, where NEWS was superior to both RETTS-A and qSOFA in the prediction of intensive care and 30-day mortality [42,43].…”

Section: Discussionsupporting

confidence: 84%

Pre-hospital triage performance and emergency medical services nurse’s field assessment in an unselected patient population attended to by the emergency medical services: a prospective observational study

Magnusson

Herlitz

Axelsson

2020

Scand J Trauma Resusc Emerg Med

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Background In Sweden, the rapid emergency triage and treatment system (RETTS-A) is used in the pre-hospital setting. With RETTS-A, patients triaged to the lowest level could safely be referred to a lower level of care. The national early warning score (NEWS) has also shown promising results internationally. However, a knowledge gap in optimal triage in the pre-hospital setting persists. This study aimed to evaluate RETTS-A performance, compare RETTS-A with NEWS and NEWS 2, and evaluate the emergency medical service (EMS) nurse’s field assessment with the physician’s final hospital diagnosis. Methods A prospective, observational study including patients (≥16 years old) transported to hospital by the Gothenburg EMS in 2016. Three comparisons were made: 1) Combined RETTS-A levels orange and red (high acuity) compared to a predefined reference emergency, 2) RETTS-A high acuity compared to NEWS and NEWS 2 score ≥ 5, and 3) Classification of pre-hospital nurse’s field assessment compared to hospital physician’s diagnosis. Outcomes of the time-sensitive conditions, mortality and hospitalisation were examined. The statistical tests included Mann–Whitney U test and Fisher’s exact test, and several binary classification tests were determined. Results Overall, 4465 patients were included (median age 69 years; 52% women). High acuity RETTS-A triage showed a sensitivity of 81% in prediction of the reference patient with a specificity of 64%. Sensitivity in detecting a time-sensitive condition was highest with RETTS-A (73%), compared with NEWS (37%) and NEWS 2 (35%), and specificity was highest with NEWS 2 (83%) when compared with RETTS-A (54%). The negative predictive value was higher in RETTS-A (94%) compared to NEWS (91%) and NEWS 2 (92%). Eleven per cent of the final diagnoses were classified as time-sensitive while the nurse’s field assessment was appropriate in 84% of these cases. Conclusions In the pre-hospital triage of EMS patients, RETTS-A showed sensitivity that was twice as high as that of both NEWS and NEWS 2 in detecting time-sensitive conditions, at the expense of lower specificity. However, the proportion of correctly classified low risk triaged patients (green/yellow) was higher in RETTS-A. The nurse’s field assessment of time-sensitive conditions was appropriate in the majority of cases.

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Section: Discussionsupporting

confidence: 84%

Pre-hospital triage performance and emergency medical services nurse’s field assessment in an unselected patient population attended to by the emergency medical services: a prospective observational study

Magnusson

Herlitz

Axelsson

2020

Scand J Trauma Resusc Emerg Med

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“…NEWS 2 has proven to be a highly useful score for the early identification of patients with sepsis in the emergency department, even when compared to new initiatives such as the Rapid Emergency Triage and Treatment System for sepsis Rapid Emergency Triage and Treatment System. [ 38 ] In other contexts, mainly Latin America, there was an initiative by de Oliveira et al [ 39 ] in Brazil, which used a prospective cohort study to evaluate nursing records to adapt and validate NEWS2 for the population. Our study is the first to validate NEWS2 in a Latin American population.…”

Section: Discussionmentioning

confidence: 99%

Validation of the National Early Warning Score (NEWS)-2 for adults in the emergency department in a tertiary-level clinic in Colombia

et al. 2021

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The National Early Warning Score (NEWS)-2 is an early warning scale that is used in emergency departments to identify patients at risk of clinical deterioration and to help establish rapid and timely management. The objective of this study was to determine the validity and prediction of mortality using the NEWS2 scale for adults in the emergency department of a tertiary clinic in Colombia. A prospective observational study was conducted between August 2018 and June 2019 at the Universidad de La Sabana Clinic. The nursing staff in the triage classified the patients admitted to the emergency room according to Emergency Severity Index and NEWS2. Demographic data, physiological variables, admission diagnosis, mortality outcome, and comorbidities were extracted. Three thousand nine hundred eighty-six patients were included in the study. Ninety-two (2%) patients required intensive care unit management, with a mean NEWS2 score of 7. A total of 158 patients died in hospital, of which 63 were women (40%). Of these 65 patients required intensive care unit management. The receiver operating characteristic curve for NEWS2 had an area of 0.90 (CI 95%: 0.87–0.92). A classification and score equivalency analysis was performed between triage and the NEWS2 scale in terms of mortality. Of the patients classified as triage I, 32.3% died, and those who obtained a NEWS2 score greater than or equal to 10 had a mortality of 38.6%. Among our population, NEWS2 was not inferior in its area under the receiver operating characteristic curve when predicting mortality than triage, and the cutoff point for NEWS2 to predict in-hospital mortality was higher.

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“…Screening tools have been shown to increase sepsis identification as compared to clinical judgment [ 5 , 6 ], but there are a few screening tools developed explicitly for the identification of sepsis in the ambulance [ 13 – 19 ]. Neither the National Early Warning score (NEWS2) [ 20 ] nor the rapid emergency triage and treatment system (RETTS) [ 21 , 22 ], an early warning score and a triage system respectively [ 20 ], are initially designed to identify sepsis. The use of NEWS2 is increasing worldwide [ 20 ].…”

Section: Introductionmentioning

confidence: 99%

“…RETTS is a triage system initially developed in Sweden [ 23 ] and is currently the most used triage system both in the ambulance and EDs. Both NEWS2 and RETTS have been proposed to be used to identify sepsis among patients with suspected infection [ 20 , 24 , 25 ], while NEWS2 has been shown to be superior to RETTS in the ED setting [ 22 ]. Neither NEWS2 nor RETTS have previously been validated with respect to sepsis identification in the ambulance.…”

Section: Introductionmentioning

confidence: 99%

Performance of NEWS2, RETTS, clinical judgment and the Predict Sepsis screening tools with respect to identification of sepsis among ambulance patients with suspected infection: a prospective cohort study

Wallgren

Sjölin

Järnbert-Pettersson

et al. 2021

Scand J Trauma Resusc Emerg Med

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Background There is little evidence of which sepsis screening tool to use in the ambulance setting. The primary aim of the current study was to compare the performance of NEWS2 (National Early Warning score 2) and RETTS (Rapid Emergency Triage and Treatment System) with respect to identification of sepsis among ambulance patients with clinically suspected infection. The secondary aim was to compare the performance of the novel Predict Sepsis screening tools with that of NEWS2, RETTS and clinical judgment. Methods Prospective cohort study of 323 adult ambulance patients with clinically suspected infection, transported to hospitals in Stockholm, during 2017/2018. The sensitivity, specificity, and AUC (Area Under the receiver operating Curve) were calculated and compared by using McNemar´s test and DeLong’s test. Results The prevalence of sepsis in the current study population was 44.6% (144 of 323 patients). No significant difference in AUC was demonstrated between NEWS2 ≥ 5 and RETTS ≥ orange. NEWS2 ≥ 7 demonstrated a significantly greater AUC than RETTS red. The Predict Sepsis screening tools ≥ 2 demonstrated the highest sensitivity (range 0.87–0.91), along with RETTS ≥ orange (0.83), but the lowest specificity (range 0.39–0.49). The AUC of NEWS2 (0.73) and the Predict Sepsis screening tools (range 0.75–0.77) was similar. Conclusions The results indicate that NEWS2 could be the better alternative for sepsis identification in the ambulance, as compared to RETTS. The Predict Sepsis screening tools demonstrated a high sensitivity and AUCs similar to that of NEWS2. However, these results need to be interpreted with caution as the Predict Sepsis screening tools require external validation. Trial registration: ClinicalTrials.gov, NCT03249597. Registered 15 August 2017—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03249597.

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Scores for sepsis detection and risk stratification – construction of a novel score using a statistical approach and validation of RETTS

Cited by 13 publications

References 27 publications

Pre-hospital triage performance and emergency medical services nurse’s field assessment in an unselected patient population attended to by the emergency medical services: a prospective observational study

Pre-hospital triage performance and emergency medical services nurse’s field assessment in an unselected patient population attended to by the emergency medical services: a prospective observational study

Validation of the National Early Warning Score (NEWS)-2 for adults in the emergency department in a tertiary-level clinic in Colombia

Performance of NEWS2, RETTS, clinical judgment and the Predict Sepsis screening tools with respect to identification of sepsis among ambulance patients with suspected infection: a prospective cohort study

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