The Impact of Age on Predictive Performance of National Early Warning Score at Arrival to Emergency Departments: Development and External Validation

Nissen, Søren Kabell; Candel, Bart G J; Nickel, Christian H.; Jonge, Evert de; Ryg, Jesper; Bogh, Søren Bie; Groot, Bas de; Brabrand, Mikkel

doi:10.1016/j.annemergmed.2021.09.434

Cited by 13 publications

(20 citation statements)

References 38 publications

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“…Based on earlier studies and our results, we agree with those authors and suggest that RDW should also be included in risk stratification of frail patients in emergency departments and hospital wards. Older patients often have non-specific presentations in the ED, and vital signs are less reliable for detecting early clinical deterioration in older patients [51][52][53]. Therefore, older patients, with or without frailty, could be one patient group that would benefit in particular from more comprehensive deep-learning risk-assessment methods.…”

Section: Discussionmentioning

confidence: 99%

Red cell distribution width and mortality in older patients with frailty in the emergency department

et al. 2023

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Background The red cell distribution width (RDW) reflects the degree of heterogeneity of red blood cells. Elevated RDW is associated both with frailty and with increased mortality in hospital-admitted patients. In this study we evaluate whether high RDW values are associated with mortality in older emergency department (ED) patients with frailty, and if the association is independent of the degree of frailty. Methods We included ED patients with the following criteria: ≥ 75 years of age, Clinical Frailty Scale (CFS) score of 4 to 8, and RDW % measured within 48 h of ED admission. Patients were allocated to six classes by their RDW value: ≤ 13%, 14%, 15%, 16%, 17%, and ≥ 18%. The outcome was death within 30 days of ED admission. Crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) for a one-class increase in RDW for 30-day mortality were calculated via binary logistic regression analysis. Age, gender and CFS score were considered as potential confounders. Results A total of 1407 patients (61.2% female), were included. The median age was 85 with an inter-quartile range (IQR) of 80–89, median CFS score 6 (IQR: 5–7), and median RDW 14 (IQR: 13–16). Of the included patients, 71.9% were admitted to hospital wards. A total of 85 patients (6.0%) died during the 30-day follow-up. Mortality rate was associated with RDW increase (p for trend < .001). Crude OR for a one-class increase in RDW for 30-day mortality was 1.32 (95% CI: 1.17–1.50, p < .001). When adjusted for age, gender and CFS-score, OR of mortality for one-class RDW increase was still 1.32 (95% CI: 1.16–1.50, p < .001). Conclusion Higher RDW values had a significant association with increased 30-day mortality risk in frail older adults in the ED, and this risk was independent of degree of frailty. RDW is a readily available biomarker for most ED patients. It might be beneficial to include it in risk stratification of older frail ED patients to identify those who could benefit from further diagnostic assessment, targeted interventions, and care planning.

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Section: Discussionmentioning

confidence: 99%

Red cell distribution width and mortality in older patients with frailty in the emergency department

et al. 2023

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“…The relatively low PPV of EWSs for identifying patients at high risk may be a problem owing to the steady increase in patients needing emergency treatment with the demographic development of greater numbers of older patients seen throughout the Western world. In this context, mortality prediction performance has been shown to improve when age is added to EWS, especially among individuals aged 80 years or older . Moreover, demographic changes in the population of patients needing emergency treatment have led to calls for a focus on nonconveyance of patients needing ambulance services .…”

Section: Discussionmentioning

confidence: 99%

Prehospital Early Warning Scores to Predict Mortality in Patients Using Ambulances

Ward¹,

Søvsø

Mogensen³

et al. 2023

JAMA Netw Open

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ImportanceEarly warning scores (EWSs) are designed for in-hospital use but are widely used in the prehospital field, especially in select groups of patients potentially at high risk. To be useful for paramedics in daily prehospital clinical practice, evaluations are needed of the predictive value of EWSs based on first measured vital signs on scene in large cohorts covering unselected patients using ambulance services.ObjectiveTo validate EWSs’ ability to predict mortality and intensive care unit (ICU) stay in an unselected cohort of adult patients who used ambulances.Design, Setting, and ParticipantsThis prognostic study conducted a validation based on a cohort of adult patients (aged ≥18 years) who used ambulances in the North Denmark Region from July 1, 2016, to December 31, 2020. EWSs (National Early Warning Score 2 [NEWS2], modified NEWS score without temperature [mNEWS], Quick Sepsis Related Organ Failure Assessment [qSOFA], Rapid Emergency Triage and Treatment System [RETTS], and Danish Emergency Process Triage [DEPT]) were calculated using first vital signs measured by ambulance personnel. Data were analyzed from September 2022 through May 2023.Main Outcomes and MeasuresThe primary outcome was 30-day-mortality. Secondary outcomes were 1-day-mortality and ICU admission. Discrimination was assessed using area under the receiver operating characteristic curve (AUROC) and area under the precision recall curve (AUPRC).ResultsThere were 107 569 unique patients (52 650 females [48.9%]; median [IQR] age, 65 [45-77] years) from the entire cohort of 219 323 patients who used ambulance services, among whom 119 992 patients (54.7%) had called the Danish national emergency number. NEWS2, mNEWS, RETTS, and DEPT performed similarly concerning 30-day mortality (AUROC range, 0.67 [95% CI, 0.66-0.68] for DEPT to 0.68 [95% CI, 0.68-0.69] for mNEWS), while qSOFA had lower performance (AUROC, 0.59 [95% CI, 0.59-0.60]; P vs other scores &lt; .001). All EWSs had low AUPRCs, ranging from 0.09 (95% CI, 0.09-0.09) for qSOFA to 0.14 (95% CI, 0.13-0.14) for mNEWS.. Concerning 1-day mortality and ICU admission NEWS2, mNEWS, RETTS, and DEPT performed similarly, with AUROCs ranging from 0.72 (95% CI, 0.71-0.73) for RETTS to 0.75 (95% CI, 0.74-0.76) for DEPT in 1-day mortality and 0.66 (95% CI, 0.65-0.67) for RETTS to 0.68 (95% CI, 0.67-0.69) for mNEWS in ICU admission, and all EWSs had low AUPRCs. These ranged from 0.02 (95% CI, 0.02-0.03) for qSOFA to 0.04 (95% CI, 0.04-0.04) for DEPT in 1-day mortality and 0.03 (95% CI, 0.03-0.03) for qSOFA to 0.05 (95% CI, 0.04-0.05) for DEPT in ICU admission.Conclusions and RelevanceThis study found that EWSs in daily clinical use in emergency medical settings performed moderately in the prehospital field among unselected patients who used ambulances when assessed based on initial measurements of vital signs. These findings suggest the need of appropriate triage and early identification of patients at low and high risk with new and better EWSs also suitable for prehospital use.

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“…Wider clinical use will require a cultural change, which recognizes the importance of the accurate measurement and recording of respiratory rate. Furthermore, early warning scores that are better calibrated over a wider risk range than either ROX or NEWS are needed to improve the risk assessment of all patients regardless of their clinical setting [ 30 ].…”

Section: Discussionmentioning

confidence: 99%

The prediction of 24-h mortality by the respiratory rate and oxygenation index compared with National Early Warning Score in emergency department patients: an observational study

Candel

Groot

Nissen

et al. 2022

European Journal of Emergency Medicine

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BackgroundThe ROX index combines respiratory rate and oxygenation to predict the response to oxygen therapy in pneumonia. It is calculated by dividing the patient's oxygen saturation, by the inspired oxygen concentration, and then by the respiratory rate (e.g. 95%/0.21/16 = 28). Since this index includes the most essential physiological variables to detect deterioration, it may be a helpful risk tool in the emergency department (ED). Although small studies suggest it can predict early mortality, no large study has compared it with the National Early Warning Score (NEWS), the most widely validated risk score for death within 24 h. Aim The aim of this study was to compare the ability of the ROX index with the NEWS to predict mortality within 24 h of arrival at the hospital. Methods This was a retrospective observational multicentre analysis of data in the Netherlands Emergency Department Evaluation Database (NEED) on 270 665 patients attending four participating Dutch EDs. The ROX index and NEWS were determined on ED arrival and prior to ED treatment. ResultsThe risk of death within 24 h increased with falling ROX and rising NEWS values. The area under the receiving operating characteristic curves for 24-h mortality of NEWS was significantly higher than for the ROX index [0.92; 95% confidence interval (CI), 0.91-0.92 versus 0.87; 95% CI, 0.86-0.88; P < 0.01]. However, the observed and predicted mortality by the ROX index was identical to mortality of 5%, after which mortality was underestimated. In contrast, up to a predicted 24-h mortality of 3% NEWS slightly underestimates mortality, and above this level over-estimates it. The standardized net benefit of ROX is slightly higher than NEWS up to a predicted 24-h mortality of 3%. Conclusion The prediction of 24-h mortality by the ROX index is more accurate than NEWS for most patients likely to be encountered in the ED. ROX may be used as a first screening tool in the ED.

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The Impact of Age on Predictive Performance of National Early Warning Score at Arrival to Emergency Departments: Development and External Validation

Cited by 13 publications

References 38 publications

Red cell distribution width and mortality in older patients with frailty in the emergency department

Red cell distribution width and mortality in older patients with frailty in the emergency department

Prehospital Early Warning Scores to Predict Mortality in Patients Using Ambulances

The prediction of 24-h mortality by the respiratory rate and oxygenation index compared with National Early Warning Score in emergency department patients: an observational study

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