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Performance of Modified Early Warning Score (MEWS) and Circulation, Respiration, Abdomen, Motor, and Speech (CRAMS) score in trauma severity and in-hospital mortality prediction in multiple trauma patients: a comparison study.

ABSTRACT: Background:With an increasing number of motor vehicle crashes, there is an urgent need in emergency departments (EDs) to assess patients with multiple trauma quickly, easily, and reliably. Trauma severity can range from a minor to major threats to life or bodily function. In-hospital mortality and trauma severity prediction in such cases is crucial in the ED for the management of multiple trauma and improvement of the outcome of these patients. Previous studies have examined the performance of Modified Early Warning Score (MEWS) or Circulation, Respiration, Abdomen, Motor, and Speech (CRAMS) score based solely on mortality prediction or injury severity prediction. However, to the best of our knowledge, the performances of both scoring systems on in-hospital mortality and trauma severity prediction have not been compared previously. This retrospective study evaluated the value of MEWS and CRAMS score to predict in-hospital mortality and trauma severity in patients presenting to the ED with multiple traumatic injuries. Methods:All study subjects were multiple trauma patients. Medical data of 1,127 patients were analyzed between January 2014 and April 2018. The MEWS and CRAMS score were calculated, and logistic regression and receiver operating characteristic curve analysis were conducted to investigate their performances regarding in-hospital mortality and trauma severity prediction. Results:For in-hospital mortality prediction, the areas under the receiver operating characteristic curve (AUROCs) for MEWS and CRAMS score were 0.90 and 0.91, respectively, indicating that both of them were good in-hospital mortality predictors. Further, our study indicated that the CRAMS score performed better in trauma severity prediction, with an AUROC value of 0.84, which was higher than that of MEWS (AUROC = 0.77). For trauma severity prediction, the optimal cut-off value for MEWS was 2, while that of the CRAMS score was 8. Conclusions:We found that both MEWS and CRAMS score can be used as predictors for trauma severity and in-hospital mortality for multiple trauma patients, but that CRAMS score was superior to MEWS for trauma severity prediction. CRAMS score should be prioritized in the prediction of trauma severity due to its excellence as a multiple trauma triage tool and potential contribution to rapid emergency rescue decisions.

SUBMITTER: Jiang X

PROVIDER: S-EPMC6598668 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Performance of Modified Early Warning Score (MEWS) and Circulation, Respiration, Abdomen, Motor, and Speech (CRAMS) score in trauma severity and in-hospital mortality prediction in multiple trauma patients: a comparison study.

Jiang Xiaobin X Jiang Ping P Mao Yuanshen Y

PeerJ 20190625

<h4>Background</h4>With an increasing number of motor vehicle crashes, there is an urgent need in emergency departments (EDs) to assess patients with multiple trauma quickly, easily, and reliably. Trauma severity can range from a minor to major threats to life or bodily function. In-hospital mortality and trauma severity prediction in such cases is crucial in the ED for the management of multiple trauma and improvement of the outcome of these patients. Previous studies have examined the performa ...[more]

PMID: 31275766

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Project description:IntroductionProviding optimal critical care in developing countries is limited by lack of recognition of critical illness and lack of essential resources. The Modified Early Warning Score (MEWS), based on physiological parameters, is validated in adult medical and surgical patients as a predictor of mortality. The objective of this study performed in Uganda was to determine the prevalence of critical illness on the wards as defined by the MEWS, to evaluate the MEWS as a predictor of death, and to describe additional risk factors for mortality.MethodsWe conducted a prospective observational study at Mulago National Referral Teaching Hospital in Uganda. We included medical and surgical ward patients over 18 years old, excluding patients discharged the day of enrolment, obstetrical patients, and patients who self-discharged prior to study completion. Over a 72-hour study period, we collected demographic and vital signs, and calculated MEWS; at 7-days we measured outcomes. Patients discharged prior to 7 days were assumed to be alive at study completion. Descriptive and inferential statistical analyses were performed.ResultsOf 452 patients, the median age was 40.5 (IQR 29-54) years, 53.3% were male, 24.3% were HIV positive, and 45.1% had medical diagnoses. MEWS ranged from 0 to 9, with higher scores representing hemodynamic instability. The median MEWS was 2 [IQR 1-3] and the median length of hospital stay was 9 days [IQR 4-24]. In-hospital mortality at 7-days was 5.5%; 41.4% of patients were discharged and 53.1% remained on the ward. Mortality was independently associated with medical admission (OR: 7.17; 95% CI: 2.064-24.930; p = 0.002) and the MEWS ? 5 (OR: 5.82; 95% CI: 2.420-13.987; p<0.0001) in the multivariable analysis.ConclusionThere is a significant burden of critical illness at Mulago Hospital, Uganda. Implementation of the MEWS could provide a useful triage tool to identify patients at greatest risk of death. Future research should include refinement of MEWS for low-resource settings, and development of appropriate interventions for patients identified to be at high risk of death based on early warning scores.

Project description:The aim of this study is to evaluate the usefulness of the pre-hospital National Early Warning Score (pNEWS) and the pre-hospital Modified Early Warning Score (pMEWS) for predicting admission and in-hospital mortality in elderly patients presenting to the emergency department (ED). We also compare the value of the pNEWS with that of the ED NEWS (eNEWS) and ED MEWS (eMEWS) for predicting admission and in-hospital mortality. This retrospective, single-centre observational study was carried out in the ED of Jikei University Kashiwa Hospital, in Chiba, Japan, from 1st April 2017 to 31st March 2018. All patients aged 65 years or older were included in this study. The pNEWS/eNEWS were derived from seven common physiological vital signs: respiratory rate, peripheral oxygen saturation, the presence of inhaled oxygen parameters, body temperature, systolic blood pressure, pulse rate and Alert, responds to Voice, responds to Pain, Unresponsive (AVPU) score, whereas the pMEWS/eMEWS were derived from six common physiological vital signs: respiratory rate, peripheral oxygen saturation, body temperature, systolic blood pressure, pulse rate and AVPU score. Discrimination was assessed by plotting the receiver operating characteristic (ROC) curve and calculating the area under the ROC curve (AUC). The median pNEWS, pMEWS, eNEWS and eMEWS were significantly higher at admission than at discharge (p < 0.001). The median pNEWS, pMEWS, eNEWS and eMEWS of non-survivors were significantly higher than those of the survivors (p < 0.001). The AUC for predicting admission was 0.559 for the pNEWS and 0.547 for the pMEWS. There was no significant difference between the AUCs of the pNEWS and the pMEWS for predicting admission (p = 0.102). The AUCs for predicting in-hospital mortality were 0.678 for the pNEWS and 0.652 for the pMEWS. There was no significant difference between the AUCs of the pNEWS and the pMEWS for predicting in-hospital mortality (p = 0.081). The AUC for predicting admission was 0.628 for the eNEWS and 0.591 for the eMEWS. The AUC of the eNEWS was significantly greater than that of the eMEWS for predicting admission (p < 0.001). The AUC for predicting in-hospital mortality was 0.789 for the eNEWS and 0.720 for the eMEWS. The AUC of the eNEWS was significantly greater than that of the eMEWS for predicting in-hospital mortality (p < 0.001). For admission and in-hospital mortality, the AUC of the eNEWS was significantly greater than that of the pNEWS (p < 0.001, p < 0.001), and the AUC of the eMEWS was significantly greater than that of the pMEWS (p < 0.01, p < 0.05). Our single-centre study has demonstrated the low utility of the pNEWS and the pMEWS as predictors of admission and in-hospital mortality in elderly patients, whereas the eNEWS and the eMEWS predicted admission and in-hospital mortality more accurately. Evidence from multicentre studies is needed before introducing pre-hospital versions of risk-scoring systems.

Project description:Objectives1) To explore the adequacy of: vital signs' recordings (respiratory and heart rate, oxygen saturation, systolic blood pressure (BP), temperature, level of consciousness and urine output) in the first 8 post-operative hours; responses to clinical deterioration. 2) To identify factors associated with death on the ward between transfer from the theatre recovery suite and the seventh day after operation.DesignRetrospective review of records of 11 patients who died plus four controls for each case.ParticipantsWe reviewed clinical records of 55 patients who met inclusion criteria (general anaesthetic, age >13, complete records) from six surgical wards in a teaching hospital between 1 May and 31 July 2009.MethodsIn the absence of guidelines for routine post-operative vital signs' monitoring, nurses' standard practice graphical plots of recordings were recoded into MEWS formats (0?=?normal, 1-3 upper or lower limit) and their responses to clinical deterioration were interpreted using MEWS reporting algorithms.ResultsNo patients' records contained recordings for all seven parameters displayed on the MEWS. There was no evidence of response to: 22/36 (61.1%) abnormal vital signs for patients who died that would have triggered an escalated MEWS reporting algorithm; 81/87 (93.1%) for controls. Death was associated with age, ?61 years (OR 14.2, 3.0-68.0); ?2 pre-existing co-morbidities (OR 75.3, 3.7-1527.4); high/low systolic BP on admission (OR 7.2, 1.5-34.2); tachycardia (?111-129 bpm) (OR 6.6, 1.4-30.0) and low systolic BP (?81-100 mmHg), as defined by the MEWS (OR 8.0, 1.9-33.1).ConclusionsGuidelines for post-operative vital signs' monitoring and reporting need to be established. The MEWS provides a useful scoring system for interpreting clinical deterioration and guiding intervention. Exploration of the ability of the Cape Town MEWS chart plus reporting algorithm to expedite recognition of signs of clinical and physiological deterioration and securing more skilled assistance is essential.

Project description:BackgroundA feasible and accurate risk prediction systems for emergency department (ED) patients is urgently required. The Modified Early Warning Score (MEWS) is a wide-used tool to predict clinical outcomes in ED. Literatures showed that machine learning (ML) had better predictability in specific patient population than traditional scoring system. By analyzing a large multicenter dataset, we aim to develop a ML model to predict in-hospital morality of the adult non traumatic ED patients for different time stages, and comparing performance with other ML models and MEWS.MethodsA retrospective observational cohort study was conducted in five Taiwan EDs including two tertiary medical centers and three regional hospitals. All consecutively adult (>17 years old) non-traumatic patients admit to ED during a 9-year period (January first, 2008 to December 31th, 2016) were included. Exclusion criteria including patients with (1) out-of-hospital cardiac arrest and (2) discharge against medical advice and transferred to other hospital (3) missing collect variables. The primary outcome was in-hospital mortality and were categorized into 6, 24, 72, 168 hours mortality. MEWS was calculated by systolic blood pressure, pulse rate, respiratory rate, body temperature, and level of consciousness. An ensemble supervised stacking ML model was developed and compared to sensitive and unsensitive Xgboost, Random Forest, and Adaboost. We conducted a performance test and examine both the area under the receiver operating characteristic (AUROC) and the area under the precision and recall curve (AUPRC) as the comparative measures.ResultAfter excluding 182,001 visits (7.46%), study group was consisted of 24,37,326 ED visits. The dataset was split into 67% training data and 33% test data for ML model development. There was no statistically difference found in the characteristics between two groups. For the prediction of 6, 24, 72, 168 hours in-hospital mortality, the AUROC of MEW and ML mode was 0.897, 0.865, 0.841, 0.816 and 0.939, 0.928, 0.913, 0.902 respectively. The stacking ML model outperform other ML model as well. For the prediction of in-hospital mortality over 48-hours, AUPRC performance of MEWS drop below 0.1, while the AUPRC of ML mode was 0.317 in 6 hours and 0.2150 in 168 hours. For each time frame, ML model achieved statistically significant higher AUROC and AUPRC than MEWS (all P < 0.001). Both models showed decreasing prediction ability as time elapse, but there was a trend that the gap of AUROC values between two model increases gradually (P < 0.001). Three MEWS thresholds (score >3, >4, and >5) were determined as baselines for comparison, ML mode consistently showed improved or equally performance in sensitivity, PPV, NPV, but not in specific.ConclusionStacking ML methods improve predicted in-hospital mortality than MEWS in adult non-traumatic ED patients, especially in the prediction of delayed mortality.

Project description:We sought to validate prognostic scores in coronavirus disease 2019 including National Early Warning Score, Modified Early Warning Score, and age-based modifications, and define their performance characteristics.DesignWe analyzed prospectively collected data from the Adaptive COVID-19 Treatment Trial. National Early Warning Score was collected daily during the trial, Modified Early Warning Score was calculated, and age applied to both scores. We assessed prognostic value for the end points of recovery, mechanical ventilation, and death for score at enrollment, average, and slope of score over the first 48 hours.SettingA multisite international inpatient trial.PatientsA total of 1,062 adult nonpregnant inpatients with severe coronavirus disease 2019 pneumonia.InterventionsAdaptive COVID-19 Treatment Trial 1 randomized participants to receive remdesivir or placebo. The prognostic value of predictive scores was evaluated in both groups separately to assess for differential performance in the setting of remdesivir treatment.Measurements and main resultsFor mortality, baseline National Early Warning Score and Modified Early Warning Score were weakly to moderately prognostic (c-index, 0.60-0.68), and improved with addition of age (c-index, 0.66-0.74). For recovery, baseline National Early Warning Score and Modified Early Warning Score demonstrated somewhat better prognostic ability (c-index, 0.65-0.69); however, National Early Warning Score+age and Modified Early Warning Score+age further improved performance (c-index, 0.68-0.71). For deterioration, baseline National Early Warning Score and Modified Early Warning Score were weakly to moderately prognostic (c-index, 0.59-0.69) and improved with addition of age (c-index, 0.63-0.70). All prognostic performance improvements due to addition of age were significant (p < 0.05).ConclusionsIn the Adaptive COVID-19 Treatment Trial 1 cohort, National Early Warning Score and Modified Early Warning Score demonstrated moderate prognostic performance in patients with severe coronavirus disease 2019, with improvement in predictive ability for National Early Warning Score+age and Modified Early Warning Score+age. Area under receiver operating curve for National Early Warning Score and Modified Early Warning Score improved in patients receiving remdesivir versus placebo early in the pandemic for recovery and mortality. Although these scores are simple and readily obtainable in myriad settings, in our data set, they were insufficiently predictive to completely replace clinical judgment in coronavirus disease 2019 and may serve best as an adjunct to triage, disposition, and resourcing decisions.

Project description:BACKGROUND:Children suffering nonaccidental trauma (NAT) are at high risk of death. It is unclear whether markers of injury severity for trauma center/system benchmarking such as Injury Severity Score (ISS) adequately characterize this. Our objective was to evaluate mortality prediction of ISS in children with NAT compared with accidental trauma (AT). METHODS:Pediatric patients younger than 16 years from the Pennsylvania state trauma registry 2000 to 2013 were included. Logistic regression predicted mortality from ISS for NAT and AT patients. Multilevel logistic regression determined the association between mortality and ISS while adjusting for age, vital signs, and injury pattern in NAT and AT patients. Similar models were performed for head Abbreviated Injury Scale (AIS). Sensitivity analysis examined impaired functional independence at discharge as an alternate outcome. RESULTS:Fifty thousand five hundred seventy-nine patients were included with 1,866 (3.7%) NAT patients. Nonaccidental trauma patients had a similar rate of mortality at an ISS of 13 as an ISS of 25 for AT patients. Nonaccidental trauma patients also have higher mortality for a given head AIS level (range, 1.2-fold to 5.9-fold higher). Injury Severity Score was a significantly greater predictor of mortality in AT patients (adjusted odds rations [AOR], 1.14; 95% confidence interval [CI], 1.13-1.15; p < 0.01) than NAT patients (AOR, 1.09; 95% CI, 1.07-1.12; p < 0.01) per 1-point ISS increase, while head injury was a significantly greater predictor of mortality in NAT patients (AOR, 3.48; 95% CI, 1.54-8.32; p < 0.01) than AT patients (AOR, 1.21; 95% CI, 0.95-1.45; p = 0.12). Nonaccidental trauma patients had a higher rate of impaired functional independence at any given ISS or head AIS level than AT patients. CONCLUSION:Nonaccidental trauma patients have higher mortality and impaired function at a given ISS/head AIS than AT patients. Conventional ISS thresholds may underestimate risk and head injury is a more important predictor of mortality in the NAT population. These findings should be considered in system performance improvement and benchmarking efforts that rely on ISS for injury characterization. LEVEL OF EVIDENCE:Epidemiologic study, level III.

Dataset Information

Performance of Modified Early Warning Score (MEWS) and Circulation, Respiration, Abdomen, Motor, and Speech (CRAMS) score in trauma severity and in-hospital mortality prediction in multiple trauma patients: a comparison study.

Publications

Performance of Modified Early Warning Score (MEWS) and Circulation, Respiration, Abdomen, Motor, and Speech (CRAMS) score in trauma severity and in-hospital mortality prediction in multiple trauma patients: a comparison study.

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