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Prehospital Point-Of-Care Lactate Increases the Prognostic Accuracy of National Early Warning Score 2 for Early Risk Stratification of Mortality: Results of a Multicenter, Observational Study.

ABSTRACT: The objective of this study was to assess whether the use of prehospital lactate (pLA) can increase the prognostic accuracy of the National Early Warning Score 2 (NEWS2) to detect the risk of death within 48 h. A prospective, multicenter study in adults treated consecutively by the emergency medical services (EMS) included six advanced life support (ALS) services and five hospitals. Patients were assigned to one of four groups according to their risk of mortality (low, low-medium, medium, and high), as determined by the NEWS2 score. For each group, the validity of pLA in our cohort was assessed by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. In this study, 3081 participants with a median age of 69 years (Interquartile range (IQR): 54-81) were included. The two-day mortality was 4.4% (137 cases). The scale derived from the implementation of the pLA improved the capacity of the NEWS2 to discriminate low risk of mortality, with an AUC of 0.910 (95% CI: 0.87-0.94; p < 0.001). The risk stratification provided by the NEWS2 can be improved by incorporating pLA measurement to more accurately predict the risk of mortality in patients with low risk.

SUBMITTER: Martin-Rodriguez F

PROVIDER: S-EPMC7231108 | biostudies-literature | 2020 Apr

REPOSITORIES: biostudies-literature

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Prehospital Point-Of-Care Lactate Increases the Prognostic Accuracy of National Early Warning Score 2 for Early Risk Stratification of Mortality: Results of a Multicenter, Observational Study.

Martín-Rodríguez Francisco F López-Izquierdo Raúl R Delgado Benito Juan F JF Sanz-García Ancor A Del Pozo Vegas Carlos C Castro Villamor Miguel Ángel MÁ Martín-Conty José Luis JL Ortega Guillermo J GJ

Journal of clinical medicine 20200418 4

The objective of this study was to assess whether the use of prehospital lactate (pLA) can increase the prognostic accuracy of the National Early Warning Score 2 (NEWS2) to detect the risk of death within 48 h. A prospective, multicenter study in adults treated consecutively by the emergency medical services (EMS) included six advanced life support (ALS) services and five hospitals. Patients were assigned to one of four groups according to their risk of mortality (low, low-medium, medium, and hi ...[more]

PMID: 32325636

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Project description:BackgroundMany studies have explored the accuracy of the National Early Warning Score 2 (NEWS2) in predicting mortality in prehospital and emergency settings, but their findings are inconsistent. Whether NEWS2 is reliable for the pre-examination and triage of patients in prehospital settings and emergency departments remains debatable. Hence, this study aimed to evaluate the accuracy of NEWS2 in predicting mortality in prehospital settings and emergency departments.MethodsWe searched PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wan Fang Data, Vip Database and SinoMed from the inception of each database to January 2023. The inclusion criteria: (I) patients in the prehospital settings or emergency departments; (II) the NEWS2 for predicting 2-day mortality, 30-day mortality, and in-hospital mortality; (III) sufficient data, such as sensitivity, specificity, overall survival, and deaths, were provided for the study; (IV) the type of study was accuracy prediction study. Two authors independently extracted data, including authors, year of publication, country of origin, study design, sample size, threshold cutoff values of NEWS2, and mortality. The PROBAST was used to assess the risk of bias in the included studies.ResultsThirty studies with 185,835 participants were included. Among the 30 included studies, 13 have a high risk of bias, and 17 have a low risk of bias. The pooled sensitivity, specificity and AUC of 2-day mortality (early mortality), 30-day mortality and in-hospital mortality were 0.81 vs. 0.76 vs. 0.72 (95% CI: 0.61, 0.80), 0.81 vs. 0.69 vs. 0.78 (95% CI: 0.49, 0.93) and 0.88 vs. 0.80 vs. 0.78 (95% CI: 0.74, 0.82), respectively.ConclusionsNEWS2 has excellent sensitivity and specificity in predicting early mortality in patients in the prehospitals setting and emergency departments. Nonetheless, it has poor performance in predicting in-hospital mortality and 30-day mortality. Our findings underpin the use of NEWS2 as a pre-examination and triage tool to predict early death in the prehospital settings and emergency departments. To improve the predictive accuracy, it should be used to monitor patients continuously rather than at a single point-in-time.

Project description: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 < .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.

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:BackgroundAcute respiratory failure occurs frequently in hospitalized patients and often starts before ICU admission. A risk stratification tool to predict mortality and risk for mechanical ventilation (MV) may allow for earlier evaluation and intervention. We developed and validated an automated electronic health record (EHR)-based model-Accurate Prediction of Prolonged Ventilation (APPROVE)-to identify patients at risk of death or respiratory failure requiring >= 48 h of MV.MethodsThis was an observational study of adults admitted to four hospitals in 2013 or a fifth hospital in 2017. Clinical data were extracted from the EHRs. The 2013 patients were randomly split 50:50 into a derivation/validation cohort. The qualifying event was death or intubation leading to MV >= 48 h. Random forest method was used in model derivation. APPROVE was calculated retrospectively whenever data were available in 2013, and prospectively every 4 h after hospital admission in 2017. The Modified Early Warning Score (MEWS) and National Early Warning Score (NEWS) were calculated at the same times as APPROVE. Clinicians were not alerted except for APPROVE in 2017cohort.ResultsThere were 68,775 admissions in 2013 and 2258 in 2017. APPROVE had an area under the receiver operator curve of 0.87 (95% CI 0.85-0.88) in 2013 and 0.90 (95% CI 0.84-0.95) in 2017, which is significantly better than the MEWS and NEWS in 2013 but similar to the MEWS and NEWS in 2017. At a threshold of > 0.25, APPROVE had similar sensitivity and positive predictive value (PPV) (sensitivity 63% and PPV 21% in 2013 vs 64% and 16%, respectively, in 2017). Compared to APPROVE in 2013, at a threshold to achieve comparable PPV (19% at MEWS > 4 and 22% at NEWS > 6), the MEWS and NEWS had lower sensitivity (16% for MEWS and NEWS). Similarly in 2017, at a comparable sensitivity threshold (64% for APPROVE > 0.25 and 67% for MEWS and NEWS > 4), more patients who triggered an alert developed the event with APPROVE (PPV 16%) while achieving a lower false positive rate (FPR 5%) compared to the MEWS (PPV 7%, FPR 14%) and NEWS (PPV 4%, FPR 25%).ConclusionsAn automated EHR model to identify patients at high risk of MV or death was validated retrospectively and prospectively, and was determined to be feasible for real-time risk identification.Trial registrationClinicalTrials.gov, NCT02488174 . Registered on 18 March 2015.

Project description:BackgroundModified Early Warning Score (MEWS) and National Early Warning Score (NEWS) are widely used in predicting the mortality and intensive care unit (ICU) admission of critically ill patients. This study was conducted to evaluate and compare the prognostic value of NEWS and MEWS for predicting ICU readmission, mortality, and related outcomes in critically ill patients at the time of ICU discharge.MethodsThis multicenter, prospective, observational study was conducted over a year, from April 2019 to March 2020, in the general ICUs of two university-affiliated hospitals in Northwest Iran. MEWS and NEWS were compared based on the patients' outcomes (including mortality, ICU readmission, time to readmission, discharge type, mechanical ventilation (MV), MV duration, and multiple organ failure after readmission) using the univariable and multivariable binary logistic regression. The receiver operating characteristic (ROC) curve was used to determine the outcome predictability of MEWS and NEWS.ResultsA total of 410 ICU patients were enrolled in this study. According to multivariable logistic regression analysis, both MEWS and NEWS were predictors of ICU readmission, time to readmission, MV status after readmission, MV duration, and multiple organ failure after readmission. The area under the ROC curve (AUC) for predicting mortality was 0.91 (95% CI = 0.88-0.94, P < 0.0001) for the NEWS and 0.88 (95% CI = 0.84-0.91, P < 0.0001) for the MEWS. There was no significant difference between the AUC of the NEWS and the MEWS for predicting mortality (P = 0.082). However, for ICU readmission (0.84 vs. 0.71), time to readmission (0.82 vs. 0.67), MV after readmission (0.83 vs. 0.72), MV duration (0.81 vs. 0.67), and multiple organ failure (0.833 vs. 0.710), the AUCs of MEWS were significantly greater (P < 0.001).ConclusionNational Early Warning Score and MEWS values of >4 demonstrated high sensitivity and specificity in identifying the risk of mortality for the patients' discharge from ICU. However, we found that the MEWS showed superiority over the NEWS score in predicting other outcomes. Eventually, MEWS could be considered an efficient prediction score for morbidity and mortality of critically ill patients.

Dataset Information

Prehospital Point-Of-Care Lactate Increases the Prognostic Accuracy of National Early Warning Score 2 for Early Risk Stratification of Mortality: Results of a Multicenter, Observational Study.

Publications

Prehospital Point-Of-Care Lactate Increases the Prognostic Accuracy of National Early Warning Score 2 for Early Risk Stratification of Mortality: Results of a Multicenter, Observational Study.

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