Downloaded from http://emj.bmj.com/ on August 23, 2017 - Published by group.bmj.com EMJ Online First, published on March 9, 2013 as 10.1136/emermed-2012-202186 Original article Utility of a single early warning score in patients with sepsis in the emergency department Alasdair R Corfield,1 Fiona Lees,2 Ian Zealley,3 Gordon Houston,4 Sarah Dickie,5 Kirsty Ward,2 Crawford McGuffie,5 on behalf of the Scottish Trauma Audit Group Sepsis Steering Group

▸ Additional material is ABSTRACT physiological parameters, a composite score can be published online only. To view Background An important element in improving the assigned to a patient, allowing early identification please visit the journal online fi (http://dx.doi.org/10.1136/ care of patients with sepsis is early identi cation and of patients who are at risk of critical illness. EWS emermed-2012-202186). early intervention. Early warning score (EWS) systems were initially established to assist in the manage- allow earlier identification of physiological deterioration. ment of patients in the general ward setting.13 14 1Emergency Department, Royal Alexandra Hospital, Paisley, UK A standardised national EWS (NEWS) has been proposed More recently there has been interest in the use of 2Information Services Division, for use across the National Health Service in the UK. EWS in the emergency department (ED) with National Services Scotland, Aim To determine whether a single NEWS on reports from single centres,15 16 although their use Glasgow, Scotland, UK emergency department (ED) arrival is a predictor of in the ED remains controversial.17 The use of a 3Radiology Department, Ninewells Hospital, Dundee, outcome, either in-hospital death within 30 days or standard single national EWS (NEWS) across the Scotland, UK intensive care unit (ICU) admission within 2 days, in National Health Service (NHS) in the UK has been 4Anaesthetic Department, patients with sepsis. recommended to improve patient care.18 Crosshouse Hospital, Methods Data were collected over a 3-month period In this study, we aimed to evaluate an EWS in a Kilmarnock, Scotland, UK as part of a national audit in 20 EDs in Scotland. All national cohort of patients with sepsis presenting to 5Emergency Department, Crosshouse Hospital, adult patients who were admitted for at least 2 days or EDs, to determine whether a single EWS in the ED Kilmarnock, Scotland, UK who died within 2 days were screened for sepsis criteria. was a useful predictor of outcome, either death or Patients with systemic inflammatory response syndrome intensive care unit (ICU) admission. Correspondence to fi criteria were included. An EWS was calculated based on Dr Alasdair R Cor eld, initial physiological observations made in the ED using Emergency Department, METHODOLOGY Royal Alexandra Hospital, the NEWS. Paisley PA2 9PN, UK; Results Complete data were available for 2003 Study population a.corfi[email protected] patients. Each rise in NEWS category was associated Data were collected over a 3-month period with an increased risk of mortality when compared to between March and May 2009 as part of the Received 28 November 2012 the lowest category (5–6: OR 1.95, 95% CI 1.21 to Scottish Trauma Audit Group (STAG) Sepsis Audit. Revised 7 February 2013 Twenty of the 25 mainland district general and Accepted 12 February 2013 3.14), (7–8: OR 2.26, 95% CI 1.42 to 3.61), (9–20: OR 5.64, 95% CI 3.70 to 8.60). This was also the case for teaching hospital EDs in Scotland participated in the combined outcome (ICU and/or mortality). the audit (Appendix 1). Conclusions An increased NEWS on arrival at ED is Adult patients (>16 years) attending as an emer- fi associated with higher odds of adverse outcome among gency were identi ed prospectively from ED or patients with sepsis. The use of NEWS could facilitate admission unit records. Hospital information patient pathways to ensure triage to a high acuity area systems were then interrogated to ascertain of the ED and senior clinician involvement at an early whether the patient had an inpatient stay of at least fi stage. 2 days. Patients who died within the rst 2 days, and who therefore may have been omitted from data collection, were identified retrospectively using General Register Office Scotland records. INTRODUCTION Patients who had an obviously non-infective cause Sepsis is defined as a systemic inflammatory for attendance such as acute cardiac ischaemia, response syndrome, provoked by an infection.12 trauma or stroke were excluded. This process iden- Sepsis continues to be a major cause of morbidity tified 27 046 patients who required case note and mortality in developed and developing coun- review in order to determine the presence of tries,34and is a significant burden on healthcare ‘sepsis’ criteria. systems in these countries.5 An important element The Surviving Sepsis Campaign Guidelines6 in improving the care of patients with sepsis is defined sepsis as ‘infection, documented or sus- early identification and early intervention, which pected’ and the presence of some of a number of has been shown to improve outcomes.67 general variables indicating physiological derange- Physiological deterioration often precedes clinical ment. Patients were included in the audit if they deterioration as patients develop critical illness.89 had: (a) a suspicion or confirmation of infection Recognition of this led to the development of within 2 days of attendance; and (b) two or more fi To cite: Cor eld AR, Lees F, the concept of the patient at risk and medical of the following physiological derangements: tem- Zealley I, et al. Emerg Med J 10–12 Published Online First: emergency teams. Early warning score (EWS) perature >38.3°C or <36°C; heart rate >90 bpm; [please include Day Month systems were then further developed to allow respiratory rate >20/min; white cell count of Year] doi:10.1136/emermed- earlier identification of physiological deterioration. >12 000/μl or <4000/μl or >10% immature 2012-202186 By assigning numerical values to various forms; acutely altered mental status; systolic blood

CorCopyrightfield AR, et al. Emerg Article Med Jauthor2013;0:1– (or6. doi:10.1136/emermed-2012-202186 their employer) 2013. Produced by BMJ Publishing Group Ltd under licence. 1 Downloaded from http://emj.bmj.com/ on August 23, 2017 - Published by group.bmj.com

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Of the 5285 patients identified, complete data were collected for 3890 (74%). Age, gender, length of stay, critical care attend- ance and outcome were recorded for all patients who met the sepsis criteria (N=5285). For each of these variables, the sample population (N=3890) was representative.19 For the purposes of this analysis, only patients who presented with or developed signs of sepsis prior to leaving the ED were included (N=2489). In this sample of 2489 patients, patients were excluded if they did not have a full set of observations made as part of their first set of observations. This resulted in a final sample size of 2003 patients (figure 1)

Definition of NEWS The NEWS contains six physiological parameters (table 1), each of which is assigned a value of between 0 and 3 along with an additional parameter for supplemental oxygen, which scores 0 or 2. The score for each of the seven parameters is summed to calculate the NEWS which may range between 0 and 20; the higher the score, the greater the deviation from normality. The NEWS is based on previous similar scoring systems.11 12 15 Observations taken on attendance were used to calculate the NEWS. For some analyses patients were divided into four cat- egories based on their total score: 0–4, 5–6, 7–8, 9–20. This analysis grouping was based on the distribution of NEWS scores to give four approximately equal sized groups for comparison. In order to assess the effect of age on all endpoints an age adjusted NEWS was also calculated (+0 points for <50 years, +2 points for 50–70 years, +3 points for >70 years).20 The NEWS uses an AVPU (alert, voice, pain, unresponsive) score to define the patient’s level of consciousness. Where an AVPU score was unavailable, the Glasgow Coma Score (GCS) Figure 1 Patient study inclusion pathway. ED, emergency was considered to be an acceptable alternative (GCS 15=A, department. GCS <15=V,P,U). pressure <90 mm Hg; and blood glucose >7.7 mmol/l (in the Endpoints absence of diabetes). Primary endpoints were ICU admission within 2 days of attend- ance and 30-day mortality (in hospital). A combined endpoint of ICU admission and/or mortality was also assessed. Data collection A total of 5285 patients fulfilled the entry criteria. Data were Statistical analysis collected retrospectively by local audit coordinators at each hos- All analyses were carried out using SPSS V.17.0 for MS pital on a variety of demographic, physiological, process and Windows. outcome variables using a standardised proforma. Where avail- Differences between medians were tested using the Mann– able, patient observations taken on attendance were recorded. Whitney U test. ORs for each endpoint were estimated using All patients were followed to discharge or death. The difficulties logistic regression, with NEWS group as the independent vari- encountered in obtaining and extracting data from case notes able and age as a continuous covariate. Receiver operating were such that a pragmatic decision was taken to stop data col- characteristic (ROC) curves plotting sensitivity (true positives) lection in July 2010. against 1-specificity (false positives) were used to measure the

Table 1 National early warning score NHS early warning score

32 1 0 1 2 3

Respiration rate ≤89–11 12–20 21–24 ≥25 Oxygen saturations ≤91 92–93 94–95 ≥96 Supplemental oxygen Yes No Temperature ≤35° 35.1–36° 36.1–38° 38.1–39° ≥39.1° Systolic blood pressure ≤90 91–100 101–110 111–219 ≥220 Pulse ≤40 41–50 51–90 91–110 111–130 ≥131 Conscious level A V,P,U A, alert; NHS, National Health Service; V,P,U, voice, pain, unresponsive.

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Original article

Table 2 Median age and NEWS by sex, admission to ICU within 2 days, 30-day outcome and combined endpoint (ICU and/or mortality) Patient age NEWS

No. patients % patients Median IQR p Value Median IQR p Value

All patients 2003 100 72 59–81 – 74–9 – Sex Male 949 47 71 59–79 0.08 7 4–9 0.13 Female 1054 53 72 59–82 6 4–9 ICU (within 2 days) No ICU 1890 94 72 59–81 0.00 6 4–9 0.00 ICU 113 6 61 49–70 9 6–12 Outcome (30 days) Alive 1706 85 70 57–80 0.00 6 4–8 0.00 Dead 297 15 77 69–85 9 6–12 Combined (ICU and/or mortality) No 1627 81 71 58–80 0.00 6 4–8 0.00 Yes 376 19 74 63–83 9 6–12 ICU, intensive care unit; NEWS, national early warning score (based on first set of observations taken in the emergency department).

accuracy of NEWS and age adjusted NEWS in predicting end- with a NEWS of 0–4, but patients with a NEWS of 7–8or point. The associated ROC area under the curve was also calcu- 9–20 were: (7–8: OR 2.01, 95% CI 1.02 to 3.97), (9–20: OR lated for each endpoint. 5.76, 95% CI 3.22 to 10.31). Statistical significance was set at p<0.05 for all analyses. All Patients aged 50–70 years were significantly more at risk of results are reported along with their associated 95% CIs and p dying within 30 days than patients aged <50 (OR 5.38, 95% CI values. 2.56 to 11.29), as were patients aged >70 (OR 9.42, 95% CI All data were anonymised prior to submission to the STAG 4.60 to 19.32). central team at the Information Services Division (ISD). The ROC curves plotting sensitivity (true positives) against Caldicott Guardian for each participating Health Board was 1-specificity (false positives) were used to measure the accuracy informed of the audit and the processes involved. ISD, as part of NEWS and age adjusted NEWS in predicting each endpoint of NHS National Services Scotland, has adopted a policy to (figure 2). With regard to ICU admission, adjusting the NEWS protect personal information. Personal health information is for age decreased the area under the curve from 0.67 to 0.61. held securely, and managed according to data protection Adjusting for age had little effect on the combined endpoint of regulations. ICU/mortality (0.71 vs 0.70). When using the NEWS to predict

RESULTS A total of 2003 patients were available for analysis; 949 (47%) Table 3 Number and percentage of patients admitted to ICU were male and 1054 (53%) female. The median age of patients within 2 days, patients who died within 30 days, and patients who was 72 years, with no significant difference in age between men were admitted to ICU and/or died, by NEWS group and women. The median NEWS for all patients was 7; there No Yes was no significant difference between men and women. The dis- EWS score No. patients % patients No. patients % patients tribution of NEWS recorded for patients on attendance is illu- strated in online supplementary figure S3. ICU (within 2 days) Differences in age and NEWS for each endpoint are shown in 0–4 512 96.8 17 3.2 table 2. Patients who were admitted to the ICU within 2 days of 5–6 445 96.9 14 3.1 attendance had a median age of 61 and were significantly 7–8 430 95.6 20 4.4 younger than those who were not (61 vs 72, p<0.05). ICU 9–20 503 89.0 62 11.0 patients also had a significantly higher NEWS than the non-ICU Total 1890 94.4 113 5.6 group (9 vs 6, p<0.05). Patients who died within 30 days were Mortality (30 days) significantly older than those who did not (77 vs 70, p<0.05) 0–4 500 94.5 29 5.5 and had a higher NEWS (9 vs 6, p<0.05). 5–6 407 88.7 52 11.3 Absolute numbers in each NEWS category are given (table 3) 7–8 390 86.7 60 13.3 and age adjusted ORs were estimated for each NEWS category 9–20 409 72.4 156 27.6 (table 4). Each rise in NEWS category was associated with an Total 1706 85.2 297 14.8 increased risk of mortality when compared to the lowest cat- Combined (ICU and/or mortality) egory (0–4): (5–6: OR 1.95, 95% CI 1.21 to 3.14), (7–8: OR 0–4 487 92.1 42 7.9 2.26, 95% CI 1.42 to 3.61), (9–20: OR 5.64, 95% CI 3.70 to 5–6 397 86.5 62 13.5 8.60). This was also the case for the combined outcome (ICU 7–8 375 83.3 75 16.7 and/or mortality): (5–6: OR 1.72, 95% CI 1.14 to 2.60), (7–8: 9–20 368 65.1 197 34.9 OR 2.17, 95% CI 1.45 to 3.25), (9–20: OR 5.78, 95% CI 4.02 Total 1627 81.2 376 18.8 to 8.31). Patients with a NEWS of 5–6 were not associated with ICU, intensive care unit; NEWS, national early warning score. an increased risk in ICU admission when compared to those

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Table 4 Age adjusted ORs for each NEWS category for admission to ICU within 2 days, 30-day mortality, and combined endpoint (ICU and/or mortality) 95% CI Variable Reference group Level p Value OR Lower Upper

ICU (within 2 days) Age (continuous covariate) 0.00 0.96 0.95 0.97 NEWS category 0–4 0.00 5–6 0.59 1.22 0.59 2.54 7–8 0.04 2.01 1.02 3.97 9–20 0.00 5.76 3.22 10.31 Mortality (30 days) Age (continuous covariate) 0.00 1.04 1.03 1.05 NEWS category 0–4 0.00 5–6 0.01 1.95 1.21 3.14 7–8 0.00 2.26 1.42 3.61 9–20 0.00 5.64 3.70 8.60 Combined (ICU and/or mortality) Age (continuous covariate) 0.01 1.01 1.00 1.02 NEWS category 0–4 0.00 5–6 0.01 1.72 1.14 2.60 7–8 0.00 2.17 1.45 3.25 9–20 0.00 5.78 4.02 8.31 NEWS categories: 0–4 (N=529), 5–6 (N=459), 7–8 (N=450), 9–20 (N=565). ICU, intensive care unit; NEWS, national early warning score.

30-day mortality, the area under the curve was increased recognised that a standardised EWS, used across the NHS could from 0.70 to 0.73 by adjusting for age, but this increase was provide a step change in improving clinical outcomes in people not significant. with acute illness.27 A standardised NHS-wide NEWS would have NEWS ROC characteristics for the combined endpoint of advantages with regard to reliability of completion and promoting ICU and/or mortality are presented in table 5. The positive pre- continuity throughout the patient’s journey. However given the dictive value illustrates that 27% of patients with a NEWS of size of the NHS and diversity of work which is undertaken, any ≥7 were admitted to the ICU within 2 days and/or died within such tool is unlikely to perform well across all patient groups. This 30 days. For a NEWS of ≥9 this rose to 35%. may give rise to false positives, or patients being falsely reassured by false negatives. There is some evidence that the use of EWS can DISCUSSION predict need for hospital admission and mortality in ED Systems for the triaging of patients are well established in emer- patients.28 29 However, Roland and Coates suggested, in a recent gency medicine. The concept of triage dates back to the commentary, that any such system proposed for the ED should be Napoleonic wars, and at its core is the assessment of a patient by validated in ED patients.17 Other scoring systems such as the mor- an experienced person to determine the priority and timescale of tality in emergency departments sepsis (MEDS) score have been treatment and intervention based on the severity of their condi- suggested as useful predictors of outcome in the ED.28 Although tion. Over the years the concept of triage has become more scien- these scoring systems have a higher sensitivity, they rely on some tific and a variety of tools utilising physiological data and laboratory investigations which necessitate a delay in obtaining the algorithms have been developed to assist with effective triage. results. The NEWS also has the advantage that it is proposed to be It is well recognised from large national audits that existing used universally; therefore a diagnosis for the patient is not systems failed to recognise or respond appropriately to early signs required in order to use the tool. of critical illness.21 22 This in turn may lead to significant morbidity This study has several potential limitations. Among the group or mortality for the patient. Many such patients exhibit physio- of patients selected for this analysis (N=2489), only 2003 could logical derangement hours before their deterioration was detected be assessed due to missing observations on attendance. This by clinical staff and hospital systems.9 Evidence suggests that a large missing information was generally only one or two of the six proportion of ward based patients receive substandard care prior to required physiological data points, but prevented an accurate ICU admission and that 20–40% of such admissions are potentially calculation of a NEWS value. No information is available for avoidable.23 This number has decreased over the last 15 years, but patients who attended and were discharged within 2 days of remains significant.24 attendance. This group should by virtue of the fact that they are In response to such findings, EWS have become increasingly discharged within 2 days have a much lower incidence of signifi- prevalent across medicine globally over the past two decades to cant illness. Our data only included ICU admission within identify the deteriorating patient and to activate an appropriate 2 days, so we are unable to comment on patients who may have response, the so called ‘track and trigger’ systems. Within the been admitted to the ICU later in their hospital admission. UK, there are many such systems in place across the NHS but However, for our target group of ED patients at presentation it most lack rigorous evaluation and validation.25 A recent postal could be argued that ICU admission more than 2 days after ED survey also highlighted that there is great variability in how such attendance is less linked to features of illness present at initial EWS are utilised in EDs across the NHS.26 ED presentation. The Royal College of Physicians of London, in its 2007 report We only collected information on in-hospital mortality. No ‘Acute medicine: the right person, in the right setting—first time’, attempt was made to follow-up patients after discharge from

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Table 5 NEWS receiver operating curve (ROC) characteristics for combined endpoint (ICU and/or mortality) Positive Negative NEWS predictive predictive Youden’s ≥ Sensitivity Specificity value value index

0 1.000 0.000 0.188 – 0.000 1 0.995 0.007 0.188 0.857 0.002 2 0.979 0.054 0.193 0.917 0.033 3 0.960 0.110 0.200 0.923 0.070 4 0.936 0.199 0.213 0.931 0.135 5 0.888 0.299 0.227 0.921 0.188 6 0.816 0.427 0.248 0.910 0.244 7 0.723 0.543 0.268 0.895 0.267 8 0.617 0.666 0.299 0.883 0.283 9 0.524 0.774 0.349 0.876 0.298 10 0.431 0.848 0.395 0.866 0.278 11 0.322 0.904 0.437 0.852 0.226 12 0.250 0.950 0.537 0.846 0.200 13 0.184 0.971 0.595 0.837 0.155 14 0.106 0.986 0.635 0.827 0.092 15 0.061 0.995 0.742 0.821 0.056 16 0.029 0.998 0.733 0.816 0.027 17 0.016 0.998 0.667 0.814 0.014 18 0.008 0.999 0.600 0.813 0.007 19 0.005 1.000 1.000 0.813 0.005 20 0.003 1.000 1.000 0.813 0.003 ICU, intensive care unit; NEWS, national early warning score.

hospital, so any patients who were discharged and died at home within 30 days are not included in our data. Our study did not record any information on patients’ co-morbidity. The data presented in this study show there is some promise for the use of a single EWS in the ED, when applied to a large cohort of patients with a potentially serious condition. Among patients who have sepsis, a single EWS of ≥7 in the ED indi- cates a 27% chance of requiring admission to the ICU within 48 h and/or death within 30 days. At this level, an argument can be made for mandating senior ED clinical review for all these patients. In addition, there could also be an argument for man- datory review by a critical care outreach team, regardless of ultimate destination. Our study only looked at patients with sepsis, so the generalisability to other serious conditions is unknown. However, given that sepsis is a common condition with potential significant morbidity and mortality but that also has a heterogeneous presentation, suggests that this approach may be more widely applicable and this potential warrants further research. This concept also lends itself to extension to prehospital care and ambulance services. Most ambulance services routinely collect the physiological data required to calculate an EWS score, and indeed some ambulance services have incorporated this into electronic patient record forms. An agreed EWS score of greater than a specific level could be used as a trigger for ambulance service pre-alert of a receiving ED. Point of care lactate testing has also been shown to be feasible in the ED.30 Serum lactate is recognised as an independent predictor of mortality in sepsis31 and there may be potential for combining Figure 2 National early warning score (NEWS) and age adjusted EWS systems and point of care to further improve diagnostic accur- NEWS receiver operating curve (ROC) for: (A) admission to intensive acy for patients at risk of adverse outcomes in sepsis.32 care unit (ICU) within 2 days; (B) 30-day mortality; (C) combined endpoint (ICU and/or mortality). Collaborators Scottish Trauma Audit Group Steering Committee.

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Utility of a single early warning score in patients with sepsis in the emergency department Alasdair R Corfield, Fiona Lees, Ian Zealley, Gordon Houston, Sarah Dickie, Kirsty Ward, Crawford McGuffie and on behalf of the Scottish Trauma Audit Group Sepsis Steering Group

Emerg Med J published online March 9, 2013

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