Does the Early Warning Score measured in the Emergency Department predict the need for life-saving intervention?

Date First Published:
June 21, 2016
Last Updated:
August 28, 2016
Report by:
James van Oppen, SHO in Emergency Medicine (Queen's Medical Centre, Nottingham)
Search checked by:
Kirsty Challen, Queen's Medical Centre, Nottingham
Three-Part Question:
In [non-trauma adult emergency department patients] does the initial [Modified Early Warning Score] predict [ICU admission in the first 48 hours]?
Search Strategy:
EMBASE 1974 to 2016 June 20 using the OVID interface.
MEDLINE 1966 to 2016 June 20 using the PubMed interface.
Search Details:
( (early warning score) OR (NEWS) OR (EWS) OR (MEWS) )
AND
(emergency department)

Limited to patients aged over 17 and to English language.
Outcome:
Altogether 144 papers were found in EMBASE and 150 in PubMed, of which 14 titles were relevant to the question. After discarding irrelevant abstracts and papers, 4 relevant articles were summarised in the table.
Relevant Paper(s):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
Nurse-administered early warning score system can be used for emergency department triage. Christensen D. Jensen N.M. Maaloe R. Rudolph S.S. Belhage B. Perrild H. 2011 Denmark ED patients: Age 2-98, medical and surgical 2b: Retrospective cohort ICU admission in first 48 hours. RR 4.1 (1.5-10.9), PPV 6%, NPV 98% for BEWS >=5. Sample taken from a streamed cohort ('red'), of which half excluded. BEWS cut-off (5) based on local protocol, with no subset analysis possible.
Death in first 48 hours. RR 20.3 (6.9-60.1), PPV 16%, NPV 99% for BEWS >=5
Utility of a single early warning score in patients with sepsis in the emergency department. Corfield A.R. Lees F. Zealley I. Houston G. Dickie S. Ward K. McGuffie C. 2014 UK 2003 ED patients aged >16 with suspected sepsis who were admitted for at least 2 days (or died within 2 days) to 20 Scottish hospitals 2b: Retrospective cohort ICU admission in first 48 hours Significantly higher admission NEWS in patients who went to ICU, predicted by NEWS >=7 (27% admitted to ICU) Data collection stopped early (though large sample completely analysed). Use of poorly-evidence age-adjusted NEWS. Patients discharged <2 days not considered.
30-day in-hospital mortality Higher NEWS associated with higher mortality.
Performance of the maximum modified early warning score to predict the need for higher care utilization among admitted emergency department patients. Heitz CR, Gaillard JP, Blumstein H, Case D, Messick C, Miller CD. 2010 USA 300 randomly selected adult ED patients, excluding trauma and cardiology 2b: Retrospective cohort Mortality or admission to intermediate or intensive care within 24 hours. All MEWS max >9 patients died or were admitted to higher care. Proposed MEWS max cut-off >=4 gave sensitivity 62%, PPV 52% Excluded cardiological presentations (disease-specific risk tool). Carried-forward rather than excluded absent data. Variable use of MEWS initial/max/admit
Do physiological scoring and a novel point of care metabolic screen predict 48-h outcome in admissions from the emergency department resuscitation area?. Jafar A.J.N. Junghans C. Kwok C.S. Hymers C. Monk K.J. Gold E. Harris T.R. 2016 UK 200 resuscitation room adult patients excluding trauma 1b: Inception cohort study New organ failure, death or escalation of care within 48hrs. MEWS predicted 48hr death (OR 1.32) and organ failure (OR 1.19) but not care escalation. All who died had MEWS >= 4 Unclear cut-off MEWS in OR calculation. Does not study patients admitted to ICU directly from ED.
Author Commentary:
High Modified Early Warning Scores predict hospital mortality reasonably well but there is no evidence as yet for utility in the Emergency Department in terms of patient prioritisation.
References:
  1. Christensen D. Jensen N.M. Maaloe R. Rudolph S.S. Belhage B. Perrild H.. Nurse-administered early warning score system can be used for emergency department triage.
  2. Corfield A.R. Lees F. Zealley I. Houston G. Dickie S. Ward K. McGuffie C.. Utility of a single early warning score in patients with sepsis in the emergency department.
  3. Heitz CR, Gaillard JP, Blumstein H, Case D, Messick C, Miller CD.. Performance of the maximum modified early warning score to predict the need for higher care utilization among admitted emergency department patients.
  4. Jafar A.J.N. Junghans C. Kwok C.S. Hymers C. Monk K.J. Gold E. Harris T.R.. Do physiological scoring and a novel point of care metabolic screen predict 48-h outcome in admissions from the emergency department resuscitation area?.