Early warning scores for detecting deterioration in adult hospital patients: systematic review and critical appraisal of methodology

BMJ, The - Trang m1501
Stephen Gerry1, Timothy Bonnici2, Jacqueline Birks1,3, Shona Kirtley1, Pradeep S. Virdee1, Peter Watkinson4, Gary S. Collins1,3
1Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
2Critical Care Division, University College London Hospitals NHS Trust, London, UK
3Oxford University Hospitals NHS Foundation Trust, Oxford, UK
4Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK

Tóm tắt

AbstractObjectiveTo provide an overview and critical appraisal of early warning scores for adult hospital patients.DesignSystematic review.Data sourcesMedline, CINAHL, PsycInfo, and Embase until June 2019.Eligibility criteria for study selectionStudies describing the development or external validation of an early warning score for adult hospital inpatients.Results13 171 references were screened and 95 articles were included in the review. 11 studies were development only, 23 were development and external validation, and 61 were external validation only. Most early warning scores were developed for use in the United States (n=13/34, 38%) and the United Kingdom (n=10/34, 29%). Death was the most frequent prediction outcome for development studies (n=10/23, 44%) and validation studies (n=66/84, 79%), with different time horizons (the most frequent was 24 hours). The most common predictors were respiratory rate (n=30/34, 88%), heart rate (n=28/34, 83%), oxygen saturation, temperature, and systolic blood pressure (all n=24/34, 71%). Age (n=13/34, 38%) and sex (n=3/34, 9%) were less frequently included. Key details of the analysis populations were often not reported in development studies (n=12/29, 41%) or validation studies (n=33/84, 39%). Small sample sizes and insufficient numbers of event patients were common in model development and external validation studies. Missing data were often discarded, with just one study using multiple imputation. Only nine of the early warning scores that were developed were presented in sufficient detail to allow individualised risk prediction. Internal validation was carried out in 19 studies, but recommended approaches such as bootstrapping or cross validation were rarely used (n=4/19, 22%). Model performance was frequently assessed using discrimination (development n=18/22, 82%; validation n=69/84, 82%), while calibration was seldom assessed (validation n=13/84, 15%). All included studies were rated at high risk of bias.ConclusionsEarly warning scores are widely used prediction models that are often mandated in daily clinical practice to identify early clinical deterioration in hospital patients. However, many early warning scores in clinical use were found to have methodological weaknesses. Early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care. Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice.Systematic review registrationPROSPERO CRD42017053324.

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Tài liệu tham khảo

10.1056/NEJM199102073240604

Donaldson M, Corrigan J, Kohn L. To err is human: building a safer health system. 2000. doi.org/10.17226/9728

10.1136/bmj.322.7285.517

10.1007/s00134-002-1496-y

Morgan R, Lloyd-Williams F, Wright M, Morgan-Warren RJ. An early warning scoring system for detecting developing critical illness. 1997. https://www.scienceopen.com/document?vid=28251d22-8476-40a6-916d-1a34796816e4

Prince Charles Hospital. Modified Early Warning Score (MEWS), Escalation and ISBAR, The Prince Charles Hospital Procedure TPCHS10085.

Deteriorating Patient Programme and National Early Warning System (NEWS) - HSE.ie. https://www.hse.ie/eng/about/who/cspd/ncps/acute-medicine/national-early-warning-score/.

10.1097/CCM.0b013e318250aa5a

10.1016/j.ijnurstu.2016.04.006

National Institute for Health and Care Excellence. Acutely ill adults in hospital: recognising and responding to deterioration. https://www.nice.org.uk/guidance/cg50.

10.1136/bmjopen-2017-019268

Royal College of Physicians . Royal College of Physicians National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. Updated report of a working party. RCP, 2017.

10.1016/j.resuscitation.2014.12.029

10.1136/emermed-2012-202186

10.1136/bmjopen-2018-022528

10.1136/bmj.k1260

10.7326/M14-0697

10.1016/j.jclinepi.2019.02.004

10.1136/bmj.i2416

10.1186/1741-7015-9-103

10.1371/journal.pmed.1001221

10.1016/j.jclinepi.2012.06.020

10.1007/s00134-007-0532-3

10.1513/AnnalsATS.201403-102OC

10.1093/jamia/ocw042

10.1002/sim.7308

10.1016/j.resuscitation.2012.09.024

10.1016/j.jbi.2008.08.010

10.1371/journal.pmed.1001744

10.7326/M18-1376

10.1097/DCC.0b013e318227761d

10.1186/1472-6947-13-28

10.1016/j.resuscitation.2013.12.011

10.1016/j.resuscitation.2011.06.033

10.1097/CCM.0000000000000038

10.1164/rccm.201406-1022OC

10.1016/j.resuscitation.2016.02.005

10.4997/JRCPE.2010.105

10.1093/bja/aem097

10.1186/s13054-018-2194-7

10.1002/jhm.1929

10.1136/bmjopen-2018-022939

10.1016/j.resuscitation.2017.10.026

10.1093/bja/aeh113

10.1016/j.resuscitation.2006.05.008

10.7861/clinmedicine.12-6-501

10.1093/qjmed/hcl112

10.1016/j.resuscitation.2008.02.011

10.1016/j.jbi.2016.09.013

10.1177/1062860612450459

10.1161/JAHA.118.008678

10.1371/journal.pone.0087073

10.1016/j.aucc.2017.11.004

10.1136/bmjgh-2017-000344

10.1016/j.resuscitation.2016.06.012

Perera, 2011, The value of the Modified Early Warning Score and biochemical parameters as predictors of patient outcome in acute medical admissions a prospective study, Acute Med, 10, 126, 10.52964/AMJA.0491

10.1016/j.resuscitation.2010.04.014

10.1016/j.resuscitation.2018.09.021

10.1093/qjmed/hcp149

10.1016/j.resuscitation.2011.03.006

10.1016/j.resuscitation.2018.06.003

10.1371/journal.pone.0059830

10.1016/j.ejim.2016.06.014

10.1016/j.resuscitation.2015.04.020

10.3906/sag-1706-67

10.1097/SLA.0000000000002665

10.1136/bmjopen-2017-019387

10.1016/j.ejim.2017.09.042

10.1007/s00408-018-0105-y

10.1111/j.1742-1241.2008.01986.x

10.1097/CCM.0000000000002648

10.1164/rccm.201604-0854OC

10.1378/chest.12-1605

10.1378/chest.11-1301

10.1093/qjmed/hcs138

10.1016/j.resuscitation.2012.06.017

10.1016/j.hrtlng.2016.08.010

10.1111/jocn.13648

10.1016/j.resuscitation.2013.08.277

10.7861/clinmedicine.9-1-30

10.1002/jhm.2132

10.1136/bmjopen-2017-020269

10.1016/j.gassur.2006.03.008

10.1308/003588406X130615

10.1186/cc10102

10.1016/j.resuscitation.2017.10.028

10.1136/thoraxjnl-2016-208436

10.1016/j.cgh.2017.12.035

10.1016/j.ajem.2015.12.067

10.1016/j.resuscitation.2011.08.022

10.1016/j.resuscitation.2016.02.020

10.15441/ceem.17.268

10.1016/j.jcrc.2017.04.024

10.1002/bjs.10267

10.1371/journal.pone.0151408

10.1016/j.aucc.2019.03.001

10.1016/j.jcrc.2018.07.011

10.1111/ane.12452

10.1016/j.iccn.2010.03.002

10.1093/qjmed/hcy053

10.1016/j.resuscitation.2013.02.007

Opio, 2013, Performance of TOTAL, in medical patients attending a resource-poor hospital in sub-Saharan Africa and a small Irish rural hospital, Acute Med, 12, 135, 10.52964/AMJA.0305

10.1111/aas.13020

10.1016/j.resuscitation.2018.09.026

10.5492/wjccm.v7.i3.39

10.1097/CCM.0000000000003359

10.1016/j.ajem.2017.04.072

10.12788/jhm.2712

10.1016/j.resuscitation.2013.12.017

10.1016/j.trstmh.2009.05.004

10.1016/j.resuscitation.2007.12.004

10.1016/j.resuscitation.2012.12.016

10.1097/CCM.0000000000002000

10.1016/j.ygyno.2016.08.153

10.1111/ijcp.12934

Stark, 2015, An early warning score predicts risk of death after inhospital cardiopulmonary arrest in surgical patients, Am Surg, 81, 916, 10.1177/000313481508101001

10.1371/journal.pone.0105695

10.1093/qjmed/94.10.521

10.6092/1590-8577/2829

10.1111/aas.12277

10.1093/qjmed/hcw229

10.1080/10428194.2017.1376744

10.1016/j.bbmt.2006.12.455

10.1016/j.eururo.2018.08.038

10.1002/14651858.CD005529.pub2

10.1016/j.resuscitation.2014.01.013

10.1186/s12911-015-0186-y

10.1002/sim.6787

10.1002/sim.7992

10.1177/962280218784726

10.2307/2290664

10.1016/j.jclinepi.2009.12.008

10.1177/0962280206074466

10.1002/9781119013563

10.1016/j.jclinepi.2009.03.017

10.1002/sim.4067

10.1097/EDE.0b013e3181a39056

10.1002/sim.5459

10.1093/eurheartj/ehu131

10.1161/CIRCULATIONAHA.115.017719

10.1002/sim.5958

10.1002/sim.6994

10.1002/sim.6152

10.1016/S0895-4356(01)00341-9

10.7326/M14-0698

10.1002/(SICI)1097-0258(19960229)15:4<361::AID-SIM168>3.0.CO;2-4

10.1002/sim.1844

10.1016/j.jclinepi.2015.12.005

10.1186/1472-6947-6-38

10.1007/s10549-011-1818-2

10.1002/sim.5941

10.1097/EDE.0b013e3181c30fb2

10.1186/s41512-019-0046-9

10.12788/jhm.3151

NHS England. National Early Warning Score (NEWS) . https://www.england.nhs.uk/ourwork/clinical-policy/sepsis/nationalearlywarningscore/.

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