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      Use of National Early Warning Score for observation for increased risk for clinical deterioration during post-ICU care at a surgical ward

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          Abstract

          Purpose

          Patients transferred from an intensive care unit (ICU) to a general ward are at risk for clinical deterioration. The aim of the study was to determine if an increase in National Early Warning Score (NEWS) value predicted worse outcomes in surgical ward patients previously treated in the ICU.

          Patients and methods

          A retrospective observational study was conducted in a cohort of gastrointestinal surgery patients after transfer from an ICU/high dependency unit (HDU). NEWS values were collected throughout the ward admission. Clinical deterioration was defined by ICU readmission or death. The ability of NEWS to predict clinical deterioration was determined using a linear mixed effect model.

          Results

          We included 124 patients, age 65.9±14.5, 60% males with an ICU Simplified Acute Physiology Score II 33.8±12.7. No patients died unexpectedly at the ward and 20 were readmitted to an ICU/HDU. The NEWS values increased by a mean of 0.15 points per hour (intercept 3.7, P<0.001) before ICU/HDU readmission according to the linear mixed effect model. NEWS at transfer from ICU was the only factor that predicted readmission (OR 1.32; 95% CI 1.01–1.72; P=0.04) at the time of admission to the ward.

          Conclusion

          Clinical deterioration of surgical patients was preceded by an increase in NEWS.

          Related collections

          Most cited references 21

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          A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study.

          To develop and validate a new Simplified Acute Physiology Score, the SAPS II, from a large sample of surgical and medical patients, and to provide a method to convert the score to a probability of hospital mortality. The SAPS II and the probability of hospital mortality were developed and validated using data from consecutive admissions to 137 adult medical and/or surgical intensive care units in 12 countries. The 13,152 patients were randomly divided into developmental (65%) and validation (35%) samples. Patients younger than 18 years, burn patients, coronary care patients, and cardiac surgery patients were excluded. Vital status at hospital discharge. The SAPS II includes only 17 variables: 12 physiology variables, age, type of admission (scheduled surgical, unscheduled surgical, or medical), and three underlying disease variables (acquired immunodeficiency syndrome, metastatic cancer, and hematologic malignancy). Goodness-of-fit tests indicated that the model performed well in the developmental sample and validated well in an independent sample of patients (P = .883 and P = .104 in the developmental and validation samples, respectively). The area under the receiver operating characteristic curve was 0.88 in the developmental sample and 0.86 in the validation sample. The SAPS II, based on a large international sample of patients, provides an estimate of the risk of death without having to specify a primary diagnosis. This is a starting point for future evaluation of the efficiency of intensive care units.
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            A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom--the ACADEMIA study.

            Many patients have physiological deterioration prior to cardiac arrest, death and intensive care unit (ICU) admission, that are detected and documented by medical and nursing staff. Appropriate early response to detected deterioration is likely to benefit patients. In a multi-centre, prospective, observational study over three consecutive days, we studied the incidence of antecedents (serious physiological abnormalities) preceding primary events (defined as in-hospital deaths, cardiac arrests, and unanticipated ICU admissions) in 90 hospitals (69 United Kingdom [UK]; 19 Australia and 2 New Zealand [ANZ]). 68 hospitals reported primary events during the three-day study period (50 United Kingdom, 16 Australia and 2 New Zealand). Data on the availability of ICU/HDU beds and cardiac arrest teams and Medical Emergency Teams were also collected. Of 638 primary events, there were 308 (48.3%) deaths, 141 (22.1%) cardiac arrests, and 189 (29.6%) unplanned ICU admissions. There were differences in the pattern of primary events between the UK and ANZ (P < 0.001). There were proportionally more deaths in the UK (52.3% versus 35.3%) and a higher number of unplanned ICU admissions in ANZ (47.3% versus 24.2%). Sixty percent (383) of primary events had a total of 1032 documented antecedents. The most common antecedents were hypotension and a fall in Glasgow Coma Scale. The proportion of ICU/HDU to general hospital beds was greater in ANZ (0.034 versus 0.016, P < 0.001) and medical emergency teams were more common in ANZ (70.0% versus 27.5%, P = 0.001). The data confirm antecedents are common before death, cardiac arrest, and unanticipated ICU admission. The study also shows differences in patterns of primary events, the provision of ICU/HDU beds and resuscitation teams, between the UK and ANZ. Future research, focusing upon the relationship between service provision and the pattern of primary events, is suggested.
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              Identification of deteriorating patients on general wards; measurement of vital parameters and potential effectiveness of the Modified Early Warning Score.

              Clear and detectable signs of deterioration have been shown to be present in many patients multiple hours before undergoing a serious life-threatening event. To date, few studies are available describing normal practice and the possible effectiveness of structured tools regarding recognition of deteriorating patients. The aim of this study was to describe the current practice in measurement and documentation of vital signs and the possible usefulness of the Modified Early Warning Score (MEWS) to identify deteriorating patients on hospital wards.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                2019
                25 February 2019
                : 15
                : 315-322
                Affiliations
                [1 ]Faculty of Medicine, Riga Stradins University, Riga, Latvia
                [2 ]Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway, pal.klepstad@ 123456ntnu.no
                [3 ]Department of Emergency Medicine and Pre-hospital Services, St Olav University Hospital, Trondheim, Norway
                [4 ]Department of Surgery, Riga Stradins University, Riga, Latvia
                [5 ]Department of Anesthesiology and Intensive Care Medicine, St Olav University Hospital, Trondheim University Hospital, Trondheim, Norway, pal.klepstad@ 123456ntnu.no
                Author notes
                Correspondence: Pål Klepstad, Department of Anesthesiology and Intensive Care Medicine, St Olav University Hospital, Trondheim University Hospital, Prinsesse Kristinas gt 3, 7006 Trondheim, Norway, Tel +47 7 257 5705, Email pal.klepstad@ 123456ntnu.no
                Article
                tcrm-15-315
                10.2147/TCRM.S192630
                6395055
                © 2019 Klepstad et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Categories
                Original Research

                Medicine

                surgical, clinical deterioration, post icu patients, early warning score

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