Modified Early Warning Score (MEWS) Identifies Critical Illness among Ward Patients in a Resource Restricted Setting in Kampala, Uganda: A Prospective Observational Study

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Abstract

Introduction

Providing optimal critical care in developing countries is limited by lack of recognition of critical illness and lack of essential resources. The Modified Early Warning Score (MEWS), based on physiological parameters, is validated in adult medical and surgical patients as a predictor of mortality. The objective of this study performed in Uganda was to determine the prevalence of critical illness on the wards as defined by the MEWS, to evaluate the MEWS as a predictor of death, and to describe additional risk factors for mortality.

Methods

We conducted a prospective observational study at Mulago National Referral Teaching Hospital in Uganda. We included medical and surgical ward patients over 18 years old, excluding patients discharged the day of enrolment, obstetrical patients, and patients who self-discharged prior to study completion. Over a 72-hour study period, we collected demographic and vital signs, and calculated MEWS; at 7-days we measured outcomes. Patients discharged prior to 7 days were assumed to be alive at study completion. Descriptive and inferential statistical analyses were performed.

Results

Of 452 patients, the median age was 40.5 (IQR 29–54) years, 53.3% were male, 24.3% were HIV positive, and 45.1% had medical diagnoses. MEWS ranged from 0 to 9, with higher scores representing hemodynamic instability. The median MEWS was 2 [IQR 1–3] and the median length of hospital stay was 9 days [IQR 4–24]. In-hospital mortality at 7-days was 5.5%; 41.4% of patients were discharged and 53.1% remained on the ward. Mortality was independently associated with medical admission (OR: 7.17; 95% CI: 2.064–24.930; p = 0.002) and the MEWS ≥ 5 (OR: 5.82; 95% CI: 2.420–13.987; p<0.0001) in the multivariable analysis.

Conclusion

There is a significant burden of critical illness at Mulago Hospital, Uganda. Implementation of the MEWS could provide a useful triage tool to identify patients at greatest risk of death. Future research should include refinement of MEWS for low-resource settings, and development of appropriate interventions for patients identified to be at high risk of death based on early warning scores.

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Most cited references 17

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ViEWS--Towards a national early warning score for detecting adult inpatient deterioration.

David R Prytherch, Gary B Smith, Paul E Schmidt … (2010)

To develop a validated, paper-based, aggregate weighted track and trigger system (AWTTS) that could serve as a template for a national early warning score (EWS) for the detection of patient deterioration. Using existing knowledge of the relationship between physiological data and adverse clinical outcomes, a thorough review of the literature surrounding EWS and physiology, and a previous detailed analysis of published EWSs, we developed a new paper-based EWS - VitalPAC EWS (ViEWS). We applied ViEWS to a large vital signs database (n=198,755 observation sets) collected from 35,585 consecutive, completed acute medical admissions, and also evaluated the comparative performance of 33 other AWTTSs, for a range of outcomes using the area under the receiver-operating characteristics (AUROC) curve. The AUROC (95% CI) for ViEWS using in-hospital mortality with 24h of the observation set was 0.888 (0.880-0.895). The AUROCs (95% CI) for the 33 other AWTTSs tested using the same outcome ranged from 0.803 (0.792-0.815) to 0.850 (0.841-0.859). ViEWS performed better than the 33 other AWTTSs for all outcomes tested. We have developed a simple AWTTS - ViEWS - designed for paper-based application and demonstrated that its performance for predicting mortality (within a range of timescales) is superior to all other published AWTTSs that we tested. We have also developed a tool to provide a relative measure of the number of "triggers" that would be generated at different values of EWS and permits the comparison of the workload generated by different AWTTSs. Copyright 2010 Elsevier Ireland Ltd. All rights reserved.

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A review and analysis of intensive care medicine in the least developed countries.

Martin W Dünser, Inipavudu Baelani, Lundeg Ganbold (2006)

To give critical care clinicians in Western nations a general overview of intensive care medicine in less developed countries and to stimulate institutional or personal initiatives to improve critical care services in the least developed countries. In-depth PubMed search and personal experience of the authors. In view of the eminent burden of disease, prevalence of critically ill patients in the least developed countries is disproportionately high. Despite fundamental logistic (water, electricity, oxygen supply, medical technical equipment, drugs) and financial limitations, intensive care medicine has become a discipline of its own in most nations. Today, many district and regional hospitals have units where severely ill patients are separately cared for, although major intensive care units are only found in large hospitals of urban or metropolitan areas. High workload, low wages, and a high risk of occupational infections with either the human immunodeficiency virus or a hepatitis virus explain burnout syndromes and low motivation in some health care workers. The four most common admission criteria to intensive care units in least developed countries are postsurgical treatment, infectious diseases, trauma, and peripartum maternal or neonatal complications. Logistic and financial limitations, as well as insufficiencies of supporting disciplines (e.g., laboratories, radiology, surgery), poor general health status of patients, and in many cases delayed presentation of severely sick patients to the intensive care unit, contribute to comparably high mortality rates. More studies on the current state of intensive care medicine in least developed countries are needed to provide reasonable aid to improve care of the most severely ill patients in the poorest countries of the world.

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Modified early warning score predicts the need for hospital admission and inhospital mortality.

V C Burch, G Tarr, C Morroni (2008)

The modified early warning score (MEWS) is a useful tool for identifying hospitalised patients in need of a higher level of care and those at risk of inhospital death. Use of the MEWS as a triage tool to identify patients needing hospital admission and those at increased risk of inhospital death has been evaluated only to a limited extent. To evaluate the use of the MEWS as a triage tool to identify medical patients presenting to the emergency department who require admission to hospital and are at increased risk of inhospital death. Physiological parameters were collected from 790 medical patients presenting to the emergency department of a public hospital in Cape Town, South Africa. MEW scores were calculated from the data and multivariate regression analysis was performed to identify independent predictors of hospital admission and inhospital mortality. The proportion of patients admitted and those who died in hospital increased significantly as the MEW score increased (p or =130 beats per minute, respiratory rate > or =30 breaths per minute, temperature > or =38.5 degrees C and an impaired level of consciousness. Independent predictors of inhospital death were: abnormal systolic blood pressure ( or =200 mm Hg), respiratory rate > or =30 breaths per minute and an impaired level of consciousness. The MEWS, specifically five selected parameters, may be used as a rapid, simple triage method to identify medical patients in need of hospital admission and those at increased risk of inhospital death.

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Author and article information

Contributors

Sachin Yende: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 17 March 2016

Publication date Collection: 2016

Volume: 11

Issue: 3

Electronic Location Identifier: e0151408

Affiliations

[1 ]Department of Medicine, McMaster University, Hamilton, Ontario, Canada

[2 ]Department of Anesthesia and Critical Care, Makerere University, Kampala, Uganda

[3 ]Department of Critical Care, McMaster University, Hamilton, Ontario, Canada

[4 ]Department of Medicine, Mulago Hospital, Kampala, Uganda

[5 ]Department of Medicine, Makerere University, Kampala, Uganda

[6 ]Department of Biostatistics, McMaster University, Hamilton, Ontario, Canada

[7 ]Department of Health Research Methodology, McMaster University, Hamilton, Ontario, Canada

[8 ]Department of Medicine, University of Toronto, Toronto, Ontario, Canada

University of Pittsburgh, UNITED STATES

Author notes

Competing Interests: The oximeters used for the study were donated by ProResp, Inc. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.

Conceived and designed the experiments: RK AK MC AFR TO J. Nalyazi IS J. Nakibuuka DC. Performed the experiments: RK AK IS J. Nalyazi. Analyzed the data: RK AB DC TD JW. Contributed reagents/materials/analysis tools: RK TD JW AB. Wrote the paper: RK AK MC AFR TO J. Nakibuuka AB DC. Coordinated research teams at university level: RK AK TO. Recruited and trained team for data collection: RK IS J. Nalyazi.

* E-mail: rebecca.kruisselbrink@ 123456medportal.ca

Article

Publisher ID: PONE-D-15-36104

DOI: 10.1371/journal.pone.0151408

PMC ID: 4795640

PubMed ID: 26986466

SO-VID: f88bf43e-78c4-44b0-ba6c-3c0bf8414ad3

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 17 August 2015

Date accepted : 26 February 2016

Page count

Figures: 3, Tables: 5, Pages: 13

Funding

The authors received no specific funding for this work. The oximeters used for the study were donated by ProResp, Inc. The funder played no role in the design, data collection, analysis, interpretation, or write-up of this study. Dr. Crowther is funded by the Heart and Stroke Foundation of Canada. Dr. Cook holds a Research Chair of the Canadian Institutes of Health Research.

Custom metadata

Data Availability All relevant data are within the paper and its Supporting Information files.