Original article 1
Modified Early Warning Score and VitalPac Early Warning Score in geriatric patients admitted to emergency department Zerrin Defne Dundara, Mehmet Ergina, Mehmet A. Karamercanb, Kursat Ayrancia, Tamer Colaka, Alpay Tuncara, Basar Candera and Mehmet Gula Objective The aim of this study was to evaluate the value of the Modified Early Warning Score (MEWS) and the VitalPac Early Warning Score (VIEWS) in predicting hospitalization and in-hospital mortality in geriatric emergency department (ED) patients.
and VIEWS were 0.727 [95% confidence interval (CI) 0.689–0.765] and 0.756 (95% CI 0.720–0.792) in predicting hospitalization, respectively. The AUCs of the MEWS and VIEWS were 0.891 (95% CI 0.844–0.937) and 0.900 (95% CI 0.860–0.941) in predicting in-hospital mortality, respectively.
Patients and methods This prospective, single-centered observational study was carried out over 1 month at the ED of a university hospital in patients 65 years of age and older presenting to the ED. The vital parameters of the patients measured on admission to ED were recorded. The MEWS and VIEWS were calculated using the recorded physiological parameters of the patients. Hospitalization and in-hospital mortality were used as the primary outcomes.
Conclusion The MEWS and VIEWS are powerful scoring systems that are easy-to-use for predicting the hospitalization and in-hospital mortality of geriatric ED patients. European Journal of Emergency Medicine 00:000–000 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Results A total of 671 patients included in the study. The median age of the patients was 75 (11) years, and 375 (55.9%) were men. The MEWS is effective for discriminating patient groups that have been discharged from ED, admitted to a ward and admitted to ICU [1 (2) vs. 1 (1) vs. 3 (3), respectively, P < 0.001]. The VIEWS is also effective for discriminating patient groups that have been discharged from ED, admitted to a ward, and admitted to ICU [2 (3) vs. 5 (5) vs. 8 (8), respectively, P < 0.001]. The AUCs of the MEWS
Introduction Life expectancy has risen worldwide because of improved prevention, diagnosis and treatment modalities. The number of patients 65 years of age and older who are presenting to emergency department (ED) is increasing in parallel with the prolongation of the average life expectancy [1]. Although geriatric presentations to ED comprise 40–50% of all ED presentations in the USA, it has been reported that 3–23% of all ED presentations comprise patients 65 years of age and older from various regions of our country [2–4]. There are specific management practices for patients 65 years of age and older at EDs because of the presence of comorbidities and the change in physiological responses to acute diseases in advanced age [1,2]. Several risk-scoring systems have been developed to define the severity class of the patients during their initial evaluation at ED [5–9]. The Modified Early Warning Score (MEWS) was developed in 2001 by Subbe et al. [6] and is based on five physiological parameters: systolic blood pressure, pulse, respiratory rate, body temperature, 0969-9546 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
European Journal of Emergency Medicine 2015, 00:000–000 Keywords: geriatrics, Modified Early Warning Score, mortality, risk-scoring systems, VitalPac Early Warning Score a Emergency Medicine Department, Meram Faculty of Medicine, Necmettin Erbakan University, Konya and bEmergency Medicine Department, Faculty of Medicine, Gazi University, Ankara, Turkey
Correspondence to Zerrin D. Dundar, MD, Emergency Medicine Department, Meram Faculty of Medicine, Necmettin Erbakan University, Acil Tıp ABD 42080, Meram, Konya, Turkey Tel: + 90 532 468 2555; fax: + 90 332 223 6181; e-mail: [email protected] Received 27 November 2014 Accepted 19 March 2015
and mental state. The VitalPac Early Warning Score (VIEWS) was defined in 2010 by Prytherch et al. [9]. Oxygen saturation and the oxygen support provided have been included in the parameters of the MEWS. Several studies have reported that risk-scoring systems which are specifically developed for geriatric patients who present to ED, are not sufficiently effective for evaluating patients in more severe conditions [10,11]. Other studies have reported that the Emergency Severity Index triage classification predicts the prognosis correctly in only half of the patients 65 years of age and older [7,12]. Although the MEWS and VIEWS were developed from ward-based patients and acute medical illness unit patients, their uses in risk stratification of ED patients have been evaluated in a limited number of studies [5,9, 13,14]. This study aims to evaluate the value of the MEWS and VIEWS in predicting hospitalization and in-hospital mortality in patients 65 years of age and older who present to ED because of acute surgical or medical diseases (nontraumatic). DOI: 10.1097/MEJ.0000000000000274
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
2 European Journal of Emergency Medicine 2015, Vol 00 No 00
Patients and methods
Measurements
Study design
The MEWS and VIEWS were calculated using the recorded physiological parameters of the patients. The MEWS used in this study was calculated using systolic blood pressure, pulse rate, respiratory rate, body temperature, and the AVPU score [6]. The scores vary between 0 and 3 for each parameter (Table 1). The minimum value of the MEWS was 0 and the maximum value was 14. The VIEWS used in this study was calculated using peripheral oxygen saturation and the presence of inhaled oxygen parameters in addition to systolic blood pressure, pulse rate, respiratory rate, body temperature, and the AVPU score [9]. The scores vary between 0 and 3 for each parameter (Table 2). The minimum value of the VIEWS was 0 and the maximum value was 21.
This prospective, single-centered observational study was carried out over 1 month at the ED of a university hospital to evaluate the values of the MEWS and VIEWS in predicting hospitalization and in-hospital mortality in medical and surgical patients 65 years of age and older presented to ED. The local ethics committee approved the study. Study settings and population
This study was carried out between 15 January 2014 and 15 February 2014 at a university hospital with emergency medicine residency program and 62 000 ED presentations annually. The 1260-bed hospital is one of the three tertiary referral medical centers of a Middle Anatolian city with a population of 2 000 000. About 63 000 (3.2%) of the population of the city is 65 years of age and older. All of the patients 65 years of age and older presented to ED because of acute medical or surgical reasons during the study period were included in the study. Patients younger than 65 years old and trauma patients were excluded from the study. The patients who had been brought to EDs after undergoing cardiopulmonary resuscitation by the emergency medical system were also excluded from the study. The emergency medicine residents meet every patient who presents to our ED. A senior resident performs the initial evaluation of the patient with the assistance of a nurse to perform the triage risk classification. The patient is then directed to the appropriate emergency room according to his/her triage level. Then, another emergency physician working in the emergency room takes over the patient’s management and follow-up. During this process, all data of the patient are recorded in a single patient chart by the triage resident and the emergency physician. The study researchers recorded the initial symptoms and physiological parameters on presentation from patients’ charts after the completion of patients’ ED visits. The senior residents, nurses, and emergency physicians were blinded to the study during the study period. Study protocol
The following information about the patients who fulfilled the study inclusion criteria was recorded: age, sex, systolic blood pressure, diastolic blood pressure, pulse rate, respiratory rate, body temperature, peripheral oxygen saturation, whether oxygen support was provided or not, and the AVPU (A: alert, V: to voice, P: to pain, and U: unresponsive) score. The patients were followed up until discharge, death, or for a maximum of 28 days. Data on the patients’ discharge from ED, admission to a ward, admission to ICU, and mortality were recorded.
Hospitalization and in-hospital mortality were used as the primary outcomes. The patients were divided into four groups: those who were discharged from ED, those admitted to a ward, those admitted to ICU, and those who died in the ED. To evaluate in-hospital mortality, the patients were divided into two groups: survivors and nonsurvivors. The intergroup differences in the physiological parameters and the scores during presentation to ED were also evaluated.
Statistical analysis
The normality analyses of the data were carried out using the Kolmogorov–Smirnov and Shapiro–Wilk tests. The data did not comply with normal distribution. The continuous variables were expressed as the median (interquartile range) and the categorical variables were expressed as count (%). The intergroup differences between the continuous variables were evaluated using the Kruskal–Wallis test and the Mann–Whitney U-test (with Bonferroni correction). The intergroup differences between the categorical variables were evaluated using the χ2 and Fischer exact tests. The predictive value of the MEWS and VIEWS for hospitalization and in-hospital mortality was evaluated using the receiver operating characteristic (ROC) analysis. The values of the areas under the ROC curve (AUC) were evaluated. The optimum cut-off points of the MEWS and VIEWS were determined for both the primary outcomes using Youden’s index (sensitivity + specificity − 1). Using these determined cut-off points, the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio (LR + ), and negative likelihood ratio (LR − ) values of both MEWS and VIEWS were calculated both for the hospitalization and the in-hospital mortality. Mortality versus MEWS and VIEWS graphs were drawn. The MEWS and VIEWS were divided into three different risk groups by determining the critical transition points of the mortality rates.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
MEWS and VIEWS in geriatric ED patients Dundar et al. 3
Table 1
Modified Early Warning Score
Systolic blood pressure (mmHg) Pulse rate (bpm) Respiratory rate (bpm) Temperature (°C) AVPU
3
2
1
0
1
2
3
< 70 – – – –
71–80 < 40
Modified Early Warning Score and VitalPac Early Warning Score in geriatric patients admitted to emergency department Zerrin Defne Dundara, Mehmet Ergina, Mehmet A. Karamercanb, Kursat Ayrancia, Tamer Colaka, Alpay Tuncara, Basar Candera and Mehmet Gula Objective The aim of this study was to evaluate the value of the Modified Early Warning Score (MEWS) and the VitalPac Early Warning Score (VIEWS) in predicting hospitalization and in-hospital mortality in geriatric emergency department (ED) patients.
and VIEWS were 0.727 [95% confidence interval (CI) 0.689–0.765] and 0.756 (95% CI 0.720–0.792) in predicting hospitalization, respectively. The AUCs of the MEWS and VIEWS were 0.891 (95% CI 0.844–0.937) and 0.900 (95% CI 0.860–0.941) in predicting in-hospital mortality, respectively.
Patients and methods This prospective, single-centered observational study was carried out over 1 month at the ED of a university hospital in patients 65 years of age and older presenting to the ED. The vital parameters of the patients measured on admission to ED were recorded. The MEWS and VIEWS were calculated using the recorded physiological parameters of the patients. Hospitalization and in-hospital mortality were used as the primary outcomes.
Conclusion The MEWS and VIEWS are powerful scoring systems that are easy-to-use for predicting the hospitalization and in-hospital mortality of geriatric ED patients. European Journal of Emergency Medicine 00:000–000 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Results A total of 671 patients included in the study. The median age of the patients was 75 (11) years, and 375 (55.9%) were men. The MEWS is effective for discriminating patient groups that have been discharged from ED, admitted to a ward and admitted to ICU [1 (2) vs. 1 (1) vs. 3 (3), respectively, P < 0.001]. The VIEWS is also effective for discriminating patient groups that have been discharged from ED, admitted to a ward, and admitted to ICU [2 (3) vs. 5 (5) vs. 8 (8), respectively, P < 0.001]. The AUCs of the MEWS
Introduction Life expectancy has risen worldwide because of improved prevention, diagnosis and treatment modalities. The number of patients 65 years of age and older who are presenting to emergency department (ED) is increasing in parallel with the prolongation of the average life expectancy [1]. Although geriatric presentations to ED comprise 40–50% of all ED presentations in the USA, it has been reported that 3–23% of all ED presentations comprise patients 65 years of age and older from various regions of our country [2–4]. There are specific management practices for patients 65 years of age and older at EDs because of the presence of comorbidities and the change in physiological responses to acute diseases in advanced age [1,2]. Several risk-scoring systems have been developed to define the severity class of the patients during their initial evaluation at ED [5–9]. The Modified Early Warning Score (MEWS) was developed in 2001 by Subbe et al. [6] and is based on five physiological parameters: systolic blood pressure, pulse, respiratory rate, body temperature, 0969-9546 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
European Journal of Emergency Medicine 2015, 00:000–000 Keywords: geriatrics, Modified Early Warning Score, mortality, risk-scoring systems, VitalPac Early Warning Score a Emergency Medicine Department, Meram Faculty of Medicine, Necmettin Erbakan University, Konya and bEmergency Medicine Department, Faculty of Medicine, Gazi University, Ankara, Turkey
Correspondence to Zerrin D. Dundar, MD, Emergency Medicine Department, Meram Faculty of Medicine, Necmettin Erbakan University, Acil Tıp ABD 42080, Meram, Konya, Turkey Tel: + 90 532 468 2555; fax: + 90 332 223 6181; e-mail: [email protected] Received 27 November 2014 Accepted 19 March 2015
and mental state. The VitalPac Early Warning Score (VIEWS) was defined in 2010 by Prytherch et al. [9]. Oxygen saturation and the oxygen support provided have been included in the parameters of the MEWS. Several studies have reported that risk-scoring systems which are specifically developed for geriatric patients who present to ED, are not sufficiently effective for evaluating patients in more severe conditions [10,11]. Other studies have reported that the Emergency Severity Index triage classification predicts the prognosis correctly in only half of the patients 65 years of age and older [7,12]. Although the MEWS and VIEWS were developed from ward-based patients and acute medical illness unit patients, their uses in risk stratification of ED patients have been evaluated in a limited number of studies [5,9, 13,14]. This study aims to evaluate the value of the MEWS and VIEWS in predicting hospitalization and in-hospital mortality in patients 65 years of age and older who present to ED because of acute surgical or medical diseases (nontraumatic). DOI: 10.1097/MEJ.0000000000000274
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
2 European Journal of Emergency Medicine 2015, Vol 00 No 00
Patients and methods
Measurements
Study design
The MEWS and VIEWS were calculated using the recorded physiological parameters of the patients. The MEWS used in this study was calculated using systolic blood pressure, pulse rate, respiratory rate, body temperature, and the AVPU score [6]. The scores vary between 0 and 3 for each parameter (Table 1). The minimum value of the MEWS was 0 and the maximum value was 14. The VIEWS used in this study was calculated using peripheral oxygen saturation and the presence of inhaled oxygen parameters in addition to systolic blood pressure, pulse rate, respiratory rate, body temperature, and the AVPU score [9]. The scores vary between 0 and 3 for each parameter (Table 2). The minimum value of the VIEWS was 0 and the maximum value was 21.
This prospective, single-centered observational study was carried out over 1 month at the ED of a university hospital to evaluate the values of the MEWS and VIEWS in predicting hospitalization and in-hospital mortality in medical and surgical patients 65 years of age and older presented to ED. The local ethics committee approved the study. Study settings and population
This study was carried out between 15 January 2014 and 15 February 2014 at a university hospital with emergency medicine residency program and 62 000 ED presentations annually. The 1260-bed hospital is one of the three tertiary referral medical centers of a Middle Anatolian city with a population of 2 000 000. About 63 000 (3.2%) of the population of the city is 65 years of age and older. All of the patients 65 years of age and older presented to ED because of acute medical or surgical reasons during the study period were included in the study. Patients younger than 65 years old and trauma patients were excluded from the study. The patients who had been brought to EDs after undergoing cardiopulmonary resuscitation by the emergency medical system were also excluded from the study. The emergency medicine residents meet every patient who presents to our ED. A senior resident performs the initial evaluation of the patient with the assistance of a nurse to perform the triage risk classification. The patient is then directed to the appropriate emergency room according to his/her triage level. Then, another emergency physician working in the emergency room takes over the patient’s management and follow-up. During this process, all data of the patient are recorded in a single patient chart by the triage resident and the emergency physician. The study researchers recorded the initial symptoms and physiological parameters on presentation from patients’ charts after the completion of patients’ ED visits. The senior residents, nurses, and emergency physicians were blinded to the study during the study period. Study protocol
The following information about the patients who fulfilled the study inclusion criteria was recorded: age, sex, systolic blood pressure, diastolic blood pressure, pulse rate, respiratory rate, body temperature, peripheral oxygen saturation, whether oxygen support was provided or not, and the AVPU (A: alert, V: to voice, P: to pain, and U: unresponsive) score. The patients were followed up until discharge, death, or for a maximum of 28 days. Data on the patients’ discharge from ED, admission to a ward, admission to ICU, and mortality were recorded.
Hospitalization and in-hospital mortality were used as the primary outcomes. The patients were divided into four groups: those who were discharged from ED, those admitted to a ward, those admitted to ICU, and those who died in the ED. To evaluate in-hospital mortality, the patients were divided into two groups: survivors and nonsurvivors. The intergroup differences in the physiological parameters and the scores during presentation to ED were also evaluated.
Statistical analysis
The normality analyses of the data were carried out using the Kolmogorov–Smirnov and Shapiro–Wilk tests. The data did not comply with normal distribution. The continuous variables were expressed as the median (interquartile range) and the categorical variables were expressed as count (%). The intergroup differences between the continuous variables were evaluated using the Kruskal–Wallis test and the Mann–Whitney U-test (with Bonferroni correction). The intergroup differences between the categorical variables were evaluated using the χ2 and Fischer exact tests. The predictive value of the MEWS and VIEWS for hospitalization and in-hospital mortality was evaluated using the receiver operating characteristic (ROC) analysis. The values of the areas under the ROC curve (AUC) were evaluated. The optimum cut-off points of the MEWS and VIEWS were determined for both the primary outcomes using Youden’s index (sensitivity + specificity − 1). Using these determined cut-off points, the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio (LR + ), and negative likelihood ratio (LR − ) values of both MEWS and VIEWS were calculated both for the hospitalization and the in-hospital mortality. Mortality versus MEWS and VIEWS graphs were drawn. The MEWS and VIEWS were divided into three different risk groups by determining the critical transition points of the mortality rates.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
MEWS and VIEWS in geriatric ED patients Dundar et al. 3
Table 1
Modified Early Warning Score
Systolic blood pressure (mmHg) Pulse rate (bpm) Respiratory rate (bpm) Temperature (°C) AVPU
3
2
1
0
1
2
3
< 70 – – – –
71–80 < 40
