Strengths and limitations of early warning scores: A systematic review and narrative synthesis

Purpose of reviewEarly identification and appropriate management of sepsis improves outcomes. Despite convincing data showing the benefits of early recognition and treatment of sepsis and septic shock, implementation of such evidence-based therapy is suboptimal. This review describes methods that ha

Implementation of the Surviving Sepsis Campaign guidelines.

Objective To describe the improvements of an early warning system for the identification of septic patients on the time to diagnosis, antibiotic delivery, and mortality. Methods This was an observational cohort study that describes the successive improvements made over a period of 10 years using an early warning system to detect sepsis, including systematic active manual surveillance, electronic alerts via a telephonist, and alerts sent directly to the mobile devices of nurses. For all periods, after an alert was triggered, early treatment was instituted according to the institutional sepsis guidelines. Results In total, 637 patients with sepsis were detected over the study period. The median triage-to-diagnosis time was reduced from 19:20 (9:10 - 38:15) hours to 12:40 (2:50 - 23:45) hours when the manual surveillance method was used (p = 0.14), to 2:10 (1:25 - 2:20) hours when the alert was sent automatically to the hospital telephone service (p = 0.014), and to 1:00 (0:30 - 1:10) hour when the alert was sent directly to the nurse's mobile phone (p = 0.016). The diagnosis-to-antibiotic time was reduced to 1:00 (0:55 - 1:30) hours when the alert was sent to the telephonist and to 0:45 (0:30 - 1:00) minutes when the alert was sent directly to the nurse's mobile phone (p = 0.02), with the maintenance of similar values over the following years. There was no difference in the time of treatment between survivors and non-survivors. Conclusion Electronic systems help reduce the triage-to-diagnosis time and diagnosis-to-antibiotic time in patients with sepsis.

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An electronic warning system helps reduce the time to diagnosis of sepsis

This evidence led to the analysis of the SSC impact in 2010, which involved 15,022 patients from 165 hospitals. This analysis revealed continuous and sustained improvements in compliance with early interventions, especially with antibiotic therapy (odds ratio - OR 0.70; p < 0.001), and blood culture requests (0.78; p < 0.001), along with a reduction in the mortality rate associated with severe sepsis or septic shock (from 30.8% to 27%; p < 0.01).

http://www.scielo.br/pdf/rbti/v27n2/en_0103-507X-rbti-27-02-0096.pdf

Systematic screening is essential for early diagnosis of severe sepsis and septic shock

Introduction: Internal carotid artery occlusion (ICAO) causes high annual rates of mortality and morbidity. It has been established that atherosclerosis is the normal cause of ICAO. As the pathogenesis of atherosclerosis may involve blood lipids, inflammatory factors and other biomarkers, the aim of this study was to assess the changes in these biomarkers and investigate the relationship between these biomarkers and the development of ICAO in stroke patients. Material and methods: A total of 89 ischaemic stroke inpatients with ICAO (ICAO group) and 89 without ICAO (control group) were studied, retrospectively. The serum was collected from each patient on the 3 rd day of admission, to measure the lipid parameters and biomarkers, e.g. high-sensitivity C-reactive protein (hs-CRP), erythrocyte sedimentation rate (ESR), and lactic acid (LA). Histories were taken including age, gender, smoking history, and disease history. Additional analysis was carried out to compare between the genders and evaluate the association between certain biomarkers and ICAO. Results: Among the 89 ICAO cases in this study, the serum levels of hs-CRP, ESR and LA were significantly higher than those in the control group (p ≤ 0.001). No significant differences were found in the mean levels of total cholesterol, triacylglycerol, HDL cholesterol or glucose, or the known risk factors. Gender also had no influence on these biomarkers. Logistic regression analysis indicated that hs-CRP, ESR and LA were significantly associated with ICAO (p ≤ 0.05). Conclusions: These results suggest that hs-CRP, ESR and LA are associated with ICAO in ischaemic stroke patients, but gender has no effect. Therefore, Hs-CRP, ESR and LA may be useful in the early detection of patients with ICAO.

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Increased high-sensitivity C-reactive protein, erythrocyte sedimentation rate and lactic acid in stroke patients with internal carotid artery occlusion

Purpose To assess whether the Modified Early Warning Score (MEWS) predicts the need for intensive care unit (ICU) transfer for patients with severe sepsis or septic shock admitted to general wards Methods A retrospective chart review of 100 general ward patients with severe sepsis or septic shock was implemented Clinical information and MEWS according to point of time between ICU group and general ward group were reviewed Data were analyzed using multivariate logistic regression and the area under the receiver operating characteristic curves with SPSS/WIN 180 program Results Thirty-eight ICU patients and sixty-two general ward patients were included In multivariate logistic regression, MEWS (odds ratio [OR] 202, 95% confidence interval [CI] 143-285), lactic acid (OR 183, 95% CI 122-273) and diastolic blood pressure (OR 089, 95% CI 080-100) were predictive of ICU transfer The sensitivity and the specificity of MEWS used with cut-off value of six were 895% and 677% for ICU transfer Conclusion MEWS is an effective predictor of ICU transfer A clinical algorithm could be created to respond to high MEWS and intervene with appropriate changes in clinical management

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Validation of a modified early warning score to predict ICU transfer for patients with severe sepsis or septic shock on general wards

Purpose: The purpose of this study was to analyze risk factors in predicting medical patients transferred to Intensive Care Unit (ICU) on the general ward. Methods: We reviewed retrospectively clinical data of 120 medical patients on the general ward and a Modified Early Warning Score (MEWS) between ICU group and general ward group. Data were analyzed with multivariate logistic regression and the area under the receiver operating characteristic curves using SPSS/WIN 18.0 program. Results: Fifty-two ICU patients and 68 general ward patients were included. In multivariate logistic regression, the MEWSs (Odds Ratio [OR], 1.91; 95% confidence interval [CI], 1.32-2.76), sequential organ failure assessment score (OR, 1.28; 95% CI, 1.10-1.72), PaO2/FiO2 ratio (OR, 0.98; 95% CI, 0.98-0.99), and saturation (OR, 0.93; 95% CI, 0.88-0.99) were predictive of ICU transfer. The sensitivity and the specificity of the MEWSs used with a cut-off value of six were 80.8% and 70.6% respectively for ICU transfer. Conclusion: These findings suggest that early prediction and treatment of patients with high risk of ICU transfer may improve the prognosis of patients.

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Ju Ry Lee

Papers

Validation of a modified early warning score to predict ICU transfer for patients with severe sepsis or septic shock on general wards

Analysis of Risk Factors to Predict Intensive Care Unit Transfer in Medical in-Patients