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Evaluation of the feasibility and performance of early warning scores to identify patients at risk of adverse outcomes in a low-middle income country setting

Abi Beane, Ambepitiyawaduge Pubudu De Silva, Nirodha De Silva, Jayasingha A Sujeewa, R M Dhanapala Rathnayake, P Chathurani Sigera, Priyantha Lakmini Athapattu, Palitha G Mahipala, Aasiyah Rashan, Sithum Bandara Munasinghe, Kosala Saroj Amarasiri Jayasinghe, Arjen M Dondorp, Rashan Haniffa
BMJ Open 2018 April 27, 8 (4): e019387
29703852

OBJECTIVE: This study describes the availability of core parameters for Early Warning Scores (EWS), evaluates the ability of selected EWS to identify patients at risk of death or other adverse outcome and describes the burden of triggering that front-line staff would experience if implemented.

DESIGN: Longitudinal observational cohort study.

SETTING: District General Hospital Monaragala.

PARTICIPANTS: All adult (age >17 years) admitted patients.

MAIN OUTCOME MEASURES: Existing physiological parameters, adverse outcomes and survival status at hospital discharge were extracted daily from existing paper records for all patients over an 8-month period.

STATISTICAL ANALYSIS: Discrimination for selected aggregate weighted track and trigger systems (AWTTS) was assessed by the area under the receiver operating characteristic (AUROC) curve.Performance of EWS are further evaluated at time points during admission and across diagnostic groups. The burden of trigger to correctly identify patients who died was evaluated using positive predictive value (PPV).

RESULTS: Of the 16 386 patients included, 502 (3.06%) had one or more adverse outcomes (cardiac arrests, unplanned intensive care unit admissions and transfers). Availability of physiological parameters on admission ranged from 90.97% (95% CI 90.52% to 91.40%) for heart rate to 23.94% (95% CI 23.29% to 24.60%) for oxygen saturation. Ability to discriminate death on admission was less than 0.81 (AUROC) for all selected EWS. Performance of the best performing of the EWS varied depending on admission diagnosis, and was diminished at 24 hours prior to event. PPV was low (10.44%).

CONCLUSION: There is limited observation reporting in this setting. Indiscriminate application of EWS to all patients admitted to wards in this setting may result in an unnecessary burden of monitoring and may detract from clinician care of sicker patients. Physiological parameters in combination with diagnosis may have a place when applied on admission to help identify patients for whom increased vital sign monitoring may not be beneficial. Further research is required to understand the priorities and cues that influence monitoring of ward patients.

TRIAL REGISTRATION NUMBER: NCT02523456.

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