Understanding the use of the National Early Warning Score 2 in acute care settings: a realist review protocol

A single early warning signs (SEWS) system for recognizing clinically deterioration outperforms the national early warning score (NEWS) by having a lower activation threshold, broader clinical scope, and faster response time

Background

The National Early Warning Score (NEWS) is a vital-signs point summation system developed to identify patients at risk of adverse events including cardiac arrests, unplanned ICU admissions, and deaths. The points are usually calculated by the Electronic Health Record after charting, recommending local actions and Rapid Response System (RRS) activation when reaching ≥ 7 points. NEWS, however, lacks consistent evidence that it improves outcome and may lead to alarm fatigue. At our institution we operate a Single Early Warning Signs (SEWS) system for RRS activation with a broader range of abnormal signs, without point summation, and bedside assessment within 10 min.

Methods

We analyzed 182 RRS activations using SEWS from July 1, 2022, to August 21, 2023, and compared the activation thresholds and dispositions that would have occurred had NEWS been used.

Findings

At the time of RRS activation using SEWS, only 10 patients (5.5%) had scored ≥ 7 NEWS points. Of the remaining 172 patients, 158 (86.8%) scored 0 to 4 NEWS points considered low risk and 14 (7.7%) scored 5 to 6 NEWS points considered medium risk (p < 0.001). Yet, 122 patients (67%) were transferred to a higher level of care including 58 patients (31.8%) to ICU. The median in-hospital cardiac arrest during the reported period was 0.8 per 1000 hospital admissions, which is substantially lower than reported rates.

Conclusion

SEWS operating with a broader clinical scope, lower activation threshold, and faster RRS activation outperformed NEWS markedly reducing in-hospital cardiac arrests.

Assessment of Inflammatory Scores in Severity Prediction for Elderly Patients with Odontogenic Infections

Background and Objectives: Odontogenic infections (OIs) can lead to severe complications, especially in elderly patients due to age-related physiological changes and comorbidities. This study aims to evaluate the predictive accuracy of inflammatory scores-APACHE II, CURB-65, SOFA, and NEWS2-in determining the severity of odontogenic infections among elderly patients (>70 years) compared to younger patients (<70 years). Materials and Methods: A retrospective cohort study was conducted on patients diagnosed with an OI at the Maxillofacial Surgery Department between January 2018 and January 2024. Patients were divided into two groups: elderly patients (>70 years, n = 49) and younger patients (<70 years, n = 64). The Symptom Severity score (SS) of odontogenic infections was calculated for all patients. Inflammatory scores-APACHE II, CURB-65, SOFA, and NEWS2-were assessed at admission and correlated with infection severity. Additional subgroup analyses were performed based on comorbidities and infection sites. Results: Elderly patients exhibited significantly higher SS scores (mean 12.47 ± 2.93) compared to younger patients (mean 7.82 ± 2.17, p < 0.001). APACHE II, CURB-65, SOFA and NEWS2 scores were significantly elevated in the elderly group (all p < 0.001). The SOFA score demonstrated the highest predictive accuracy for severe OIs in elderly patients, with an area under the curve (AUC) of 0.89 (95% CI: 0.82-0.95). Subgroup analyses revealed that comorbidities such as diabetes mellitus and cardiovascular disease significantly influenced infection severity (p < 0.05). Conclusions: Inflammatory scores, particularly SOFA, are effective in predicting the severity of odontogenic infections in elderly patients. The integration of these scores into clinical practice may enhance early identification of high-risk patients and improve management strategies.

Intensive care unit admission criteria: a scoping review

Background

Effectively identifying deteriorated patients is vital to the development and validation of automated systems designed to predict clinical deterioration. Existing outcome measures used for this purpose have significant limitations. Published criteria for admission to high acuity inpatient areas may represent markers of patient deterioration and could inform the development of alternate outcome measures.

Objectives

In this scoping review, we aimed to characterise published criteria for admission of adult inpatients to high acuity inpatient areas including intensive care units. A secondary aim was to identify variables that are extractable from electronic health records (EHRs).

Data sources

Electronic databases PubMed and ProQuest EBook Central were searched to identify papers published from 1999 to date of search. We included publications which described prescriptive criteria for admission of adult inpatients to a clinical area with a higher level of care than a general hospital ward.

Charting methods

Data was extracted from each publication using a standardised data-charting form. Admission criteria characteristics were summarised and cross-tabulated for each criterion by population group.

Results

Five domains were identified: diagnosis-based criteria, clinical parameter criteria, organ-support criteria, organ-monitoring criteria and patient baseline criteria. Six clinical parameter-based criteria and five needs-based criteria were frequently proposed and represent variables extractable from EHRs. Thresholds for objective clinical parameter criteria varied across publications, and by disease subgroup, and universal cut-offs for criteria could not be elucidated.

Conclusions

This study identified multiple criteria which may represent markers of deterioration. Many of the criteria are extractable from the EHR, making them potential candidates for future automated systems. Variability in admission criteria and associated thresholds across the literature suggests clinical deterioration is a heterogeneous phenomenon which may resist being defined as a single entity via a consensus-driven process.

Predicting posthospitalization falls in Brazilian older adults: External validation of the Carpenter instrument

OBJECTIVES

This study sought to explore and externally validate the Carpenter instrument's efficacy in predicting postdischarge fall risk among older adults admitted to the emergency department (ED) for reasons other than falls or related injuries.

METHODS

A prospective cohort study was conducted on 779 patients aged ≥ 65 years from a tertiary hospital in São Paulo, Brazil, who were monitored for up to 6 months post-ED hospitalization. The Carpenter instrument, which evaluates the four risk factors nonhealing foot sores, self-reported depression, inability to self-clip toenails, and prior falls, was utilized to assess fall risk. Follow-up by telephone occurred at 30, 90, and 180 days to identify falls and mortality. Fine-Gray models estimated the predictive power of Carpenter instrument for future falls, considering death as a competing event and sociodemographic factors, frail status, and clinical measures as confounders.

RESULTS

Among 779 patients, 68 (9%) experienced a fall within 180 days post-ED admission, and 88 (11%) died. The majority were male (54%), with a mean age of 79 years. Upon utilizing the Carpenter score, those with a higher fall risk (≥2 points) displayed more comorbidities, greater frailty, and increased clinical severity at baseline. Regression analyses showed that every additional point on the Carpenter score increased the hazard of falls by 73%. Two primary contributors to its predictive potential were identified: a history of falls in the preceding year and an inability to self-clip toenails. However, the instrument's discriminative accuracy was suboptimal, with an area under the curve of 0.62.

CONCLUSIONS

While the Carpenter instrument associated with a higher 6-month postadmission fall risk among older adults post-ED visit, its accuracy for individual patient decision making was limited. Given the significant impact of falls on health outcomes and health care costs, refining risk assessment tools remains essential. Future research should focus on enhancing these assessments and devising targeted proactive strategies.

Development of National Antimicrobial Intravenous-to-Oral Switch Criteria and Decision Aid

INTRODUCTION

Antimicrobial stewardship (AMS) strategies, such as intravenous-to-oral switch (IVOS), promote optimal antimicrobial use, contributing to safer and more effective patient care and tackling antimicrobial resistance (AMR).

AIM

This study aimed to achieve nationwide multidisciplinary expert consensus on antimicrobial IVOS criteria for timely switch in hospitalised adult patients and to design an IVOS decision aid to operationalise agreed IVOS criteria in the hospital setting.

METHOD

A four-step Delphi process was chosen to achieve expert consensus on IVOS criteria and decision aid; it included (Step One) Pilot/1st round questionnaire, (Step Two) Virtual meeting, (Step Three) 2nd round questionnaire and (Step 4) Workshop. This study follows the Appraisal of Guidelines for Research and Evaluation II instrument checklist.

RESULTS

The Step One questionnaire of 42 IVOS criteria had 24 respondents, 15 of whom participated in Step Two, in which 37 criteria were accepted for the next step. Step Three had 242 respondents (England n = 195, Northern Ireland n = 18, Scotland n = 18, Wales n = 11); 27 criteria were accepted. Step Four had 48 survey respondents and 33 workshop participants; consensus was achieved for 24 criteria and comments were received on a proposed IVOS decision aid. Research recommendations include the use of evidence-based standardised IVOS criteria.

DISCUSSION AND CONCLUSION

This study achieved nationwide expert consensus on antimicrobial IVOS criteria for timely switch in the hospitalised adult population. For criteria operationalisation, an IVOS decision aid was developed. Further research is required to provide clinical validation of the consensus IVOS criteria and to expand this work into the paediatric and international settings.

The transcultural adaptation and validation of the Chinese version of the Attitudes Toward Recognizing Early and Noticeable Deterioration scale

Background

In China, clinical deterioration events present a real problem for every clinical nurse. Patient deterioration is determined in part by nurses' attitudes toward early recognition of clinical deterioration. However, research on attitudes toward the early identification of clinical deterioration is still in its infancy, and even less research has been done on ward nurses' attitudes toward the early identification of clinical deterioration. To drive behavioral change and improve the care of deteriorating patients, nurses need comprehensive, valid, and reliable tools to assess their attitudes toward early identification of deterioration.

Objective

In this study, we aimed to translate the Attitudes Toward Recognizing Early and Noticeable Deterioration (ATREND) scale into Chinese and to assess its validity and reliability tests.

Methods

From March 2022 to July 2022, the ATREND scale was translated, back-translated, and cross-culturally adapted into the Chinese version using a modified Brislin translation model. Then, 460 ward nurses were recruited from tertiary Grade A general hospitals in two cities: Shenyang and Jinzhou in Liaoning Province, China. Reliability analyses were conducted using internal consistency, split-half, and test-retest reliability. We convened a committee of experts to determine the validity of the content. Tests of the structural validity of the scale were conducted using exploratory and validation factor analyses.

Results

The Cronbach's α value of the Chinese version of the ATREND scale was 0.804, and the Cronbach's α value of the dimensions ranged from 0.782 to 0.863. The split-half reliability and test-retest reliability were 0.846 and 0.711, respectively. Furthermore, the scale has an index of content validity of 0.922, indicating a high level of content validity. In exploratory factor analysis, eigenvalues, total variance explained, and scree plot supported a three-factor structure. The three-factor model supported by this study was confirmed by confirmatory factor analysis (CFA). Moreover, the model fitting indexes (e.g., χ ²/DF = 1.498, GFI = 0.954, RMSEA = 0.047) were all within acceptable limits based on the CFA.

Conclusion

The Chinese version of the scale is reliable and valid among ward nurses. Nursing educators and clinicians will be able to develop targeted educational programs to enhance the competence and behaviors of Chinese ward nurses in recognizing clinical deterioration. It will be based on the developed scale to assess Chinese nurses' attitudes and practices regarding early recognition of clinical deterioration. As a result, it is necessary to consider the Chinese scale's three-factor structure. The developed three-factor structured scale will assess Chinese ward nurses' attitudes and practices toward patient observation and vital sign-monitoring empowerment, enlightening them on the importance of patient observation, encouraging ward nurses to use a wider range of patient assessment techniques to capture early signs of clinical deterioration, and helping ward nurses to develop clinical confidence to monitor clinical deterioration.