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Resulting from 15 years of global clinical research and support of medical staff, Tapa Healthcare has built an insight into the clinical workflow and the substantial frustrations affecting you today.

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READS’ advanced Simple Clinical Score (SCS) and Early Warning Score (EWS) models, quickly and accurately identify all levels of risk during patient admission. READS provides unrivalled clinical information, highly predictive alerts, triggers and prioritised intervention mechanisms.

Next Generation Early Warning Score (EWS)

READS utilises and is compatible with multiple EWS, and also builds in advanced algorithms that go far beyond vital signs.

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Tapa Healthcare Research Papers

READS Concept



READS: The Rapid Electronic Assessment Documentation System.

Authors: Hickey A., Gleeson M., Kellett J.

Patient documentation is time consuming and can detract from care. The authors report a novel computer programme that manipulates routinely collected information to quantify nursing workload, along with the reason for admission, functional status, estimates of in-hospital mortality and life expectancy. The programme stores information in a database, and produces a print-out in a situation/background/assessment/recommendation (SBAR) format.

The average time taken to enter 629 patient encounters was 6.6 minutes. Pain was the most common presentation for low workload patients, while high workload patients often presented with altered mental status and reduced mobility. There was only a modest correlation between the risk of death and nursing workload. The programme measures nursing workload without further paperwork, and improves routine documentation with a legible brief report that is automatically generated. This report can be shared and provides data that is immediately available for day-to-day care, audit, quality control and service planning.

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Medical documentation: part of the solution, or part of the problem? A narrative review of the literature on the time spent on and value of medical documentation.

Authors: Clynch N, Kellett J.
BACKGROUND:

Even though it takes up such a large part of all clinicians' working day the medical literature on documentation and its value is sparse.

METHODS:

Medline searches combining the terms medical records, documentation, time, and value or efficacy or benefit yielded only 147 articles. This review is based on the relevant articles selected from this search and additional studies gathered from the personal experience of the authors and their colleagues.

RESULTS:

Documentation now occupies a quarter to half of doctors' time yet much of the information collected is of dubious or unproven value. Most medical records departments still use the traditional paper chart, and there is considerable debate on the benefits of electronic medical records (EMRs). Although EMRs contains a lot more information than a paper record clinicians do not find it easy to getting useful information out of them. Unlike the paper chart narrative is difficult to enter into most EMRs so that they do not adequately communicate the patient's "story" to clinicians. Recent innovations have the potential to address these issues.

CONCLUSION:

Although documentation is widespread throughout the health care industry there has been almost no formal research into its value, on how to enhance its value, or on whether the time spent on it has negative effects on patient care.

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Using the Guttman scale to define and estimate measurement error in items over time: the case of cognitive decline and the meaning of "points lost".

Authors: R.E. Tractenberg, F. Yumoto, P.S. Aisen, J.A. Kaye, R.J. Mislevy

We used a Guttman model to represent responses to test items over time as an approximation of what is often referred to as "points lost" in studies of cognitive decline or interventions. To capture this meaning of "point loss", over four successive assessments, we assumed that once an item is incorrect, it cannot be correct at a later visit. If the loss of a point represents actual decline, then failure of an item to fit the Guttman model over time can be considered measurement error. This representation and definition of measurement error also permits testing the hypotheses that measurement error is constant for items in a test, and that error is independent of "true score", which are two key consequences of the definition of "measurement error"--and thereby, reliability--under Classical Test Theory.

We tested the hypotheses by fitting our model to, and comparing our results from, four consecutive annual evaluations in three groups of elderly persons: a) cognitively normal (NC, N = 149); b) diagnosed with possible or probable AD (N = 78); and c) cognitively normal initially and a later diagnosis of AD (converters, N = 133). Of 16 items that converged, error-free measurement of "cognitive loss" was observed for 10 items in NC, eight in converters, and two in AD. We found that measurement error, as we defined it, was inconsistent over time and across cognitive functioning levels, violating the theory underlying reliability and other psychometric characteristics, and key regression assumptions.

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Should systematic risk assessment and immediate intervention of the acutely ill patient replace the traditional management paradigm?

Author: Kellett J.
Abstract

The outcome of the traditional diagnostic history and physical depends entirely on the availability, ability and diligence of an individual doctor. An alternative is a team-based approach that performs the following tasks: a focused assessment, monitoring of the response to initial treatment, and then determining what further management is appropriate (calling for urgent help if it is required). This concept is based on risk prediction rather than diagnosis, and is captured by the mnemonic FAITH3 (Focused Assessment, Initial Treatment, hAssessing response, calling for Help and Handing over care).

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How much of NEWS could be measured by a machine, and would it work?

Author: Kellett J.
Abstract

The National Early Warning Score (NEWS)1 based on VitalpacTM Early Warning Score (ViEWS)2 has been introduced in hospitals across the UK following a recommendation by the Royal College of Physicians. This aggregate weighted track and trigger system includes mental status, body core temperature, systolic blood pressure, heart rate and three respiratory parameters: breathing rate, use of supplementary oxygen, and oxygen saturations. Currently industry is developing vital sign platforms that should make it possible to continuously monitor more patients both inside and outside hospital.

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Mobility measures should be added to the National Early Warning Score (NEWS)

Brabrand M, Kellett J.
Abstract

Although the National Early Warning Score (NEWS) has been introduced in hospitals across the UK it is not clear how the score should be used. Escalation protocols suggest that only patients with a high score should trigger the most aggressive response. However, the majority of patients who die in hospital do not have an elevated score on admission and, indeed, many patients will have a low score on the day they die. A single score, calculated at a specific point in time, is only a point estimate.

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Assessment Methodologies and Clinical Scores



National Early Warning Score (NEWS) - Standardising the assessment of acute-illness severity in the NHS. Report of a working party.

Authors: London: Royal College of Physicians (RCP);2012.

Early detection, timeliness and competency of clinical response are a triad of determinants of clinical outcome in people with acute illness. Numerous recent national reports on acute clinical care have advocated the use of so-called ‘early warning scores’ (EWS), ie ‘track-and-trigger systems’ to efficiently identify and respond to patients who present with or develop acute illness. A number of EWS systems are currently in use across the NHS, however, the approach is not standardised. This variation in methodology and approach can result in a lack of familiarity with local systems when staff move between clinical areas/hospitals – the various EWS systems are not necessarily equivalent or interchangeable.

Put simply, when assessing acutely ill patients using these various scores, we are not speaking the same language and this can lead to a lack of consistency in the approach to detection and response to acute illness. This lack of standardisation also bedevils attempts to embed a culture of training and education in the assessment and response to acute illness for all grades of healthcare professionals across the NHS. Building upon recommendations in the RCP’s Acute Medicine Task Force report Acute medical care: the right person, in the right setting – first time, published in 2007, the RCP commissioned a multidisciplinary group to develop a National Early Warning Score (NEWS).

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The Simple Clinical Score predicts mortality for days after admission to an acute medical unit.

J. Kellett, B. Deane .
BACKGROUND:

Predictive scores such as APACHE II and SAPS II have been used to assess patients in intensive care units, but only the modified early warning (MEW) score has been used to assess acutely ill general medical patients.

DESIGN:

Observational study of predictors of mortality.

SETTING:

Small Irish rural hospital.

METHODS:

From 17 February 2000 to 29 January 2004, 9964 consecutive patients admitted as acute medical emergencies were divided into a derivation cohort of 6736 patients and a validation cohort of 3228 patients.

RESULTS:

In the derivation cohort, 316 patients (4.7%) died within 30 days of hospital admission. Under univariate analysis, age, vital signs and 18 categorical variables were associated with increased risk of death, and nine with reduced risk. Logistic regression identified 16 independent predictors of 30-day mortality, from which the Simple Clinical Score was derived, stratifying patients into five risk classes. In each class, mortality was not significantly different between the derivation and validation cohorts: 0–0.1% for very low risk, 1.5–1.6% for low risk, 3.8–3.9% for average risk, 9.0–10.3% for high risk, and 29.2–34.4% for very high risk.

DISCUSSION:

The Simple Clinical Score quickly and accurately identifies patients at both a low and high risk of death from the first to the 30th day after admission, enabling prompt triage and placement within a health-care facility.

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The Cape Triage Score – a triage system for South Africa.

Authors: L A Wallis, S B Gottschalk, D Wood, S Bruijns, S de Vries, C Balfour, on behalf of the Cape Triage Group

The Cape Triage Score (CTS) has been derived by the Cape Triage Group (CTG) for use in emergency units throughout South Africa. It can also be used in the pre-hospital setting, although it is not designed for mass casualty situations. The CTS comprises a physiologically based scoring system and a list of discriminators, designed to triage patients into one of five priority groups for medical attention. Three versions have been developed, for adults, children and infants. As part of the ongoing assessment process the CTG would value feedback from the readers of this Journal.

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Assessing the need for hospital admission by the cape triage discriminator presentations and the simple clinical score.

Authors: Andrew Emmanuel, Asyik Ismail, John Kellett
AIM:

There is uncertainty about how to assess unselected acutely ill medical patients at the time of their admission to hospital. This study examined the use of the Simple Clinical Score (SCS) and the medically relevant Cape Triage discriminator clinical presentations to determine the need for admission to an acute medical unit.

METHOD:

A prospective study of 270 unselected consecutive acute medical admissions. On presentation to hospital patients were grouped into one of 5 risk classes according to their SCS and to one of four Cape Triage colour-coded risk discriminator presentations (CTP).

RESULTS:

221 (82%) patients had an urgent or very urgent CTP. Although 60 patients were deemed very low risk by the SCS at the time of admission, only 13 of these patients a delayed priority CTP. All but three of the 95 patients in high SCS risk classes did not have an urgent or very urgent CTP. The ability of the CTP to predict outcomes was inferior to the SCS—the AUROC for in-hospital death was 0.94 for the SCS and 0.64 for CTP.

CONCLUSION:

Nearly all patients in the highest risk SCS classes were detected as urgent or very urgent by the CTP. However, most patients admitted in the lowest risk SCS class also were considered urgent or very urgent by the CTP and, therefore, had presentations that justified admission. Although CTP predict outcome poorly they can be used together with the SCS to rapidly assess the need for admission and to prioritise management.

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Simple bedside assessment of level of consciousness: comparison of two simple assessment scales with the Glasgow Coma scale

Authors: A. F. McNarry, D. R. Goldhill
SUMMARY:

Neurological assessment is an essential component of early warning scores used to identify seriously ill ward patients. We investigated how two simple scales (ACDU – Alert, Confused, Drowsy, Unresponsive; and AVPU – Alert, responds to Voice, responds to Pain, Unresponsive) compared to each other and also to the more complicated Glasgow Coma Scale (GCS). Neurosurgical nurses recorded patients' conscious level with each of the three scales. Over 7 months, 1020 analysable measurements were collected. Both simple scales identified distinct GCS ranges, although some overlap occurred (p < 0.001). Median GCS scores associated with AVPU were 15, 13, 8 and 6 and for ACDU were 15, 13, 10 and 6. The median values of ACDU were more evenly distributed than AVPU and may therefore be better at identifying early deteriorations in conscious level when they occur in critically ill ward patients.

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Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation–Sedation Scale (RASS).

Authors: E. Wesley Ely, MD, MPH; Brenda Truman, RN, MSN; Ayumi Shintani, PhD, MPH; Jason W. W. Thomason, MD; Arthur P. Wheeler, MD; Sharon Gordon, PsyD; Joseph Francis, MD, MPH; Theodore Speroff, PhD; Shiva Gautam, PhD; Richard Margolin, MD; Curtis N. Sessler, MD; Robert S. Dittus, MD, MPH; Gordon R. Bernard, MD
Context

Goal-directed delivery of sedative and analgesic medications is recommended as standard care in intensive care units (ICUs) because of the impact these medications have on ventilator weaning and ICU length of stay, but few of the available sedation scales have been appropriately tested for reliability and validity.

Objective

To test the reliability and validity of the Richmond Agitation-Sedation Scale (RASS).

Design

Prospective cohort study.

Setting

Adult medical and coronary ICUs of a university-based medical center.

Participants

Thirty-eight medical ICU patients enrolled for reliability testing (46% receiving mechanical ventilation) from July 21, 1999, to September 7, 1999, and an independent cohort of 275 patients receiving mechanical ventilation were enrolled for validity testing from February 1, 2000, to May 3, 2001.

Main Outcome Measures

Interrater reliability of the RASS, Glasgow Coma Scale (GCS), and Ramsay Scale (RS); validity of the RASS correlated with reference standard ratings, assessments of content of consciousness, GCS scores, doses of sedatives and analgesics, and bispectral electroencephalography.

Results

In 290-paired observations by nurses, results of both the RASS and RS demonstrated excellent interrater reliability (weighted κ, 0.91 and 0.94, respectively), which were both superior to the GCS (weighted κ, 0.64; P<.001 for both comparisons). Criterion validity was tested in 411-paired observations in the first 96 patients of the validation cohort, in whom the RASS showed significant differences between levels of consciousness (P<.001 for all) and correctly identified fluctuations within patients over time (P<.001). In addition, 5 methods were used to test the construct validity of the RASS, including correlation with an attention screening examination (r = 0.78, P<.001), GCS scores (r = 0.91, P<.001), quantity of different psychoactive medication dosages 8 hours prior to assessment (eg, lorazepam: r = − 0.31, P<.001), successful extubation (P = .07), and bispectral electroencephalography (r = 0.63, P<.001). Face validity was demonstrated via a survey of 26 critical care nurses, which the results showed that 92% agreed or strongly agreed with the RASS scoring scheme, and 81% agreed or strongly agreed that the instrument provided a consensus for goal-directed delivery of medications.

Conclusions

The RASS demonstrated excellent interrater reliability and criterion, construct, and face validity. This is the first sedation scale to be validated for its ability to detect changes in sedation status over consecutive days of ICU care, against constructs of level of consciousness and delirium, and correlated with the administered dose of sedative and analgesic medications.

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The early mortality associated with agitation and sedation in acutely ill medical patients.

Authors: Clifford M., Ridley A., Gleeson M., Kellett J.
SUMMARY

The UK and Ireland have recently introduced a National Early Warning Score (NEWS) as part of the routine assessment of patients [1]. NEWS is determined from the patient's heart and breathing rate, blood pressure, temperature, oxygen saturation, the use of supplemental oxygen and mental alertness. It attributes the same weighting to patients who only respond to voice or pain or who are completely unresponsive. Therefore, like other bedside tools used to assess level of consciousness [2] NEWS only considers how sedated a patient is, and ignores other alterations in mental status such as agitation, a common feature of delirium.

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A global clinical measure of fitness and frailty in elderly people.

Authors: Rockwood K, Song X, MacKnight CA, et al.
ABSTRACT

There is no single generally accepted clinical definition of frailty. Previously developed tools to assess frailty that have been shown to be predictive of death or need for entry into an institutional facility have not gained acceptance among practising clinicians. We aimed to develop a tool that would be both predictive and easy to use. We developed the 7-point Clinical Frailty Scale and applied it and other established tools that measure frailty to 2305 elderly patients who participated in the second stage of the Canadian Study of Health and Aging (CSHA). We followed this cohort prospectively; after 5 years, we determined the ability of the Clinical Frailty Scale to predict death or need for institutional care, and correlated the results with those obtained from other established tools.

The CSHA Clinical Frailty Scale was highly correlated (r = 0.80) with the Frailty Index. Each 1-category increment of our scale significantly increased the medium-term risks of death (21.2% within about 70 mo, 95% confidence interval [CI] 12.5%-30.6%) and entry into an institution (23.9%, 95% CI 8.8%-41.2%) in multivariable models that adjusted for age, sex and education. Analyses of receiver operating characteristic curves showed that our Clinical Frailty Scale performed better than measures of cognition, function or comorbidity in assessing risk for death (area under the curve 0.77 for 18-month and 0.70 for 70-month mortality). Frailty is a valid and clinically important construct that is recognizable by physicians. Clinical judgments about frailty can yield useful predictive information.

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A four item scale based on gait for the immediate global assessment of acutely ill medical patients – one look is more than 1000 words

Authors: Kellett J, Clifford M, Ridley A, Murray A, Gleeson M.
BACKGROUND

Documentation of the global assessment of acutely ill medical patients is time consuming and may detract from patient care.

SETTING

Small Irish rural hospital.

METHODS

The clinical information required for the global assessment of 2954 patients attending the Medical Assessment Unit in a small rural hospital was collected for analysis in a computer database.

RESULTS

A four item scale based on whether the patients had a Stable gait, Unstable gait, needed Help to walk or was Bedridden (i.e. SUHB scale) was strongly correlated with 30-day in-hospital mortality, mental status, history of falls, manual handling requirements, and the presence of pressure sores, dementia and incontinence. The c statistics of the SUHB scale for 30-day in-hospital mortality, mental status, history of falls, manual handling requirements, and the presence of pressure sores, dementia and incontinence were 0.85, 0.79, 0.79, 0.94, 0.80, 0.86 and 0.88, respectively.

CONCLUSION

A four item scale of gait instantly captures almost as much information as detailed documentation.

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Acute Pain Management: Scientific Evidence (3rd edition)

Authors: Macintyre PE, Schug SA, Scott DA, Visser EJ, Walker SM; APM:SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine
FOREWORD

Less than a generation ago the prevalent attitude towards acute pain was widespread acceptance as inevitable, and frequent indifference to its suboptimal management. Now, proper pain management is understood to be a fundamental human right and integral to the ethical, patient-centred and cost-effective practice of modern medicine. This progress is the result of dedicated efforts by health care professionals worldwide, including many in Australia and New Zealand who have contributed to past and present editions of Acute Pain: Scientific Evidence.

The consistently high standards of Acute Pain: Scientific Evidence have established it as the foremost English-language resource of its type worldwide. Changes between successive editions reflect not simply accumulation of clinical evidence in this dynamic field, but also advancing sophistication in methods of evidence synthesis and decision support. Chaired by Associate Professor Pam Macintyre, assisted by many contributors and a distinguished editorial subgroup of Professor Stephan Schug, Associate Professor David Scott, Dr Eric Visser and Dr Suellen Walker, the working party responsible for the Third Edition of Acute Pain: Scientific Evidence have continued to aggregate new clinical evidence and to expand the range of topics.

Even more, they have synthesised and presented the consolidated evidence in a clear, user-friendly fashion and highlighted instances where prior editions’ conclusions have been altered by new findings.

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Validity of 24-h recall ratings of pain severity: biasing effects of “Peak” and “End” pain.

Authors: Jensen MP, Mardekian J, Lakshminarayanan M. Boye ME.
ABSTRACT

Despite the frequent use of pain recall ratings in clinical research, there remains doubt about the ability of individuals to accurately recall their pain. In particular, previous research indicates the possibility that the most pain experienced during a recall period and the most recent pain experienced (known as peak and end effects, respectively) might bias recall ratings. The current study used data from a published clinical trial to determine the relative validity of a 24-h recall rating of average post-operative pain and the nature and extent of any biasing influence of peak and end effects on nine separate 24-h recall ratings. The results supported a statistically significant but small biasing influence of both peak and end pain. Also, the influence of peak pain was stronger than that of end pain. However, the biasing impact of both peak and end pain together was very small, suggesting that 24-h recall ratings are adequately valid indicants of average pain for patients participating in post-surgery clinical pain trials.

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Relationships between measurement of pain using visual analog score and morphine requirements during postoperative intravenous morphine titration.

Authors: Aubrun G, Langeron O, Quesnel C. Coriat P, Riou B.
ABSTRACT

RELIEF of acute pain during the postoperative period is an important task for anesthesiologists. Intravenous administration of opioids is usually recommended for acute pain relief in the immediate postoperative period, 1 and use of small intravenous boluses of morphine in the PACU allows a rapid titration of the dose needed for adequate pain relief. 1–3 Very few studies have assessed morphine titration in the postoperative period, 4,5 and the evolution of pain during intravenous morphine titration is poorly understood. We analyzed a large database of patients receiving titrated intravenous morphine in the immediate postoperative period to study the relationship between the measurement of pain using the visual analog scale (VAS) score and the amount of morphine needed to obtain pain relief. The current study addresses several major issues: (1) Is there a threshold of VAS score that should be considered to be indicative of severe pain? Although several studies have defined minor pain and/or pain relief (VAS score ≤ 30), few previous studies have tried to define severe pain. 6,7 Moreover, these studies actually compared two measurements of pain (VAS and a simplified verbal rating scale) 6,7 that assess the same parameter: the patient's perception of pain. In the current study, we used a variable that is not directly related to the patient's self assessment, i.e. , the amount of morphine required to obtain pain relief. (2) What are the characteristics of the relationship between initial VAS score and subsequent morphine requirements to obtain pain relief? (3) What is the evolution of the VAS score during the pain relief process?

An outstanding feature of the clinical use of opioids is the extraordinary variation in dose requirements for pain management. 8 Therefore, we believed that only a study conducted in a large population would be able to answer to these questions and that the responses would be clinically relevant despite this individual variability.

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Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease (COPD).

Authors: Registered Nurses’ Association of Ontario (2005)
ABSTRACT

This guideline, Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with COPD, will address the nursing assessment and management of stable, unstable and acute dyspnea associated with COPD.

It is acknowledged that individual competencies of nurses vary between nurses and across categories of nursing professionals (RNs and RPNs) and are based on knowledge, skills, attitudes and judgement enhanced over time by experience and education. It is expected that individual nurses will perform only those aspects of care for which they have received appropriate education and experience. Both RNs and RPNs should seek consultation in instances where the patient’s care needs surpass the individual nurse’s ability to act independently.

Although this guideline contains recommendations for Registered Nurses (RNs) and Registered Practical Nurses (RPNs), caring for individuals with chronic obstructive pulmonary disease is an interdisciplinary endeavour. It is acknowledged that effective care depends on a coordinated interdisciplinary approach incorporating ongoing communication between health professionals and patients. Personal preferences and unique needs as well as the personal and environmental resources of each individual patient must always be kept in mind

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Changes and their prognostic implications in the abbreviated VitalPACTM early warning score (ViEWS) after admission to hospital of 18,853 acutely ill medical patients.

Authors: Kellett J, Woodworth S., Wang F., Huang W.
Background

The best performing early warning score is Vitalpac™ Early Warning Score (ViEWS). However, it is not known how often, to what extent and over what time frame any early warning scores change, and what the implications of these changes are.

Setting

Thunder Bay Regional Health Sciences Center, Ontario, Canada.

Methods

The changes in the first three complete sets of the six variables required to retrospectively calculate the abbreviated version of ViEWS (that did not include mental status) after admission to hospital of 18,853 acutely ill medical patients, and their relationship to subsequent in-hospital mortality were examined.

Results

In the 10.4 SD 20.1 (median 5.0) hours between admission and the second recording the score changed in only 5.9% of patients and these changes were of no prognostic value. By the time of the third recording 34.9 SD 21.7 (median 30.0) hours after admission a change in score was clearly associated with a corresponding change in in-hospital mortality (e.g. for patients with an initial score of 5 an increase between the first and third recording of ≥4 points was associated with an increased mortality (OR 6.5 95% CI 2.3–15.9, p < 0.00001), whereas a reduction of ≤−4 points was associated with a reduced mortality (OR 0.4 95% CI 0.2–0.9, p 0.03)).

Conclusion

After a median interval of 30 h both the initial abbreviated ViEWS recording and subsequent changes in it both predict clinical outcome. It remains to be determined what interventions during this time frame will improve patient outcomes.

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Changes and their prognostic implications in the abbreviated VitalPACTM Early Warning Score (ViEWS) after admission to hospital of 18,827 surgical patients.

Authors: Kellett J, Wang F., Woodworth S. Huang W.
Background

It is not known how often, to what extent and over what time frame any early warning scores change in surgical patients, and what the implications of these changes are.

Setting

Thunder Bay Regional Health Sciences Centre, Ontario, Canada.

Methods

The changes in the first three recordings of the abbreviated version of the VitalPAC™ Early Warning Score (ViEWS) after admission to hospital of 18,827 surgical patients, and their relationship to subsequent in-hospital mortality were examined.

Results

In the 2.0 SD 2.4 h between admission and the second recording the score changed in 12.6% of patients. If the initial abbreviated ViEWS was =2 points (78% of all patients) the in-hospital mortality was 0.5%, and not significantly different in the 3.7% of patients that either increased or decreased their score. Patients who had an initial score =3 had a significantly higher overall in-hospital mortality (odds ratio 5.48, Chi-square 120.72, p < 0.0001). Of these patients, those with a lower second score (42.3% of patients) had a significantly lower in-hospital mortality than those with an unchanged second score (i.e. 1.5% versus 3.3%, odds ratio 0.43, Chi-square 11.08, p < 0.001).

Conclusion

The abbreviated ViEWS score measured on admission identifies the majority of surgical patients who are at low risk of in-hospital death. Patients with an initial abbreviated ViEWS =3 who do not reduce their score within 2–3 h of admission have a further significantly increased mortality.

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Trajectories of the averaged abbreviated Vitalpac early warning score (AbEWS) and clinical course of 44,531 consecutive admissions hospitalized for acute medical illness.

Authors: Murray A, Kellett j, Huang W, Woodworth S, Wang F.
Background

It is not known how often, to what extent and over what time frame any early warning scores change, and what the implications of these changes are.

Setting

Thunder Bay Regional Health Sciences Center, Ontario, Canada.

Methods

he averaged vital signs measured over different time periods of 44,531 consecutive acutely ill medical admissions were determined and then combined to calculate the averaged abbreviated version of the Vitalpac early warning score (AbEWS) during each time period examined.

Results

18% of all in-hospital deaths within 30 days are in patients with a low AbEWS on admission. Those admitted with a low AbEWS are more likely to increase their score and those admitted with a high score are more likely to lower it. Paradoxically, patients who have an averaged score over the first 6h in hospital that is lower than on admission have increased in-hospital mortality. Thereafter patients with an increase in the averaged score have almost twice the mortality of those with a decreased score. 4.7% of patients have a low averaged score on the day they die.

Conclusion

AbEWS, without clinical judgment, cannot be used to detect those patients who do not need to be admitted to hospital or are suitable for discharge. A period of observation of at least 12h is required before the trajectory of AbEWS is of prognostic value, and any "improvement" that occurs before this time may be illusory.

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How to follow the NEWS.

Authors: Kellett J, Murray A.
Background

It is not known how best to respond to changes in the National Early Warning Score (NEWS) after hospital admission. This report manipulates and extrapolates previously published data on the trajectories of the abbreviated early warning score (AbEWS i.e. NEWS that does not include mental status).

Methods

Trajectories of averaged AbEWS for patients for their first 5 days in hospital and their last 5 days in hospital were combined to obtain an approximation of what happens to the average patient while in hospital.

Results

The trajectories of patients admitted with a low score are different from those admitted with a high score. Patients should be observed for 12 to 24 hours before their outcome can be predicted. The score of most patients who die in hospital trends upward on the second or third day after admission. Patients admitted with a score of 0-2 who raise their score to >=3 have a ten-fold increase in-hospital mortality.

Conclusion

The trajectories of early warning scores after admission are of prognostic importance, and escalation protocols should relate changes in the score to its initial value on admission.

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Who will be sicker in the morning? Changes in the Simple Clinical Score the day after admission and the subsequent outcomes of acutely ill unselected medical patients

Authors: Kellett J., Emmanel A., Deane B.
Background

All doctors are haunted by the possibility that a patient they reassured yesterday will return seriously ill tomorrow. We examined changes in the Simple Clinical Score (SCS) the day after admission, factors that might influence these changes and the relationship of these changes to subsequent clinical outcome.

Method

The SCS was recorded in 1165 patients on admission and again the following day (i.e. 25.0±15.8 h later). The abilities of 51 variables that might predict changes in the SCS were examined.

Results

The day after admission 16.1% of patients had been discharged home, 31.4% had decreased their SCS by 2.4±1.6 points, 38.6% had an unchanged SCS, 12.0% had increased their SCS by 2.1±1.7 points and 1.2% had died. Patients with an increased SCS had higher in-hospital mortality (10% vs. 1.1%, OR 10.1, p<.001) and a longer length of stay (9.4±9.6 vs. 5.6±7.0 days, p<.001). There was no consistent association between the SCS recorded at admission and SCS increase. Only nursing home residence, heart failure and a Medical Admission Risk System laboratory data score >0.09 were found to be independent predictors of SCS increase.

Conclusion

The SCS of 12% of patients increases the day after admission to hospital, which is associated with a ten-fold increase of in-hospital mortality. Low SCS risk patients are just as likely to have a SCS increase as high risk patients.

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Trends in weighted vital signs and the clinical course of 44,531 acutely ill medical patients while in hospital.

Authors: Kellett J, Murray A, Woodworth S, Huang W.
Background

Little is known about the changes and trends of individual vital signs during the course of acute illness in hospital.

Methods

The weighted points of the VitalPAC Early Warning Score (ViEWS) were assigned to each vital sign value measured on 44,531 acutely ill medical patients while they were hospitalized in the Thunder Bay Regional Health Sciences Centre, Ontario, Canada. These ViEWS weighted vital signs were averaged for every 24 hour period for five days after admission and five days before death or discharge and then combined to obtain an approximation of the trajectory of each vital sign while in hospital.

Results

Compared with the other vital signs, the ViEWS weighted points for respiratory rate increase the most in patients who died in hospital and decrease the most in survivors. Combining respiratory rate with the weighted points for any of the other vital signs reduced rather than increased their monitoring performance.

Conclusion

Trends in respiratory rate, measured by observation at the bedside and given a ViEWS weighting is the best predictor of clinical outcome; minor changes predicted clinical outcome several days in advance.

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Prognosis and Risk Factors for Deterioration in Patients Admitted to a Medical Emergency Department

Authors: Henriksen DP, Brabrand M, Lassen AT
Objective

Patients that initially appear stable on arrival to the hospital often have less intensive monitoring of their vital signs, possibly leading to excess mortality. The aim was to describe risk factors for deterioration in vital signs and the related prognosis among patients with normal vital signs at arrival to a medical emergency department (MED).

Design and Setting

Single-centre, retrospective cohort study of all patients admitted to the MED from September 2010-August 2011.

Subjects

Patients were included when their vital signs (systolic blood pressure, pulse rate, respiratory rate, Glasgow Coma Scale, oxygen saturation and temperature) were within the normal range at arrival. Deterioration was defined as a deviation from the defined normal range 2–24 hours after arrival.

Results

4292 of the 6257 (68.6%) admitted to the MED had a full set of vital signs at first presentation, 1440/4292 (33.6%) had all normal vital signs and were included in study, 44.0% were male, median age 64 years (5th/95th percentile: 21–90 years) and 446/1440 (31.0%) deteriorated within 24 hours. Independent risk factors for deterioration included age 65–84 years odds ratio (OR): 1.79 (95% confidence interval [CI]: 1.27–2.52), 85+ years OR 1.67 (95% CI: 1.10–2.55), Do-not-attempt-to-resuscitate order OR 3.76 (95% CI: 1.37–10.31) and admission from the open general ED OR 1.35 (95% CI: 1.07–1.71). Thirty-day mortality was 7.9% (95% CI: 5.5–10.7%) among deteriorating patients and 1.9% (95% CI: 1.2–3.0%) among the non-deteriorating, hazard ratio 4.11 (95% CI: 2.38–7.10).

Among acutely admitted medical patients who arrive with normal vital signs, 31.0% showed signs of deterioration within 24 hours. Risk factors included old age, Do-not-attempt-to-resuscitate order, admission from the open general ED. Thirty-day mortality among patients with deterioration was four times higher than among non-deteriorating patients. Further research is needed to determine whether intensified monitoring of vital signs can help to prevent deterioration or mortality among medical emergency patients.

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The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation

Authors: Jones AE, Trzeciak S, Kline JA.
Abstract

Organ failure worsens outcome in sepsis. The Sequential Organ Failure Assessment (SOFA) score numerically quantifies the number and severity of failed organs. We examined the utility of the SOFA score for assessing outcome of patients with severe sepsis with evidence of hypoperfusion at the time of emergency department (ED) presentation. Prospective observational study. Urban, tertiary ED with an annual census of >110,000. ED patients with severe sepsis with evidence of hypoperfusion.

Inclusion criteria: suspected infection, two or more criteria of systemic inflammation, and either systolic blood pressure <90 mm Hg after a fluid bolus or lactate >or=4 mmol/L. Exclusion criteria: age <18 years or need for immediate surgery. SOFA scores were calculated at ED recognition (T0) and 72 hours after intensive care unit admission (T72).

The primary outcome was in-hospital mortality. The area under the receiver operating characteristic curve was used to evaluate the predictive ability of SOFA scores at each time point. The relationship between Delta SOFA (change in SOFA from T0 to T72) was examined for linearity. A total of 248 subjects aged 57 +/- 16 years, 48% men, were enrolled over 2 years. All patients were treated with a standardized quantitative resuscitation protocol; the in-hospital mortality rate was 21%. The mean SOFA score at T0 was 7.1 +/- 3.6 points and at T72 was 7.4 +/- 4.9 points. The area under the receiver operating characteristic curve of SOFA for predicting in-hospital mortality at T0 was 0.75 (95% confidence interval 0.68-0.83) and at T72 was 0.84 (95% confidence interval 0.77-0.90).

The Delta SOFA was found to have a positive relationship with in-hospital mortality. The SOFA score provides potentially valuable prognostic information on in-hospital survival when applied to patients with severe sepsis with evidence of hypoperfusion at the time of ED presentation.

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Validations



A comparison of severity of illness scoring systems for intensive care unit patients: results of a multicenter, multinational study. The European/North American Severity Study Group.

Authors: Gauntlett W., Subbe C., Kellett J.
Objective

To compare the performance of three severity of illness scoring systems used commonly for intensive care unit (ICU) patients in a large international data set. The systems analyzed were versions II and III of the Acute Physiology and Chronic Health Evaluation (APACHE) system, versions I and II of the Simplified Acute Physiology Score (SAPS), and versions I and II of the Mortality Probability Model (MPM), computed at admission and after 24 hrs in the ICU.

Design

A multicenter, multinational cohort study.

Setting

One hundred thirty-seven ICUs in 12 European and North American countries.

Patients

During a 3-month period, 14,745 patients were consecutively admitted to 137 ICUs enrolled in the study.

Interventions

Collection of information necessary to compute the APACHE II and APACHE III scores, SAPS I and SAPS II, and MPM I and MPM II scores. Patients were followed until hospital discharges. Statistical comparison, including indices of calibration (goodness-of-fit) and discrimination (area under the receiver operating characteristic curve).

Measurements and Main Results

Despite having acceptable receiver operating characteristic areas, the older versions of the systems analyzed (APACHE II, SAPS, and MPM I computed at admission-MPM I computed after 24 hrs in the ICU) demonstrated poor calibration for the whole database. The new versions of the systems (SAPS II and MPM II) were superior to their older counterparts. This superiority is reflected by larger receiver operating characteristic areas and better fit. The APACHE III system improved its receiver operating characteristic area compared with the APACHE II system, which showed the best fit of the old systems analyzed.

Conclusions

The new versions of the severity systems analyzed (APACHE III, SAPS II, MPM II) perform better than their older counterparts (APACHE II, SAPS I, and MPM I). APACHE II, SAPS II, and MPM II show good discrimination and calibration in this international database.

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Collaborative Audit of Risk Evaluation in Medical Emergency Treatment (CARE-MET I) - an international pilot.

Authors: Subbe C.P., Gauntlett W., Kellett J.
Background

The absence of an accepted model for risk-adjustment of acute medical admissions leads to suboptimal clinical triage and serves as a disincentive to compare outcomes in different hospitals. The Simple Clinical Score (SCS) is a model based on 16 clinical parameters affecting hospital mortality.

Methods

We undertook a feasibility pilot in 21 hospitals in Europe and New Zealand each collecting data for 12 or more consecutive medical emergency admissions. Data from 281 patients was analysed.

Results

Severity of illness as estimated by SCS was related to risk of admission to the Intensive Care Unit (p<0.001) but not to the Coronary Care Unit. Mortality increased from 0% in the Very Low Risk group to 22% in the Very High Risk Group (p<0.0001). Very low scores were associated with earlier discharge as opposed to very high scores (mean length of stay of 2.4 days vs 5.6 days, p<0.001). There were differences in the pattern of discharges in different hospitals with comparable SCS data. Clinicians reported no significant problems with the collection of data for the score in a number of different health care settings.

Conclusion

The SCS appears to be a feasible tool to assist clinical triage of medical emergency admissions. The ability to view the profile of the SCS for different clinical centres opens up the possibility of accurate comparison of outcomes across clinical centres without distortion by different regional standards of health care. This pilot study demonstrates that the adoption of the SCS is practical across an international range of hospitals.

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The simple clinical score: a tool for benchmarking of emergency admissions in acute internal medicine.

Authors: Subbe CP, Jishi F, Hibbs RAB.
Abstract

Quality of care in intensive care and surgery has benefited from establishing comparative standards. At present there is no accepted tool to compare outcomes for emergency admissions in internal medicine. The Simple Clinical Score (SCS) was used in 1098 consecutive medical emergency admissions to adjust mortality for severity of illness. Hospital mortality adjusted for severity of illness and length of stay in the cohort was in keeping with mortality in the Irish derivation study with a trend towards lower mortality in the very high-risk group. Three parameters with poor reproducibility were identified. The SCS has several potential applications: identification of patients with low risk of death suitable for early hospital discharge; early identification of patients with a high risk of death, who will require care in critical care areas (or specialist palliative care); and benchmarking of acute medical departments internationally in a similar way to how APACHE II scoring has been used in critical care units worldwide.

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Assessment of disease-severity scoring systems for patients with sepsis in general internal medicine departments

Authors: Ghanem-Zoubi et al.
Abstract

Due to the increasing burden on hospital systems, most elderly patients with non-surgical sepsis are admitted to general internal medicine departments. Disease-severity scoring systems are used for stratification of patients for utilization management, performance assessment, and clinical research. Some widely used scoring systems for septic patients are inappropriate when rating non-surgical patients in a non-intensive care unit (ICU) environment mainly because their calculations require types of data that are frequently unavailable. This study aimed to assess the fitness of four scoring systems for septic patients hospitalized in general internal medicine departments: modified early warning score (MEWS), simple clinical score (SCS), mortality in emergency department sepsis (MEDS) score, and rapid emergency medicine score (REMS). We prospectively collected computerized data of septic patients admitted to general internal medicine departments in our community-based university hospital. We followed 28-day in-hospital mortality, overall in-hospital mortality, and 30- and 60-day mortality. Using a logistic regression procedure we calculated the area under ROC curve (AUC) for every scoring system. Between February 1st, 2008 and April 30th, 2009 we gathered data of 1,072 patients meeting sepsis criteria on admission to general internal medicine departments. The 28-day mortality was 19.4%. The AUC for the MEWS was 0.65-0.70, for the SCS 0.76-0.79, for the MEDS 0.73-0.75, and for the REMS, 0.74-0.79. Using Hosmer-Lemeshow statistics, a lack of fit was found for the MEDS model. All scoring systems performed better than calculations based on sepsis severity. The SCS and REMS are the most appropriate clinical scores to predict the mortality of patients with sepsis in general internal medicine departments.

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Simple clinical score is associated with mortality and length of stay of acute general medical admissions to an Australian hospital.

Authors: Li JYZ, Yong TY, Hackendorf P, Roberts S, O’Brien L, Sharma Y, et al.
Background

In a rural Irish hospital, a simple clinical score (SCS) determined at the time of admission enabled stratification of acute general medical admissions into five categories that were associated incrementally with patients' immediate and 30-day mortality. The aim of this study was to examine the representative performance of this SCS in predicting the outcomes of general medical admissions to an Australian teaching hospital.

Methods

A retrospective chart review was undertaken of a representative sample from 480 admissions in 2007 to an urban university teaching hospital in Australia. The SCS was calculated and related to that patient's outcome in terms of mortality, length of stay, nursing home placement on discharge, the occurrence of medical emergency team call and intensive care unit transfer. These data were compared, where possible, with the outcomes reported in the Irish hospital.

Results

Four hundred and seventeen complete sets of data allowed calculation of the SCS. There were significant linear correlations of the SCS (divided into quintiles) and patients' in-hospital and 30-day mortality, their length of stay and their discharge to a nursing home. There was no association of the SCS and the patients' readmission rate, intensive care unit transfer rate or likelihood of a medical emergency team call. The significant trends replicated those from the Irish hospital.

Conclusion

The SCS can predict significant outcomes for general medical admissions in an Australian hospital despite obvious differences to the hospital of its derivation. A wider study of Australasian hospitals and the performance of the SCS as a predictor of general medical admission outcomes is underway.

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Simple clinical score is associated with mortality and length of stay of acute general medical admissions to an Australian hospital.

Authors: Li JYZ, Yong TY, Hackendorf P, Roberts S, O’Brien L, Sharma Y, et al.
Background

In a rural Irish hospital, a simple clinical score (SCS) determined at the time of admission enabled stratification of acute general medical admissions into five categories that were associated incrementally with patients' immediate and 30-day mortality. The aim of this study was to examine the representative performance of this SCS in predicting the outcomes of general medical admissions to an Australian teaching hospital.

Methods

A retrospective chart review was undertaken of a representative sample from 480 admissions in 2007 to an urban university teaching hospital in Australia. The SCS was calculated and related to that patient's outcome in terms of mortality, length of stay, nursing home placement on discharge, the occurrence of medical emergency team call and intensive care unit transfer. These data were compared, where possible, with the outcomes reported in the Irish hospital.

Results

Four hundred and seventeen complete sets of data allowed calculation of the SCS. There were significant linear correlations of the SCS (divided into quintiles) and patients' in-hospital and 30-day mortality, their length of stay and their discharge to a nursing home. There was no association of the SCS and the patients' readmission rate, intensive care unit transfer rate or likelihood of a medical emergency team call. The significant trends replicated those from the Irish hospital.

Conclusion

The SCS can predict significant outcomes for general medical admissions in an Australian hospital despite obvious differences to the hospital of its derivation. A wider study of Australasian hospitals and the performance of the SCS as a predictor of general medical admission outcomes is underway.

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Risk scoring systems for adults admitted to the emergency department: a systematic review

Authors: Brabrand M, Folkestad L, Clausen NG, Knudsen T, Hallas J.
Background

Patients referred to a medical admission unit (MAU) represent a broad spectrum of disease severity. In the interest of allocating resources to those who might potentially benefit most from clinical interventions, several scoring systems have been proposed as a triaging tool. Even though most scoring systems are not meant to be used on an individual level, they can support the more inexperienced doctors and nurses in assessing the risk of deterioration of their patients. We therefore performed a systematic review on the level of evidence of literature on scoring systems developed or validated in the MAU. We hypothesized that existing scoring systems would have a low level of evidence and only few systems would have been externally validated.

Methods

We conducted a systematic search using Medline, EMBASE and the Cochrane Library, according to the PRISMA guidelines, on scoring systems developed to assess medical patients at admission. The primary endpoints were in-hospital mortality or transfer to the intensive care unit. Studies derived for only a single or few diagnoses were excluded. The ability to identify patients at risk (discriminatory power) and agreement between observed and predicted outcome (calibration) along with the method of derivation and validation (application on a new cohort) were extracted.

Results

We identified 1,655 articles. Thirty were selected for further review and 10 were included in this review. Eight systems used vital signs as variables and two relied mostly on blood tests.Nine systems were derived using regression analysis and eight included patients admitted to a MAU. Six systems used in-hospital mortality as their primary endpoint. Discriminatory power was specified for eight of the scoring systems and was acceptable or better in five of these. The calibration was only specified for four scoring systems. In none of the studies impact analysis or inter-observer reliability were analyzed. None of the systems reached the highest level of evidence.

Conclusion

None of the 10 scoring systems presented in this article are perfect and all have their weaknesses. More research is needed before the use of scoring systems can be fully implemented to the risk assessment of acutely admitted medical patients.

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External Validation of the Simple Clinical Score and the HOTEL Score, Two Scores for Predicting Short-Term Mortality after Admission to an Acute Medical Unit

Authors: Stræde M, Brabrand M
Background

Clinical scores can be of aid to predict early mortality after admission to a medical admission unit. A developed scoring system needs to be externally validated to minimise the risk of the discriminatory power and calibration to be falsely elevated. We performed the present study with the objective of validating the Simple Clinical Score (SCS) and the HOTEL score, two existing risk stratification systems that predict mortality for medical patients based solely on clinical information, but not only vital signs.

Methods

Pre-planned prospective observational cohort study.

Setting

Danish 460-bed regional teaching hospital.

Results

We included 3046 consecutive patients from 2 October 2008 until 19 February 2009. 26 (0.9%) died within one calendar day and 196 (6.4%) died within 30 days. We calculated SCS for 1080 patients. We found an AUROC of 0.960 (95% confidence interval [CI], 0.932 to 0.988) for 24-hours mortality and 0.826 (95% CI, 0.774–0.879) for 30-day mortality, and goodness-of-fit test, χ2 = 2.68 (10 degrees of freedom), P = 0.998 and χ2 = 4.00, P = 0.947, respectively. We included 1470 patients when calculating the HOTEL score. Discriminatory power (AUROC) was 0.931 (95% CI, 0.901–0.962) for 24-hours mortality and goodness-of-fit test, χ2 = 5.56 (10 degrees of freedom), P = 0.234.

Conclusion

We find that both the SCS and HOTEL scores showed an excellent to outstanding ability in identifying patients at high risk of dying with good or acceptable precision.

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Validation of an abbreviated Vitalpac™ Early Warning Score (ViEWS) in 75,419 consecutive admissions to a Canadian regional hospital.

Authors: Kellett J, Kim A.
Background

The early warning score derived from 198,755 vital sign sets in the Vitalpac™ database (ViEWS) has an area under the receiver operator characteristic curve (AUROC) for death of acute unselected medical patients within 24h of 88%.

Methods

This study validated an abbreviated version of ViEWS, which did not include mental status, in 75,419 consecutive patients admitted to the Thunder Bay Regional Health Sciences Center between 2005 and 2010.

Results

The abbreviated score had an AUROC for death within 48 h of admission of 93% for all patients and 89% for medical patients - there were no significant differences in the discrimination of the score between surgical and medical patients or patients admitted to different medical sub-specialty services. The AUROC for intensive care patients, however, was significantly lower at 72%. Although medical patients appeared to have a higher mortality than surgical patients with the same score, these only reached statistical significance for surgical patients with a score between 3 and 10 points, stroke patients between 3 and 6 points, oncology patients between 7 and 10 points, and ICU patients with 3 or more points.

Conclusion

The abbreviated ViEWS score has comparable discrimination to the original score and has reasonable "goodness of fit" for most patients except for those requiring intensive care.

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Validation of the VitalPAC™ Early Warning Score (ViEWS) in acutely ill medical patients attending a resource-poor hospital in sub-Saharan Africa.

Authors: Opio MO, Nansubuga G., Kellett J.
Background

The VitalPAC™ Early Warning Score (ViEWS) has an area under the receiver operator characteristic curve (AUROC) for death of acute unselected medical patients within 24h of 88% and the UK National Early Warning Scores is based on it. The score's discrimination has been validated on patients in the developed world, but nothing is known of its performance in resource-poor hospitals.

Methods

ViEWS was validated in 844 acutely ill medical patients admitted to Kitovu Hospital, Masaka, Uganda.

Results

The AUROC for death within 24h of admission was 88.6% (95% CI 82.5-94.7%). The inability to walk without help was found to be an additional independent predictor of in-hospital mortality, and ViEWS modified to include it had an AUROC for death within 24h of 91.9% (95% CI 86.5-97.2%).

Conclusion

The discrimination of ViEWS in a resource poor sub-Saharan Africa hospital is the same as in the developed world. Inability to walk without help was found to be an additional independent predictor of mortality.

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Validation of the VitalPACTM Early Warning Score (ViEWS) in acutely ill medical patients admitted to a Model 2 Irish hospital

Authors: Kellett J., Clifford M., Ridley A., Gleeson M.
Background

The VitalPAC early warning score (ViEWS) has an area under the receiver operator characteristic curve (AUROC) for death of acute unselected medical patients within 24h of 88% and the UK and Irish National Early Warning Scores are based on it. So far the score’s discrimination has not been validated in an Irish hospital

Methods

The vital signs of all patients admitted to Nenagh Hospital through its Medical Assessment Unit(MAU) between August 6th 2011 and November 23rd 2012 were entered into a computer program that automatically calculated ViEWS. During the study period 3117 patients were admitted to the hospital of whom 86 died (2.8%) - the MAU admitted 81% of these patients. Data on 2519individual patients and 8,823 sets ofvital signs were recorded.

Results

77 of the patients entered into the study (3.1%) died in hospital and36 of these patients (1.4%) died within 24 hours of their vital signs being recorded. No deaths occurred within 24 hours in the 982 patients with a ViEWS value of zero, and only 5 deaths occurred in patients with a ViEWS value from 1-3. The AUROC for ViEWS was 90.8% (95% CI 84.2-97.3%).

Conclusion

The discrimination of ViEWS in Nenagh General Hospital is the same as originally reported in UK patients.

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In-hospital mortality of acutely ill medical patients admitted to a resource poor hospital in sub-Saharan Africa and to a Canadian regional hospital compared using the abbreviated VitalPAC Early Warning Score.

Authors: OpioMO, Nansubuga G., Kellett J
Background

The development of validated early warning scores that only require the measurement of vital signs at the bedside has provided for the first time a practical and affordable method of comparing the outcomes of similar patients admitted to hospital in the developed and developing world.

Methods

We compared the outcomes of patients with the same abbreviated version of the VitalPAC early warning score at the time of hospital admission in a Canadian and Ugandan hospital. 844 acutely ill medical patients admitted to Kitovu Hospital, Masaka, Uganda and 48,696 patients admitted to the Thunder Bay Regional Health Sciences Centre (TBRHSC), Ontario, Canada were examined.

Results

Apart from those patients with an abbreviated ViEWS value of 10 there was no statistically significant difference in the in-hospital mortality of Kitvou and TBRHSC patients with the same score on admission. Using arbitrary ranges of the abbreviated ViEWS the 30day Kaplan-Meier survival curves of Kitovu patients were either the same or better than those of TBRHSC patients.

Conclusion

The in-hospital mortality of patients with the same abbreviated ViEWS on hospital admission is similar in TBRHSC and Kitovu Hospital.

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Early warning scores generated in developed healthcare settings are not sufficient at predicting early mortality in Blantyre, Malawi: a prospective cohort study.

Authors: Wheeler I., Price C., Sitch A., Banda P., Kellett J., Nyirenda M., Rylance J.
Aim

Early warning scores (EWS) are widely used in well-resourced healthcare settings to identify patients at risk of mortality. The Modified Early Warning Score (MEWS) is a well-known EWS used comprehensively in the United Kingdom. The HOTEL score (Hypotension, Oxygen saturation, Temperature, ECG abnormality, Loss of independence) was developed and tested in a European cohort; however, its validity is unknown in resource limited settings. This study compared the performance of both scores and suggested modifications to enhance accuracy.

Methods

A prospective cohort study of adults (≥18 yrs) admitted to medical wards at a Malawian hospital. Primary outcome was mortality within three days. Performance of MEWS and HOTEL were assessed using ROC analysis. Logistic regression analysis identified important predictors of mortality and from this a new score was defined.

Results

Three-hundred-and-two patients were included. Fifty-one (16.9%) died within three days of admission. With a cut-point ≥2, the HOTEL score had sensitivity 70.6% (95% CI: 56.2 to 82.5) and specificity 59.4% (95% CI: 53.0 to 65.5), and was superior to MEWS (cut-point ≥5); sensitivity: 58.8% (95% CI: 44.2 to 72.4), specificity: 56.2% (95% CI: 49.8 to 62.4). The new score, dubbed TOTAL (Tachypnoea, Oxygen saturation, Temperature, Alert, Loss of independence), showed slight improvement with a cut-point ≥2; sensitivity 76.5% (95% CI: 62.5 to 87.2) and specificity 67.3% (95% CI: 61.1 to 73.1).

Conclusion

Using an EWS generated in developed healthcare systems in resource limited settings results in loss of sensitivity and specificity. A score based on predictors of mortality specific to the Malawian population showed enhanced accuracy but not enough to warrant clinical use. Despite an assumption of common physiological responses, disease and population differences seem to strongly determine the performance of EWS. Local validation and impact assessment of these scores should precede their adoption in resource limited settings

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Supporting Papers



The diagnoses and co-morbidity encountered in the hospital practice of acute internal medicine.

Authors: Kellett J., Deane B
Background

The exact medical conditions that every internist needs to know how to diagnose and treat have seldom been explicitly stated. This paper reports an analysis of the conditions, as identified by ICD9 coding, cared for by general internists working in a representative Irish hospital.

Methods

In this observational study covering the period from February 17, 2000 to January 29, 2004, the ICD9 codes and mortality of 9214 consecutive patients admitted as acute medical emergencies were examined.

Results

The mean number of ICD9 codes per patient was 4.0+/-1.8 (median 4.0 codes); 935 patients (10.1%) had one ICD9 code and 2972 (32.3%) had six ICD9 codes recorded at the time of discharge. As the number of ICD9 codes recorded increased, so did patient age, 30-day mortality and length of hospital stay. Thirty-four conditions were found to be associated with a statistically significant increased risk of 30-day mortality, and eight with a significantly reduced risk. Of the remaining conditions (i.e. those with neither an increased nor reduced risk of mortality), 32 were observed in 1% or more of all patients.

Discussions

Nearly all of the clinical presentations encountered are encompassed within an average of four combinations of 74 conditions, 34 of which are associated with an increased risk of death.

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Derivation and validation of a score based on Hypotension, Oxygen saturation, low Temperature, ECG changes and Loss of independence (HOTEL) that predicts early mortality between 15 min and 24 h after admission to an acute medical unit.

Authors: Kellett J., Deane B., Gleeson M.
Background

Predictive scores such as APACHE II have been used to assess patients in intensive care units, but few scores have been used to assess acutely ill general medical patients.

Design

Examination of the ability of clinical variables documented at the time of admission to predict early mortality between 15 min and 24 h after admission.

Setting

An Irish rural hospital.

Subjects

10,290 consecutive patients admitted as acute medical emergencies, divided into a derivation cohort of 6947 patients and a validation cohort of 3343 patients.

Results

40 patients of the derivation cohort (0.6%) died within 24h of hospital admission. Multivariate analysis revealed 11 independent predictors of early death from which a simplified model with minimal loss of predictive ability was derived. Since this model contained only the five variables of Hypotension (systolic blood pressure<100 mm Hg), low Oxygen saturation (<90%), low Temperature (<35 degrees C, abnormal ECG and Loss of independence (unable to stand unaided) it was named the HOTEL score (one point for each variable). There were no differences in the early mortality predicted by this score between the derivation and validation cohorts-the area under the receiver operator characteristic curves for the derivation and validation cohorts were 86.5% and 85.4%, respectively. None of the patients with a score of zero died within 15 min and 24 h and a score of one had an early mortality of 0.3% in both cohorts. A score of two had an early mortality of 0.9% in the derivation cohort and 1.7% in the validation cohort, while a score of three or greater had an early mortality of 10.2% in the derivation and 5.6% the validation cohort.

Conclusion

The HOTEL score quickly identifies patients at a low and high risk of death between 15 min and 24 h after admission, thus enabling prompt triage and placement within a health care facility.

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What diagnoses may make patients more seriously ill than they first appear? Mortality according to the Simple Clinical Score Risk Class at the time of admission compared to the observed mortality of different ICD9 codes identified on death or discharge

Authors: Kellett J.,Deane B.
Background

The Simple Clinical Score (SCS) determined at the time of admission places acutely ill general medical patients into one of five risk classes associated with an increasing risk of death within 30 days. The cohort of acute medical patient that the SCS was derived from had, on average, four combinations of 74 groupings of ICD9 codes. This paper reports the ICD9 codes associated with the different SCS risk classes and identifies those ICD9 codes with a greater observed mortality than that of other patients in the same SCS risk class.

Design

Observational study.

Setting

A small Irish rural hospital.

Methods

The 30-day mortality rates of the 74 commonest ICD9 groupings coded at the time of discharge of 9214 consecutive acutely ill medical patients were compared with the mortality rates associated with their SCS risk class determined at the time of their admission.

Results

There was no difference between the observed and the predicted mortality rates for very low risk patients regardless of ICD9 groupings, even though several of these patients suffered from all but two of the 34 ICD9 code groupings associated with an increased risk of death. Within the remaining four risk classes only 14 ICD9 groupings had an observed mortality greater from that of all other patients in the same SCS risk class.

Conclusion

The Simple Clinical Score (SCS) determined at the time of admission identifies patients at very low risk of death regardless of what diagnoses are subsequently made during their hospitalisation. Nevertheless, patients with a very low risk of death according to their SCS risk class may still have a life-threatening condition that requires treatment in hospital. For higher risk patients only 14 ICD9 code groupings were associated with an observed mortality greater than that of others in the same SCS risk group.

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A pragmatic triage system to reduce length of stay in medical emergency admission: feasibility study and health economic analysis.

Authors: Subbe CP, Kellett J, Whitaker CJ, Jishi F, White A, Price S, Ward-Jones J, Hubbard RE, Eeles E, Williams.
Background

Departments of Internal Medicine tend to treat patients on a first come first served basis. The effects of using triage systems are not known.

Methods

We studied a cohort in an Acute Medical Unit (AMU). A computer-assisted triage system using acute physiology, pre-existing illness and mobility identified five distinct risk categories. Management of the category of very low risk patients was streamlined by a dedicated Navigator. Main outcome parameters were length of hospital stay (LOS) and overall costs. Results were adjusted for the degree of frailty as measured by the Clinical Frailty Scale (CFS). A six month baseline phase and intervention phase were compared.

Results

6764 patients were included: 3084 in the baseline and 3680 in the intervention phase. Patients with very low risk of death accounted for 40% of the cohort. The LOS of the 1489 patients with very low risk of death in the intervention group was reduced by a mean of 1.85days if compared with the 1276 patients with very low risk in the baseline cohort. This was true even after adjustment for frailty. Over the six month period the cost of care was reduced by £250,158 in very low patients with no increase in readmissions or 30 day mortality.

Conclusion

Implementation of an advanced triage system had a measurable impact on cost of care for patients with very low risk of death. Patients were safely discharged earlier to their own home and the intervention was cost-effective.

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When should a doctor see me when I get sick? A study of the time of day acutely ill medical patients present and the time they wait to see a doctor in Ireland.

Authors: Kellett J, Deane B.
Background

Reconfiguration of the Irish Health Service has diverted of large numbers of acutely ill medical patients to a reduced number of hospitals and may have caused in delays in treatment. Although prompt care improves outcomes for patients with acute myocardial infarction, stroke, infection and shock, there is surprisingly little evidence for its value in other conditions.

Methods

The time of admission and time patients waited to be seen and clerked by a doctor was reviewed on all medical patients admitted to Nenagh Hospital prior to service reconfiguration (i.e. from 17 February 2000 to 6 March 2004).

Results

Over the study period of 1442, days 9435 patients were admitted (i.e. 6.5 patients per day or 0.3 per hour) and waited 37.6 SD 53.1 min after admission before they were seen by a doctor. The peak time of admission is in the late afternoon and early evening and there was a liner correlation between the delay before seeing a doctor and the time of admission. The 1095 patients who waited 80 min or more to be seen and clerked by a doctor (median delay 120 min) were more likely to die (odds ratio 1.36 95% CI 1.03–1.81, p <0.03).

Conclusion

Waiting to be seen by a doctor may increase the risk of death to some patients. For these patients it is probably safer to be seen quickly by any doctor, rather than travel many miles and wait several hours to see a better one.

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The prediction of the in-hospital mortality of acutely ill medical patients by electrocardiogram (ECG) dispersion mapping compared with established risk factors and predictive scores--a pilot study.

Authors: Kellett J, Rasool S.
Objective

ECG dispersion mapping (ECG-DM) is a novel technique that analyzes low amplitude ECG oscillations and reports them as the myocardial micro-alternation index (MMI). This study compared the ability of ECG-DM to predict in-hospital mortality with traditional risk factors such as age, vital signs and co-morbid diagnoses, as well as three predictive scores: the Simple Clinical Score (SCS)--based on clinical and ECG findings, and two Medical Admission Risk System scores--one based on vital signs and laboratory data (MARS), and one only on laboratory data (LD).

Methods

A convenient sample of 455 acutely ill medical patients (mean age 69.7±14.0 years) had their vital signs, mental and functional status recorded and a 12 lead ECG, routine laboratory investigations and ECG-DM performed immediately after admission to hospital. Each patient's in-hospital course and diagnoses at death or discharge were reviewed.

Results

Of the vital signs only oxygen saturation and respiratory rate were statistically significant predictors of death. The continuous variables that predicted death the best were: MARS, SCS, LD, white cell count and MMI. The categorical variables that predicted in-hospital mortality with highest Chi-square were: a diagnosis of stroke, SCS>=12, LD>0.10, MARS>0.09 and MMI>36%.

Conclusion

ECG-DM may be a clinically useful predictor of in-hospital mortality. ECG-DM is inexpensive, only takes a few seconds to perform and requires no skill to interpret.

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ECG dispersion mapping predicts clinical deterioration, measured by increase in the Simple Clinical Score.

Authors: Kellett J, Emmanuel A, Rasool S.
Objective

ECG dispersion mapping (ECG-DM) is a novel technique that reports abnormal ECG microalternations. We report the ability of ECG-DM to predict clinical deterioration of acutely ill medical patients, as measured by an increase in the Simple Clinical Score (SCS) the day after admission to hospital.

Methods

453 acutely ill medical patients (mean age 69.7 +/- 14.0 years) had the SCS recorded and ECGDM performed immediately after admission to hospital.

Results

46 patients had an SCS increase 20.8 +/- 7.6 hours after admission. Abnormal micro-alternations during left ventricular re-polarization had the highest association with SCS increase (p=0.0005). Logistic regression showed that only nursing home residence and abnormal micro-alternations during re-polarization of the left ventricle were independent predictors of SCS increase with an odds ratio of 2.84 and 3.01, respectively.

Conclusion

ECG-DM changes during left ventricular re-polarization are independent predictors of clinical deterioration the day after hospital admission.

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