Original Contributions| Volume 58, ISSUE 6, P882-891, June 2020

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National Early Warning Score Is Modestly Predictive of Care Escalation after Emergency Department-to-Floor Admission



      Decompensation on the medical floor is associated with increased in-hospital mortality.


      Our aim was to determine the accuracy of the National Early Warning Score (NEWS) in predicting early, unplanned escalation of care in patients admitted to the hospital from the emergency department (ED) compared to the Shock Index (SI) and the quick Sepsis-Related Organ Failure Assessment (qSOFA) score.


      We conducted a retrospective cohort study of patients admitted directly from the ED to monitored or unmonitored beds (November 9, 2015 to April 30, 2018) in 3 hospitals. Interhospital transfers were excluded. Patient data, vital status, and bed assignment were extracted from the electronic medical record. Scores were calculated using the last set of vital signs prior to leaving the ED. Primary endpoint was in-hospital death or placement in an intermediate or intensive care unit within 24 h of admission from the ED. Scores were compared using the area under the receiver operating curve (AUROC).


      Of 46,018 ED admissions during the study window, 39,491 (85.8%) had complete data, of which 3.7% underwent escalation in level of care within 24 h of admission. NEWS outperformed (AUROC 0.69; 95% confidence interval [CI] 0.68–0.69) qSOFA (AUROC 0.63; 95% CI 0.62–0.63; p < 0.001) and SI (AUROC 0.60; 95% CI 0.60–0.61; p < 0.001) at predicting unplanned escalations or death at 24 h.


      This multicenter study found NEWS was superior to the qSOFA score and SI in predicting early, unplanned escalation of care for ED patients admitted to a general medical-surgical floor.


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        • Liu V.
        • Kipnis P.
        • Rizk N.W.
        • Escobar G.J.
        Adverse outcomes associated with delayed intensive care unit transfers in an integrated healthcare system.
        J Hosp Med. 2012; 7: 224-230
        • Escobar G.J.
        • Greene J.D.
        • Gardner M.N.
        • Marelich G.P.
        • Quick B.
        • Kipnis P.
        Intra-hospital transfers to a higher level of care: contribution to total hospital and intensive care unit (ICU) mortality and length of stay (LOS).
        J Hosp Med. 2011; 6: 74-80
        • Escarce J.J.
        • Kelley M.A.
        Admission source to the medical intensive care unit predicts hospital death independent of APACHE II score.
        JAMA. 1990; 264: 2389-2394
        • Goldhill D.R.
        • Sumner A.
        Outcome of intensive care patients in a group of British intensive care units.
        Crit Care Med. 1998; 26: 1337-1345
        • Subbe C.P.
        • Kruger M.
        • Rutherford P.
        • Gemmel L.
        Validation of a modified Early Warning Score in medical admissions.
        QJM. 2001; 94: 521-526
        • Smith G.B.
        • Prytherch D.R.
        • Meredith P.
        • Schmidt P.E.
        • Featherstone P.I.
        The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death.
        Resuscitation. 2013; 84: 465-470
        • Churpek M.M.
        • Snyder A.
        • Han X.
        • et al.
        qSOFA, SIRS, and Early Warning Scores for detecting clinical deterioration in infected patients outside the ICU.
        Am J Respir Crit Care Med. 2017; 195: 906-911
        • Jarvis S.
        • Kovacs C.
        • Briggs J.
        • et al.
        Can binary early warning scores perform as well as standard early warning scores for discriminating a patient’s risk of cardiac arrest, death or unanticipated intensive care unit admission?.
        Resuscitation. 2015; 93: 46-52
        • Jones M.
        NEWSDIG: The National Early Warning Score Development and Implementation Group.
        Clin Med. 2012; 12: 501-503
        • Churpek M.M.
        • Yuen T.C.
        • Huber M.T.
        • Park S.Y.
        • Hall J.B.
        • Edelson D.P.
        Predicting cardiac arrest on the wards: a nested case-control study.
        Chest. 2012; 141: 1170-1176
        • Smith M.E.B.
        • Chiovaro J.C.
        • O’Neil M.
        • et al.
        Early Warning System scores for clinical deterioration in hospitalized patients: a systematic review.
        Ann Am Thorac Soc. 2014; 11: 1454-1465
        • Churpek M.M.
        • Yuen T.C.
        • Park S.Y.
        • Meltzer D.O.
        • Hall J.B.
        • Edelson D.P.
        Derivation of a cardiac arrest prediction model using ward vital signs.
        Crit Care Med. 2012; 40: 2102-2108
        • Henning D.J.
        • Bhatraju P.K.
        • Johnson N.J.
        • et al.
        Physician judgment and circulating biomarkers predict 28-day mortality in emergency department patients.
        Crit Care Med. 2019; 47: 1513-1521
        • Alam N.
        • Vegting I.L.
        • Houben E.
        • et al.
        Exploring the performance of the National Early Warning Score (NEWS) in a European emergency department.
        Resuscitation. 2015; 90: 111-115
        • Alam N.
        • Hobbelink E.L.
        • van Tienhoven A.J.
        • van de Ven P.M.
        • Jansma E.P.
        • Nanayakkara P.W.B.
        The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review.
        Resuscitation. 2014; 85: 587-594
        • Raith E.P.
        • Udy A.A.
        • Bailey M.
        • et al.
        Prognostic accuracy of the SOFA score, SIRS criteria, and qSOFA score for in-hospital mortality among adults with suspected infection admitted to the intensive care unit.
        JAMA. 2017; 317: 290-300
        • Rady M.Y.
        • Smithline H.A.
        • Blake H.
        • Nowak R.
        • Rivers E.
        A comparison of the shock index and conventional vital signs to identify acute, critical illness in the emergency department.
        Ann Emerg Med. 1994; 24: 685-690
        • Hanley J.A.
        • McNeil B.J.
        The meaning and use of the area under a receiver operating characteristic (ROC) curve.
        Radiology. 1982; 143: 29-36
        • DeLong E.R.
        • DeLong D.M.
        • Clarke-Pearson D.L.
        Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach.
        Biometrics. 1988; 44: 837-845
        • Royal College of Physicians
        National Early Warning Score (NEWS) 2.
        (Available at:)
        • Youden W.J.
        Index for rating diagnostic tests.
        Cancer. 1950; 3: 32-35
        • Montoya K.F.
        • Charry J.D.
        • Calle-Toro J.S.
        • Núñez L.R.
        • Poveda G.
        Shock index as a mortality predictor in patients with acute polytrauma.
        J Acute Dis. 2015; 4: 202-204
        • Hwang S.Y.
        • Jo I.J.
        • Lee S.U.
        • et al.
        Low accuracy of positive qSOFA criteria for predicting 28-day mortality in critically ill septic patients during the early period after emergency department presentation.
        Ann Emerg Med. 2018; 71: 1-9.e2
        • Centers for Medicare and Medicaid Services
        Defining the Medicare Severity Diagnosis Related Groups (MS-DRGs), version 34.0.
        (Available at:)
        • Pimentel M.A.F.
        • Redfern O.C.
        • Gerry S.
        • et al.
        A comparison of the ability of the National Early Warning Score and the National Early Warning Score 2 to identify patients at risk of in-hospital mortality: a multi-centre database study.
        Resuscitation. 2019; 134: 147-156
        • Ruger J.P.
        • Lewis L.M.
        • Richter C.J.
        Identifying high-risk patients for triage and resource allocation in the ED.
        Am J Emerg Med. 2007; 25: 794-798
        • Marco C.A.
        • Schoenfeld C.N.
        • Keyl P.M.
        • Menkes E.D.
        • Doehring M.C.
        Abdominal pain in geriatric emergency patients: variables associated with adverse outcomes.
        Acad Emerg Med. 1998; 5: 1163-1168
        • Irvin T.T.
        Abdominal pain: a surgical audit of 1190 emergency admissions.
        Br J Surg. 1989; 76: 1121-1125
        • Tolentino J.C.
        • Stoltzfus J.C.
        • Harris R.
        • et al.
        Comorbidity-polypharmacy score predicts readmissions and in-hospital mortality: a six-hospital health network experience.
        J Basic Clin Pharm. 2017; 8 (Available at:): 98-103
        • Evans D.C.
        • Cook C.H.
        • Christy J.M.
        • et al.
        Comorbidity-polypharmacy scoring facilitates outcome prediction in older trauma patients.
        J Am Geriatr Soc. 2012; 60: 1465-1470
        • Wengerter B.C.
        • Pei K.Y.
        • Asuzu D.
        • Davis K.A.
        Rothman Index variability predicts clinical deterioration and rapid response activation.
        Am J Surg. 2018; 215: 37-41
        • van Rooijen C.R.
        • de Ruijter W.
        • van Dam B.
        Evaluation of the threshold value for the Early Warning Score on general wards.
        Neth J Med. 2013; 71 (Available at:): 38-43 = 1264
        Date accessed: September 26, 2019
        • Drower D.
        • McKeany R.
        • Jogia P.
        • Jull A.
        Evaluating the impact of implementing an early warning score system on incidence of in-hospital cardiac arrest.
        N Z Med J. 2013; 126 (Available at:): 26-34
        Date accessed: September 26, 2019
        • Gardner-Thorpe J.
        • Love N.
        • Wrightson J.
        • Walsh S.
        • Keeling N.
        The value of Modified Early Warning Score (MEWS) in surgical in-patients: a prospective observational study.
        Ann R Coll Surg Engl. 2006; 88: 571-575
        • Wolkewitz M.
        • Vonberg R.P.
        • Grundmann H.
        • et al.
        Risk factors for the development of nosocomial pneumonia and mortality on intensive care units: application of competing risks models.
        Crit Care. 2008; 12: R44
        • Donowitz L.G.
        • Wenzel R.P.
        • Hoyt J.W.
        High risk of hospital-acquired infection in the ICU patient.
        Crit Care Med. 1982; 10: 355-357
        • Pittet D.
        • Tarara D.
        • Wenzel R.P.
        Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality.
        JAMA. 1994; 271: 1598-1601
        • Mochizuki K.
        • Shintani R.
        • Mori K.
        • et al.
        Importance of respiratory rate for the prediction of clinical deterioration after emergency department discharge: a single-center, case-control study.
        Acute Med Surg. 2016; 4: 172-178
        • Heitz C.R.
        • Gaillard J.P.
        • Blumstein H.
        • Case D.
        • Messick C.
        • Miller C.D.
        Performance of the maximum modified early warning score to predict the need for higher care utilization among admitted emergency department patients.
        J Hosp Med. 2010; 5: E46-E52