Early warning scores in the emergency department to identify patients at risk of sepsis and death: A retrospective cohort pilot study
CCCF ePoster library. Skitch S. Nov 1, 2016; 150969; 88
Dr. Steven Skitch
Dr. Steven Skitch
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Topic: Retrospective or Prospective Cohort Study

Early warning scores in the emergency department to identify patients at risk of sepsis and death: A retrospective cohort pilot study

Skitch, Steven1,2; Vu, Anthony3; McInnis, Laura3; Benjamin, Tam1; Xu, Michael4; Fox-Robichaud, Alison1.
1Divison of Critical Care Medicine, McMaster University, Hamilton, Canada; 2Divison of Emergency Medicine, McMaster University, Hamilton, Canada; 3Medical student, McMaster University, Hamilton, Canada; 4Masters of Health Research Methodology Candidate, McMaster University, Canada. 

Grant acknowledgements:
This project received funding from the Hamilton Health Sciences Resident Research Grant in Patient Safety as well as the Hamilton Health Sciences Department Quality and Patient Safety Award awarded to Benjamin Tam. Funding parties were not involved in the design of the study.


Introduction: Early warning scores (EWSs) use physiological variables to identify patients at risk of deterioration. EWSs may be useful in the emergency department (ED) to facilitate recognition of sepsis (1-2). The Hamilton Early Warning Score (HEWS) was developed as part of quality improvement process in our health system (see Table 1). HEWS was found to be a significant predictor of critical inpatient events and when combined with a critical care outreach team reduced the incidence of cardiac arrest and death (3). The current study examined HEWS at ED triage among a cohort of admitted patients.

Objectives: To examine the predictive ability of HEWS at ED triage as a predictor of sepsis and in-hospital mortality among a cohort of patients admitted to hospital via the ED.
Methods: This study is a retrospective analysis of a database of consecutive admitted ward patients during the six-month implementation of HEWS monitoring at two tertiary academic centers. Patients who experienced a critical event during admission and were admitted via the ED were included. Critical events were defined as death, cardiac arrest, or ICU transfer. Controls were randomly selected from the database in a two-to-one ratio using an algorithm to match index patients based upon burden of comorbid illness. HEWS for each patient was calculated based upon triage vitals. Patients who met systemic inflammatory response syndrome criteria and were admitted with an infection related diagnoses were considered septic. Receiver operator characteristic (ROC) curves were used to evaluate HEWS at ED triage as a predictor of likelihood of meeting criteria for sepsis and for in-hospital mortality among septic patients. Only patients with complete ED data were included in analysis.  
Results: The final sample of 740 patients included 109 patients (15%) who met criteria for sepsis and 157 patients (21%) who died while in-hospital. Table 2 presents the demographic characteristics for septic and non-septic patients. Septic patients were significantly more likely to arrive by ambulance, to be assigned a Canadian Triage and Acuity Scale (CTAS) level of at least II, and to die while in-hospital. ROC analysis indicated that HEWS at ED triage had fair discriminative ability for predicting likelihood of meeting criteria for sepsis with an area under the curve (AUC) of 0.77 [95%CI: 0.21–0.82]. HEWS at ED triage had good discriminative ability for predicting likelihood of both meeting criteria for sepsis and experiencing in-hospital mortality with an AUC of 0.83 [95%CI: 0.75–0.91]. These ROC curves are presented in figure 1. Exploratory analyses were conducted to examine the utility of HEWS in identifying septic patients who were assigned an initial CTAS level of III or lower. This cut-off was selected based upon recommendations that septic patients should be assigned at minimum CTAS level of II (4). In our sample, 42 patients meeting sepsis criteria were assigned a CTAS level of III or IV. The mean HEWS score for these patient was 2.8 (SD = 2.1) which was significantly greater than non-septic CTAS III or IV patients (M = 1.4, SD = 1.7), t(433) = 5.3. p <.01.
Conclusion: The HEWS has potential utility in the ED as a means of improving identification of patients with sepsis. Further research is needed to determine if the HEWS can be incorporated as part of ED triage to allow earlier screening and intervention and thereby prevent deterioration of these patients.

  1. Keep J, Messmer a., Sladden R, Burrell N, Pinate R, Tunnicliff M, et al. National early warning score at Emergency Department triage may allow earlier identification of patients with severe sepsis and septic shock: a retrospective observational study. Emerg Med 2016; 33(1)37-41.
  2. Corfield AR, Lees F, Zealley I, Houston G, Dickie S, Ward K, et al. Utility of a single early warning score in patients with sepsis in the emergency department. Emerg Med J 2014; 31(6):482–7.
  3. Tam B, Xu M, Fox-Robichaud A. Hamilton Early Warning Score: predict, prevent and protect. Crit Care 2015; 19(Suppl 1):P501.
  4. Sweet D, Marsden J, Ho K, Krause C, Russell JA. Emergency management of sepsis: The simple stuff saves lives. B C Med J. 2012;54(4):176–82. 

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