Examining the Utility of the Hamilton Early Warning Score (HEWS) in the Emergency Department for Predicting Sepsis and ICU admission: A Prospective Longitudinal Study
CCCF ePoster library. Faidi W. Nov 9, 2018; 233359
Walaa Faidi
Walaa Faidi
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Abstract
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Introduction: Rapid deterioration of patients in inpatient wards has been more effectively detected and managed with the use of early warning scores. The Hamilton Early Warning Score (HEWS) has been shown to detect patients with risk for a critical event1. In a retrospective review of emergency department (ED) admissions HEWS had good prediction for sepsis and ICU admission2. The quick Sequential Organ Failure Assessment (qSOFA) has been recommended by the Society of Critical Care Medicine and The European Society of Intensive Care Medicine to enhance screening potentially septic patients outside of the ICU3. As part of an observational biomarker study (SEPSIS-ED) in the Hamilton Health Sciences adult ED’s, we hypothesized HEWS would be superior to qSOFA in identifying septic patients.



Objective: Our primary study objective was to verify the utility of HEWS in predicting a critical event (ICU admission secondary to sepsis) in patients with suspected infection seen in the ED, as well the predictive utility of qSOFA in conjunction CTAS.



Methods: Adult patients (>18 years) presenting to the ED at the Hamilton General Hospital with physician suspected infection were deemed eligible for the study. Triage vital signs, HEWS, qSOFA score, initial laboratory results and past medical history including demographics such as age and sex were collected. Our study cohort was part of the SEPSIS-ED study meeting the requirements for waiver of informed consent as per our local Research Ethics Board approval (HiREB #0660). Continuous variables were compared using the independent sample t-test and the Mann-Whitney U test for parametric and non-parametric data sets respectively. Binomial variables were analyzed with either Chi-squared or Fisher’s exact test.



Results:



The cohort included 134 patients with suspected infection. As shown in Table 1, the average age was 66.9±18.1 years; 69 were male (51.5%). Most arrived by EMS (n=98, 73.1%), 11 were admitted to the ICU (8.2%), the median time to be seen by an ED MD was 73 mins (IQR=134), the median HEWS was 3 (IQR=4), the most common CTAS designation was 2 (n=66, 49.3%) and 26 patients met the ≥2 qSOFA criteria (19.4%). Patients admitted to the ICU had higher serum sodium (136, IQR=6), high sensitivity troponin (86, IQR=231), and lactate levels (3.1, IQR=5); were seen quicker by the ED MD; more likely to arrive by EMS, have a higher HEWS and meet ≥2 qSOFA criteria (p<0.05). CTAS was not a significant predictor of a critical event (i.e. ICU admission). A HEWS of ≥5 was associated with a 7.37-fold increase in odds of an ICU admission (95%CI: 1.82 to 29.07), making it the strongest predictor of a critical event, followed by ≥2 qSOFA (OR=4.05, 95%CI: 1.13 to 14.51) and a point increment in lactate level (OR=1.81, 95%CI: 1.26 to 2.61).



Conclusions:



In patients who present to the ED with suspected infection HEWS ≥5 was the strongest predictor of an ICU admission.  We have confirmed that a HEWS≥ 5 should serve as a strong indicator to healthcare staff that the patient could be at risk for a critical event such as sepsis. Next steps: Identify patients in our cohort with a discharge diagnosis of sepsis and identify reliable predictors in comparison to qSOFA.


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