Do social determinants increase the risk of an in-hospital critical event when admitted to medicine or surgery?
CCCF ePoster library. Lee D. Nov 7, 2018; 234655; 33
David Lee
David Lee
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The Hamilton Early Warning Score (HEWS) is an electronic bedside tool that uses vital sign abnormalities to detect potential critical events.  HEWS at ED triage had poor (AUROC 0.62) discriminative ability for predicting the likelihood of critical event during subsequent hospital stay but better discrimination for critical events in patients who are septic (AUROC 0.82).1,2 New evidence suggests using social determinants may assist in predicting adverse events. A Danish study found that among septic ICU patients, low income was significantly associated with increased 30-day mortality.3 In 2010, McMaster University and the Hamilton Spectator collaborated on the Code Red project which described the disparities in the determinants of health and health status that exists in the City of Hamilton’s neighbourhoods.4,5


The primary objective of our study was to determine whether the addition of social determinants such as postal code and income level add predictive value to the current HEWS.


The study population was derived from a existing database of patients admitted to one of 8 adult medical or surgical wards at the Hamilton General and Juravinski hospitals over a 6-month period from January to June 2015. Cases experienced a critical event defined as an unplanned intensive care unit admission, cardiopulmonary resuscitation, or unexpected death. Controls were matched to cases in a 2-to-1 ratio controlling for comorbidities defined by their Charlson Comorbidity Index. To this case-control data was added the first half of the postal code and the income tertiles for these areas of Hamilton. We used the 2010 Hamilton Code Red report to define postal codes residing in higher risk areas.4,5 Conditional Regression was used to evaluate the correlation between HEWS at ED triage, residing in a high risk area, and income tertiles as a predictor for critical events.


The cohort consisted of  798 patients 270 of whom experienced a critical event (45.1%). Chi-Square analysis identified that residing in Code Red areas (p=0.01) and an elevated HEWS at ED triage (p=0.00) as significant. Conditional regression analysis identified Code Red areas (p=0.02, RR= 1.81) and HEWS (p=0.03, RR= 1.27) but not income tertiles as predictors for critical events.


We found that residing in a Code Red area within Hamilton placed patients admitted to a medicine or surgical ward at increased risk for a critical event. Income level, as determined by one’s postal code was not found to be a predictor for critical event. Further investigation into the utility of early warning scores should consider other social determinants such as education and housing quality as well access to a primary care physician and transportation.


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