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Observational Study
. 2019 Jan 17;9(1):e024636.
doi: 10.1136/bmjopen-2018-024636.

Combination of the National Early Warning Score (NEWS) and inflammatory biomarkers for early risk stratification in emergency department patients: results of a multinational, observational study

Andreas Eckart #  1 , Stephanie Isabelle Hauser #  1 , Alexander Kutz  1 , Sebastian Haubitz  1   2 , Pierre Hausfater  3   4 , Devendra Amin  5 , Adina Amin  5 , Andreas Huber  6 , Beat Mueller  1   7 , Philipp Schuetz  1   7
Affiliations
Observational Study

Combination of the National Early Warning Score (NEWS) and inflammatory biomarkers for early risk stratification in emergency department patients: results of a multinational, observational study

Andreas Eckart et al. BMJ Open. .

Abstract

Objectives: The National Early Warning Score (NEWS) helps to estimate mortality risk in emergency department (ED) patients. This study aimed to investigate whether the prognostic value of the NEWS at ED admission could be further improved by adding inflammatory blood markers (ie, white cell count (WCC), procalcitonin (PCT) and midregional-proadrenomedullin (MR-proADM).

Design: Secondary analysis of a multinational, observational study (TRIAGE study, March 2013-October 2014).

Setting: Three tertiary care centres in France, Switzerland and the USA.

Participants: A total of 1303 adult medical patients with complete NEWS data seeking ED care were included in the final analysis. NEWS was calculated retrospectively based on admission data.

Main outcome measures: The primary outcome was all-cause 30-day mortality. Secondary outcome was intensive care unit (ICU) admission. We used multivariate regression analyses to investigate associations of NEWS and blood markers with outcomes and area under the receiver operating curve (AUC) as a measure of discrimination.

Results: Of the 1303 included patients, 54 (4.1%) died within 30 days. The NEWS alone showed fair prognostic accuracy for all-cause 30-day mortality (AUC 0.73), with a multivariate adjusted OR of 1.26 (95% CI 1.13 to 1.40, p<0.001). The AUCs for the prediction of mortality using the inflammatory markers WCC, PCT and MR-proADM were 0.64, 0.71 and 0.78, respectively. Combining NEWS with all three blood markers or only with MR-proADM clearly improved discrimination with an AUC of 0.82 (p=0.002). Combining the three inflammatory markers with NEWS improved prediction of ICU admission (AUC 0.70vs0.65 when using NEWS alone, p=0.006).

Conclusion: NEWS is helpful in risk stratification of ED patients and can be further improved by the addition of inflammatory blood markers. Future studies should investigate whether risk stratification by NEWS in addition to biomarkers improve site-of-care decision in this patient population.

Trial registration number: NCT01768494; Post-results.

Keywords: internal medicine; risk management.

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Conflict of interest statement

Competing interests: AK, BM, PH and PS have received research grants and support from BRAHMS AG (now ThermoFisher Scientific Biomarkers) and bioMérieux for attending meetings and fulfilling speaking engagements. BM has served as a consultant to both companies

Figures

Figure 1
Figure 1
Discriminative performance of NEWS, blood markers and combination of NEWS and blood markers for the prediction of all-cause 30-day mortality (A) and ICU admission (B). NEWS was calculated without oxygen supplementation data and thus represents ‘NEWS - potentially minus 2’. NEWS, National Early Warning Score; MR-proADM, midregional proadrenomedullin; PCT, procalcitonin; WCC, white cell count.
Figure 2
Figure 2
Kaplan-Meier survival estimates stratified by admission NEWS category (A), white cell count (WCC) (B), procalcitonin (PCT) (C), and MR-proadrenomedullin (MR-proADM) (D). NEWS was calculated without oxygen supplementation data and thus represents ‘NEWS - potentially minus 2’.
See this image and copyright information in PMC

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