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Multicenter Study
. 2023 Apr 26;23(1):45.
doi: 10.1186/s12873-023-00814-w.

The utility of the Rapid Emergency Medicine Score (REMS) compared with three other early warning scores in predicting in-hospital mortality among COVID-19 patients in the emergency department: a multicenter validation study

Onlak Ruangsomboon  1 , Nutthida Phanprasert  1 , Supawich Jirathanavichai  1 , Chanokporn Puchongmart  2 , Phetsinee Boonmee  3 , Netiporn Thirawattanasoot  4 , Thawonrat Dorongthom  5 , Nattakarn Praphruetkit  1 , Apichaya Monsomboon  6
Affiliations
Multicenter Study

The utility of the Rapid Emergency Medicine Score (REMS) compared with three other early warning scores in predicting in-hospital mortality among COVID-19 patients in the emergency department: a multicenter validation study

Onlak Ruangsomboon et al. BMC Emerg Med. .

Abstract

Background: Many early warning scores (EWSs) have been validated to prognosticate adverse outcomes of COVID-19 in the Emergency Department (ED), including the quick Sequential Organ Failure Assessment (qSOFA), the Modified Early Warning Score (MEWS), and the National Early Warning Score (NEWS). However, the Rapid Emergency Medicine Score (REMS) has not been widely validated for this purpose. We aimed to assess and compare the prognostic utility of REMS with that of qSOFA, MEWS, and NEWS for predicting mortality in emergency COVID-19 patients.

Methods: We conducted a multi-center retrospective study at five EDs of various levels of care in Thailand. Adult patients visiting the ED who tested positive for COVID-19 prior to ED arrival or within the index hospital visit between January and December 2021 were included. Their EWSs at ED arrival were calculated and analysed. The primary outcome was all-cause in-hospital mortality. The secondary outcome was mechanical ventilation.

Results: A total of 978 patients were included in the study; 254 (26%) died at hospital discharge, and 155 (15.8%) were intubated. REMS yielded the highest discrimination capacity for in-hospital mortality (the area under the receiver operator characteristics curves (AUROC) 0.771 (95% confidence interval (CI) 0.738, 0.804)), which was significantly higher than qSOFA (AUROC 0.620 (95%CI 0.589, 0.651); p < 0.001), MEWS (AUROC 0.657 (95%CI 0.619, 0.694); p < 0.001), and NEWS (AUROC 0.732 (95%CI 0.697, 0.767); p = 0.037). REMS was also the best EWS in terms of calibration, overall model performance, and balanced diagnostic accuracy indices at its optimal cutoff. REMS also performed better than other EWSs for mechanical ventilation.

Conclusion: REMS was the early warning score with the highest prognostic utility as it outperformed qSOFA, MEWS, and NEWS in predicting in-hospital mortality in COVID-19 patients in the ED.

Keywords: Early warning score; Rapid emergency medicine score; covid-19.

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Conflict of interest statement

All the authors declare no conflicts of interest.

Figures

Fig. 1
Fig. 1
Distribution of early warning scores and in-hospital mortality stratified by each early warning score in emergency patients with COVID-19. (A) qSOFA score. (B) NEWS score. (C) MEWS score. (D) REMS score Abbreviations: qSOFA, quick Sequential Organ Failure Assessment; MEWS, Modified Early Warning Score; NEWS, National Early Warning Score; REMS, Rapid Emergency Medicine Score
Fig. 2
Fig. 2
Receiver operator characteristic curves for early warning scores for in-hospital mortality and mechanical ventilation in emergency patients with COVID-19 (A) In-hospital mortality. (B) Mechanical ventilation. Abbreviations: qSOFA, quick Sequential Organ Failure Assessment; MEWS, Modified Early Warning Score; NEWS, National Early Warning Score; REMS, Rapid Emergency Medicine Score
Fig. 3
Fig. 3
Calibration plots of early warning scores for in-hospital mortality in emergency patients with COVID-19 (A) qSOFA score. (B) MEWS score. (C) NEWS score. (D) REMS score. Hollow circles denote groups of predicted risk. Vertical line through hollow circles denote 95% confidence intervals. The distribution of non-events of the outcome (0) and events of the outcome (1) by expected probability are denoted by the rug plot (light grey) along the x axis Abbreviations: qSOFA, quick Sequential Organ Failure Assessment; MEWS, Modified Early Warning Score; NEWS, National Early Warning Score; REMS, Rapid Emergency Medicine Score
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