The Value of Prehospital Early Warning Scores to Predict in - Hospital Clinical Deterioration: A Multicenter, Observational Base-Ambulance Study.

OBJECTIVES: Early warning scores are clinical tools capable of identifying prehospital patients with high risk of deterioration. We sought here to contrast the validity of seven early warning scores in the prehospital setting and specifically, to evaluate the predictive value of each score to determine early deterioration-risk during the hospital stay, including mortality at one, two, three and seven- days since the index event. Methods: A prospective multicenter observational based-ambulance study of patients treated by six advanced life support emergency services and transferred to five Spanish hospitals between October 1, 2018 and December 31, 2019. We collected demographic, clinical, and laboratory variables. Seven risk score were constructed based on the analysis of prehospital variables associated with death within one, two, three and seven days since the index event. The area under the receiver operating characteristics was used to determine the discriminant validity of each early warning score. Results: A total of 3,273 participants with acute diseases were accurately linked. The median age was 69 years (IQR, 54-81 years), 1,348 (41.1%) were females. The overall mortality rate for patients in the study cohort ranged from 3.5% for first-day mortality (114 cases), to 7% for seven-day mortality (228 cases). The scores with the best performances for one-day mortality were Vitalpac Early Warning Score with an area under the receiver operating characteristic (AUROC) of 0.873 (95% CI: 0.81-0.9), for two-day mortality, Triage Early Warning Score with an AUROC of 0.868 (95% CI: 0.83-0.9), for three and seven-days mortality the Modified Rapid Emergency Medicine Score with an AUROC of 0.857 (0.82-0.89) and 0.833 (95% CI: 0.8-0.86). In general, there were no significant differences between the scores analyzed. Conclusions: All the analyzed scores have a good predictive capacity for early mortality, and no statistically significant differences between them were found. The National Early Warning Score 2, at the clinical level, has certain advantages. Early warning scores are clinical tools that can help in the complex decision-making processes during critical moments, so their use should be generalized in all emergency medical services.

Accuracy of prehospital point-of-care lactate in early in-hospital mortality.

BACKGROUND: Emergency medical services (EMS) routinely face complex scenarios where decisions should be taken with limited clinical information. The development of fast, reliable and easy to perform warning biomarkers could help in such decision-making processes. The present study aims at characterizing the validity of point-of-care lactate (pLA) during prehospital tasks for predicting in-hospital mortality within two days after the EMS assistance. MATERIALS AND METHODS: Prospective, multicentric, ambulance-based and controlled observational study without intervention, including six advanced life support and five hospitals. The pLA levels were recorded during EMS assistance of adult patients. The validity of pLA to determine the in-hospital mortality was assessed by the area under the curve (AUC) of the receiver operating curve (ROC). RESULTS: A total of 2997 patients were considered in the study, with a median of 69 years (IQR 54-81) and 41.4% of women. The median pLA value was 2.7 mmol/L (1.9-3.8) in survivors and 5.7 mmol/L (4.4-7.6) in nonsurvivors. The global discrimination level of pLA reached an AUC of 0.867, being 1.9 mmol/L and 4 mmol/L the cut-off point for low and high mortality. The discrimination value of pLA was not affected by sex, age or pathology. CONCLUSIONS: Our results highlight the clinical importance of prehospital pLA to determine the in-hospital risk of mortality. The incorporation of pLA into the EMS protocols could improve the early identification of risky patients, leading to a better care of such patients.

Early detection of intensive care needs and mortality risk by use of five early warning scores in patients with traumatic injuries: An observational study.

OBJECTIVE: The purpose of this research was to evaluate the predictive capacity of five Early Warning Scores in relation to the clinical evolution of adult patients with different types of trauma. RESEARCH METHODOLOGY: We conducted a longitudinal, prospective, observational study, calculating the Early Warning Scores [Modified Early Warning Score (MEWS), National Early Warning Score 2 (NEWS-2), VitalPAC Early Warning Score (ViEWS), Modified Rapid Emergency Medicine Score (MREMS), and Rapid Acute Physiology Score (RAPS)] upon arrival of patients to the emergency department. SETTING: In total, 445 cases of traumatic injuries were included in the study. MAIN OUTCOME MEASURES: The predictive capacity was verified with the data on admission to intensive care units (ICU) and mortality at two, seven and 30 days. RESULTS: 201 patients were hospitalized and 244 were discharged after being attended in the emergency department. 91 cases (20.4%) required ICU care and 4.7% of patients died (21 patients) within two days, 6.5% (29 patients) within seven days and 9.7% (43 patients) within 30 days. The highest area under the curve for predicting the need for ICU care was obtained by the National Early Warning Score 2 and the VitalPAC Early Warning Score. For predicting mortality, the Modified Rapid Emergency Medicine Score obtained the best scores for two-day mortality, seven-day mortality and 30-day mortality. CONCLUSIONS: Every Early Warning Score analyzed in this study obtained good results in predicting adverse effects in adult patients with traumatic injuries, creating an opportunity for new clinical applications in the emergency department.

Accuracy of early warning scores for predicting serious adverse events in pre-hospital traumatic injury.

BACKGROUND: Traumatically injured patients are at higher risk of serious adverse events. Numerous physiological scoring systems are employed as diagnostic and/or prognostic tools. The objective of this study was to evaluate the scales most commonly used by emergency medical services for the early detection of prehospital serious adverse events. METHODS: Design. Preliminary longitudinal prospective observational study without intervention study in adults with prehospital traumatic injury. SETTING: The study was carried out in the public health system of Castile and León (Spain), from April 1, 2018 to October 31, 2019, involving seven advanced life support units and five hospitals. PARTICIPANTS: Traumatically injured patients over 18 years of age who were stabilized and transferred in advanced life support units to their referral hospital. MAIN OUTCOME MEASURES: Appearance of serious adverse events at the prehospital level at the scene or during the transfer to the emergency department. RESULTS: A total of 346 patients were included in the study. The median age was 50 years (IQR: 38-65). 32 cases (7.8%) presented serious adverse events at the prehospital level. Areas under the curve for the detection of serious adverse events were obtained with the Prehospital Index (0.979; 95% CI: 0.94-1.00) and National Early Warning Score 2 (0.956; 95% CI: 0.90-1.00); p <0.001 for all scores. The Prehospital Index had a positive probability coefficient of 78.4 (95% CI: 62.8-68.6) and the National Early Warning Score 2 obtained 52.9 (95% CI: 39.7-65.6). A comparison of the curves was not significant for any of the scores studied (p> 0.05). CONCLUSIONS: All scoring systems were able to detect prehospital serious adverse events early in traumatic injury; therefore, any of the scoring systems could be useful and represent an ideal tool for routine use by emergency medical services in cases of traumatic injury.