RESUMEN
BACKGROUND: In hospitals in England, patients' vital signs are monitored and summarized into the National Early Warning Score (NEWS); this score is more accurate than the Quick Sepsis-related Organ Failure Assessment (qSOFA) score at identifying patients with sepsis. We investigated the extent to which the accuracy of the NEWS is enhanced by developing and comparing 3 computer-aided NEWS (cNEWS) models (M0 = NEWS alone, M1 = M0 + age + sex, M2 = M1 + subcomponents of NEWS + diastolic blood pressure) to predict the risk of sepsis. METHODS: We included all emergency medical admissions of patients 16 years of age and older discharged over 24 months from 2 acute care hospital centres (York Hospital [YH] for model development and a combined data set from 2 hospitals [Diana, Princess of Wales Hospital and Scunthorpe General Hospital] in the Northern Lincolnshire and Goole National Health Service Foundation Trust [NH] for external model validation). We used a validated Canadian method for defining sepsis from administrative hospital data. RESULTS: The prevalence of sepsis was lower in YH (4.5%, 1596/35 807) than in NH (8.5%, 2983/35 161). The C statistic increased across models (YH: M0 0.705, M1 0.763, M2 0.777; NH: M0 0.708, M1 0.777, M2 0.791). For NEWS of 5 or higher, sensitivity increased (YH: 47.24% v. 50.56% v. 52.69%; NH: 37.91% v. 43.35% v. 48.07%), the positive likelihood ratio increased (YH: 2.77 v. 2.99 v. 3.06; NH: 3.18 v. 3.32 v. 3.45) and the positive predictive value increased (YH: 11.44% v. 12.24% v. 12.49%; NH: 22.75% v. 23.55% v. 24.21%). INTERPRETATION: From the 3 cNEWS models, model M2 is the most accurate. Given that it places no additional burden of data collection on clinicians and can be automated, it may now be carefully introduced and evaluated in hospitals with sufficient informatics infrastructure.
Asunto(s)
Enfermedad Crítica/terapia , Puntuación de Alerta Temprana , Servicio de Urgencia en Hospital , Sepsis/diagnóstico , Enfermedad Crítica/mortalidad , Hospitalización , Humanos , Puntuaciones en la Disfunción de Órganos , Admisión del Paciente , Medición de Riesgo , Sepsis/mortalidadRESUMEN
OBJECTIVES: To develop a logistic regression model to predict the risk of sepsis following emergency medical admission using the patient's first, routinely collected, electronically recorded vital signs and blood test results and to validate this novel computer-aided risk of sepsis model, using data from another hospital. DESIGN: Cross-sectional model development and external validation study reporting the C-statistic based on a validated optimized algorithm to identify sepsis and severe sepsis (including septic shock) from administrative hospital databases using International Classification of Diseases, 10th Edition, codes. SETTING: Two acute hospitals (York Hospital - development data; Northern Lincolnshire and Goole Hospital - external validation data). PATIENTS: Adult emergency medical admissions discharged over a 24-month period with vital signs and blood test results recorded at admission. INTERVENTIONS: None. MAIN RESULTS: The prevalence of sepsis and severe sepsis was lower in York Hospital (18.5% = 4,861/2,6247; 5.3% = 1,387/2,6247) than Northern Lincolnshire and Goole Hospital (25.1% = 7,773/30,996; 9.2% = 2,864/30,996). The mortality for sepsis (York Hospital: 14.5% = 704/4,861; Northern Lincolnshire and Goole Hospital: 11.6% = 899/7,773) was lower than the mortality for severe sepsis (York Hospital: 29.0% = 402/1,387; Northern Lincolnshire and Goole Hospital: 21.4% = 612/2,864). The C-statistic for computer-aided risk of sepsis in York Hospital (all sepsis 0.78; sepsis: 0.73; severe sepsis: 0.80) was similar in an external hospital setting (Northern Lincolnshire and Goole Hospital: all sepsis 0.79; sepsis: 0.70; severe sepsis: 0.81). A cutoff value of 0.2 gives reasonable performance. CONCLUSIONS: We have developed a novel, externally validated computer-aided risk of sepsis, with reasonably good performance for estimating the risk of sepsis for emergency medical admissions using the patient's first, electronically recorded, vital signs and blood tests results. Since computer-aided risk of sepsis places no additional data collection burden on clinicians and is automated, it may now be carefully introduced and evaluated in hospitals with sufficient informatics infrastructure.
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Sistemas de Apoyo a Decisiones Clínicas/organización & administración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Sepsis/epidemiología , Choque Séptico/epidemiología , Factores de Edad , Anciano , Anciano de 80 o más Años , Algoritmos , Estudios Transversales , Sistemas de Apoyo a Decisiones Clínicas/normas , Femenino , Pruebas Hematológicas , Mortalidad Hospitalaria , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Pronóstico , Reproducibilidad de los Resultados , Medición de Riesgo , Sepsis/diagnóstico , Sepsis/mortalidad , Índice de Severidad de la Enfermedad , Factores Sexuales , Choque Séptico/diagnóstico , Choque Séptico/mortalidad , Signos VitalesRESUMEN
BACKGROUND: The National Early Warning Score (NEWS) is being replaced with NEWS2 which adds 3 points for new confusion or delirium. We estimated the impact of adding delirium on the number of medium/high level alerts that are triggers to escalate care. METHODS: Analysis of emergency medical admissions in two acute hospitals (York Hospital (YH) and Northern Lincolnshire and Goole NHS Foundation Trust hospitals (NH)) in England. Twenty per cent were randomly assigned to have delirium. RESULTS: The number of emergency admissions (YH: 35584; NH: 35795), mortality (YH: 5.7%; NH: 5.5%), index NEWS (YH: 2.5; NH: 2.1) and numbers of NEWS recorded (YH: 879193; NH: 884072) were similar in each hospital. The mean number of patients with medium level alerts per day increased from 55.3 (NEWS) to 69.5 (NEWS2), a 25.7% increase in YH and 64.1 (NEWS) to 77.4 (NEWS2), a 20.7% increase in NH. The mean number of patients with high level alerts per day increased from 27.3 (NEWS) to 34.4 (NEWS2), a 26.0% increase in YH and 29.9 (NEWS) to 37.7 (NEWS2), a 26.1% increase in NH. CONCLUSIONS: The addition of delirium in NEWS2 will have a substantial increase in medium and high level alerts in hospitalised emergency medical patients. Rigorous evaluation of NEWS2 is required before widespread implementation because the extent to which staff can cope with this increase without adverse consequences remains unknown.
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Delirio , Puntuación de Alerta Temprana , Servicio de Urgencia en Hospital , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Delirio/diagnóstico , Delirio/epidemiología , Servicio de Urgencia en Hospital/normas , Servicio de Urgencia en Hospital/estadística & datos numéricos , Inglaterra , Femenino , Humanos , Masculino , Persona de Mediana Edad , Admisión del Paciente/normas , Admisión del Paciente/estadística & datos numéricos , Estudios RetrospectivosRESUMEN
OBJECTIVES: There are no established mortality risk equations specifically for emergency medical patients who are admitted to a general hospital ward. Such risk equations may be useful in supporting the clinical decision-making process. We aim to develop and externally validate a computer-aided risk of mortality (CARM) score by combining the first electronically recorded vital signs and blood test results for emergency medical admissions. DESIGN: Logistic regression model development and external validation study. SETTING: Two acute hospitals (Northern Lincolnshire and Goole NHS Foundation Trust Hospital (NH)-model development data; York Hospital (YH)-external validation data). PARTICIPANTS: Adult (aged ≥16 years) medical admissions discharged over a 24-month period with electronic National Early Warning Score(s) and blood test results recorded on admission. RESULTS: The risk of in-hospital mortality following emergency medical admission was 5.7% (NH: 1766/30 996) and 6.5% (YH: 1703/26 247). The C-statistic for the CARM score in NH was 0.87 (95% CI 0.86 to 0.88) and was similar in an external hospital setting YH (0.86, 95% CI 0.85 to 0.87) and the calibration slope included 1 (0.97, 95% CI 0.94 to 1.00). CONCLUSIONS: We have developed a novel, externally validated CARM score with good performance characteristics for estimating the risk of in-hospital mortality following an emergency medical admission using the patient's first, electronically recorded, vital signs and blood test results. Since the CARM score places no additional data collection burden on clinicians and is readily automated, it may now be carefully introduced and evaluated in hospitals with sufficient informatics infrastructure.
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Enfermedad Aguda/mortalidad , Registros Electrónicos de Salud/estadística & datos numéricos , Pruebas Hematológicas/estadística & datos numéricos , Mortalidad Hospitalaria , Admisión del Paciente/estadística & datos numéricos , Medición de Riesgo/estadística & datos numéricos , Signos Vitales , Adulto , Anciano , Anciano de 80 o más Años , Estudios Transversales , Sistemas de Apoyo a Decisiones Clínicas/normas , Sistemas de Apoyo a Decisiones Clínicas/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Registros de Hospitales/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Medicina Estatal/estadística & datos numéricos , Reino UnidoRESUMEN
Objective Routine administrative data have been used to show that patients admitted to hospitals over the weekend appear to have a higher mortality compared to weekday admissions. Such data do not take the severity of sickness of a patient on admission into account. Our aim was to incorporate a standardized vital signs physiological-based measure of sickness known as the National Early Warning Score to investigate if weekend admissions are: sicker as measured by their index National Early Warning Score; have an increased mortality; and experience longer delays in the recording of their index National Early Warning Score. Methods We extracted details of all adult emergency medical admissions during 2014 from hospital databases and linked these with electronic National Early Warning Score data in four acute hospitals. We analysed 47,117 emergency admissions after excluding 1657 records, where National Early Warning Score was missing or the first (index) National Early Warning Score was recorded outside ±24 h of the admission time. Results Emergency medical admissions at the weekend had higher index National Early Warning Score (weekend: 2.53 vs. weekday: 2.30, p < 0.001) with a higher mortality (weekend: 706/11,332 6.23% vs. weekday: 2039/35,785 5.70%; odds ratio = 1.10, 95% CI 1.01 to 1.20, p = 0.04) which was no longer seen after adjusting for the index National Early Warning Score (odds ratio = 0.99, 95% CI 0.90 to 1.09, p = 0.87). Index National Early Warning Score was recorded sooner (-0.45 h, 95% CI -0.52 to -0.38, p < 0.001) for weekend admissions. Conclusions Emergency medical admissions at the weekend with electronic National Early Warning Score recorded within 24 h are sicker, have earlier clinical assessments, and after adjusting for the severity of their sickness, do not appear to have a higher mortality compared to weekday admissions. A larger definitive study to confirm these findings is needed.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Mortalidad Hospitalaria/tendencias , Admisión del Paciente/estadística & datos numéricos , Índice de Severidad de la Enfermedad , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Inglaterra/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de TiempoRESUMEN
Campath-1H (alemtuzumab) is the most effective monoclonal antibody in single-agent use in B-cell chronic lymphocytic leukemia (CLL) with reported response rates of 33% to 70%. Combination therapy is now the conventional treatment for most hematologic malignancies. Monoclonal antibody treatments may sensitize tumor cells to subsequent chemotherapy. We report the combination of Campath-1H with fludarabine in patients with CLL refractory to each agent used singly. Six patients who had received a median of 8 courses of fludarabine (range, 4-10 courses) and 16 weeks of Campath-1H (range, 8-32 weeks) were treated. Five patients responded, including one who had a complete response by National Cancer Institute criteria. The responses observed were better in each patient than responses after each agent used singly. Complete morphologic bone marrow responses were seen in 3 patients, including eradication of disease measured by sensitive flow cytometry in 2. Campath-1H combined with fludarabine is a highly promising novel therapy for refractory CLL.