Evaluation of the threshold value for the Early Warning Score on general wards.

INTRODUCTION: The Early Warning Score (EWS) is used for early detection of deteriorating vital parameters and has been correlated with adverse outcomes. Unfortunately, neither its value on general wards nor the optimal cut-off value have been investigated. We aimed to find the optimal cut-off value for EWS on general wards, and investigated the possibility to raise this value from EWS ≥ 3 without compromising sensitivity too much. METHODS: From May 2010 until May 2011, EWS was calculated from vital parameters in all patients in medical and surgical wards in the Medical Centre Alkmaar. Cut-off value was defined as EWS ≥ 3, unless otherwise specified. Six responses were defined and categorised as interventions (infusion prescription, medication changes, ICU consultation) and other actions (no action, change EWS cut-off value, oxygen supplementation), and it was registered whenever the threshold was exceeded. RESULTS: 71,911 EWS values were obtained, 31,728 (44%) on medical wards and 40,183 (56%) on surgical wards. On medical wards, the cut-off value was exceeded 3734 times, and response was registered in 29% of the cases with 141 (12%) interventions. On surgical wards, the cut-off value was exceeded 3279 times, and response was registered in 19% of the cases with 633 (36%) interventions. Sensitivity and specificity for EWS ≥ 3 could not be calculated. For a calculated cut-off at EWS ≥ 4, sensitivity decreased to 74%. CONCLUSION: Raising the EWS threshold to 4 on general wards in the hospital would lead to an unacceptable decrease in sensitivity. Therefore, we recommend that the pre-defined cut-off should remain 3, with the possibility to personalise the threshold.

Ain't No Sunshine When She's Gone: Pseudohypoparathyroidism Discovered in an Adult.

An 18-year-old negroid woman presented with progressive cramps in both hands. She was Jamaican and had moved to The Netherlands 8 months before. On physical examination Trousseau's sign was positive. Laboratory analysis showed severe hypocalcaemia (1.17 mmol/L) and hyperphosphatemia (2.0 mmol/L). Urinary excretion of both calcium (0.8 mmol/day) and phosphate (5 mmol/day) was low, as is seen in hypoparathyroidism. However, the PTH level was increased (22.1 pmol/L), whereas 25-(OH)-vitamin D was low (31 nmol/L). An Ellsworth-Howard test showed only a fivefold increase in urinary phosphate excretion after administration of synthetic PTH, supporting the diagnosis pseudohypoparathyroidism. Upon treatment with calcium supplementation and alfacalcidol, her symptoms disappeared. Pseudohypoparathyroidism (PHP) is a rare hereditary disorder resembling hypoparathyroidism, although plasma PTH levels are elevated. PHP is caused by alterations in the PTH receptor, inducing target tissue resistance to PTH. This results in hypocalcaemia and hyperphosphatemia, while PTH levels are elevated. The diagnosis is confirmed by the Ellsworth-Howard test, which will show a 100-fold increase in phosphate excretion if the PTH receptor functions properly. Treatment is lifelong supplementation of calcium and alfacalcidol. In our patient, symptoms were probably evoked by the lack of sunlight in Dutch winter, decreasing vitamin D levels and thereby aggravating hypocalcaemia.