NEWS2, S/F-ratio and ROX-index at emergency department for the prediction of adverse outcomes in COVID-19 patients: An external validation study.

BACKGROUND: In the context of the COVID-19 pandemic, the early and accurate identification of patients at risk of deterioration was crucial in overcrowded and resource-limited emergency departments. This study conducts an external validation for the evaluation of the performance of the National Early Warning Score 2 (NEWS2), the S/F ratio, and the ROX index at ED admission in a large cohort of COVID-19 patients from Colombia, South America, assessing the net clinical benefit with decision curve analysis. METHODS: A prospective cohort study was conducted on 6907 adult patients with confirmed COVID-19 admitted to a tertiary care ED in Colombia. The study evaluated the diagnostic performance of NEWS2, S/F ratio, and ROX index scores at ED admission using the area under the receiver operating characteristic curve (AUROC) for discrimination, calibration, and decision curve analysis for the prediction of intensive care unit admission, invasive mechanical ventilation, and in-hospital mortality. RESULTS: We included 6907 patients who presented to the ED with confirmed SARS-CoV-2 infection from March 2020 to November 2021. Mean age was 51 (35-65) years and 50.4% of patients were males. The rate of intensive care unit admission was 28%, and in-hospital death was 9.8%. All three scores have good discriminatory performance for the three outcomes based on the AUROC. S/F ratio showed miscalibration at low predicted probabilities and decision curve analysis indicated that the NEWS2 score provided a greater net benefit compared to other scores across at a 10% threshold to decide ED admission at a high-level of care facility. CONCLUSIONS: The NEWS2, S/F ratio, and ROX index at ED admission have good discriminatory performances in COVID-19 patients for the prediction of adverse outcomes, but the NEWS2 score has a higher net benefit underscoring its clinical utility in optimizing patient management and resource allocation in emergency settings.

External validation of two clinical prediction models for mortality in COVID-19 patients (4C and NEWS2), in three centers in Medellín, Colombia: Assessing the impact of vaccination over time.

OBJECTIVES: External validation of the 4C and NEWS2 scores for the prediction of in-hospital mortality in COVID-19 patients, and evaluation of its operational performance in two time periods: before and after the start of the vaccination program in Colombia. METHODS: Retrospective cohort in three high complexity hospitals in the city of Medellín, Colombia, between June 2020 and April 2022. RESULTS: The areas under the ROC curve (AUC) for the 4C mortality risk score and the NEWS2 were 0.75 (95% CI 0.73-0.78) and 0.68 (95% CI 0.66-0.71), respectively. For the 4C score, the AUC for the first and second periods was 0.77 (95% CI 0.74-0.80) and 0.75 (95% CI 0.71-0.78); whilst for the NEWS2 score, it was 0.68 (95% CI 0.65-0.71) and 0.69 (95% CI 0.64-0.73). The calibration for both scores was adequate, albeit with reduced performance during the second period. CONCLUSIONS: The 4C mortality risk score proved to be the more adequate predictor of in-hospital mortality in COVID-19 patients in this Latin American population. The operational performance during both time periods remained similar, which shows its utility notwithstanding major changes, including vaccination, as the pandemic evolved.

Derivación y validación de un nuevo puntaje predictivo de mortalidad por covid-19 en la altura / Derivation and Validation of a New covid-19 Predictive Score for Mortality at High Altitude / Derivação e validação de um novo escore preditivo de mortalidade por covid-19 em altitude

Objetivo: desarrollar un puntaje predictivo de mortalidad para pacientes con covid-19. Materiales y méto-dos: estudio retrospectivo, analítico, observacional y transversal, realizado en dos fases. Se revisaron 620 historias clínicas con una cohorte de derivación de 320 pacientes y una de validación de 300 pacientes. Las variables se analizaron con test de Anova, chi cuadrado de Pearson y análisis multivariante con regresión binaria, que determinaron sensibilidad, especificidad y valor predictivo negativo y positivo. Los puntajes se compararon mediante curvas cor con los scoresnews y hews. Resultados: los dos puntajes obtenidos incluyeron valores de edad, conteo de linfocitos, SatO2/FiO2, leucocitos, plaquetas, ausencia de síntomas, hipertensión arterial, epid y dhl. El área bajo la curva (abc) fue de 0.838 para el puntaje con dhl, con una mortalidad del 100 % para 7.75 puntos o más, y un abc de 0.826 para el primer puntaje. En la cohorte de validación, el abc para el primer puntaje fue de 0.831 y para el score con dhl fue 0.855. El puntaje hewsobtuvo un abc de 0.451, y el news, un abc de 0.396. Conclusiones: se desarrollaron dos herramientas para predecir mortalidad en pacientes con covid-19, con alto poder de discriminación, superior a los puntajes británicos hews y news

Objetivo: desarrollar un puntaje predictivo de mortalidad para pacientes con covid-19. Materiales y méto-dos: estudio retrospectivo, analítico, observacional y transversal, realizado en dos fases. Se revisaron 620 historias clínicas con una cohorte de derivación de 320 pacientes y una de validación de 300 pacientes. Las variables se analizaron con test de Anova, chi cuadrado de Pearson y análisis multivariante con regresión binaria, que determinaron sensibilidad, especificidad y valor predictivo negativo y positivo. Los puntajes se compararon mediante curvas cor con los scoresnews y hews. Resultados: los dos puntajes obtenidos incluyeron valores de edad, conteo de linfocitos, SatO2/FiO2, leucocitos, plaquetas, ausencia de síntomas, hipertensión arterial, epid y dhl. El área bajo la curva (abc) fue de 0.838 para el puntaje con dhl, con una mortalidad del 100 % para 7.75 puntos o más, y un abc de 0.826 para el primer puntaje. En la cohorte de validación, el abc para el primer puntaje fue de 0.831 y para el score con dhl fue 0.855. El puntaje hewsobtuvo un abc de 0.451, y el news, un abc de 0.396. Conclusiones: se desarrollaron dos herramientas para predecir mortalidad en pacientes con covid-19, con alto poder de discriminación, superior a los puntajes británicos hews y news

Objetivo: desenvolver um escore preditivo de mortalidade para pacientes com covid-19. Materiais e Métodos: estudo retrospectivo, analítico, observacional e transversal, realizado em duas fases. Foram revisados 620 prontuários, com uma coorte de derivação de 320 pacientes e uma coorte de validação de 300 pacientes. As variáveis foram analisadas com teste anova, qui-quadrado de Pearson e análise multivariada com regressão binária, determinando sensibilidade, especificidade, valor preditivo nega-tivo e positivo. As pontuações foram comparadas por meio de curvas cor com as pontuações news e hews. Resultados: os dois escores obtidos incluíram valores de: idade, contagem de linfócitos, SatO2/FiO2, leucócitos, plaquetas, ausência de sintomas, hipertensão arterial, epid e dhl. A área sob a curva (abc) foi de 0,838 para o escore dhl, com 100 % de mortalidade para 7,75 pontos ou mais, e uma abc de 0,826 para o primeiro escore. Na coorte de validação, a abc para o primeiro escore foi de 0,831 e para o escore com dhl foi de 0,855. A pontuação hews obteve abc de 0,451 e o news uma abc de 0,396. Conclusões: foram desenvolvidas duas ferramentas para prever mortalidade em pacientes com covid-19, com alto poder de discriminação, superior aos escores britânicos hews e news

COVID-19: Asociación entre la clasificación de riesgo y el Modified Early Warning Score y los resultados hospitalarios / COVID-19: Association of risk classification with the Modified Early Warning Score and hospital outcomes / COVID-19: Associação da classificação de risco com o Modified Early Warning Score e os desfechos hospitalares

Objetivo: evaluar la asociación entre las categorías de clasificación de riesgo y el Modified Early Warning Score y los resultados de los pacientes con COVID-19 en el servicio de emergencia Método: estudio transversal, realizado con 372 pacientes hospitalizados con diagnóstico de COVID-19 atendidos en la Recepción con Clasificación de Riesgo en Urgencias. En este estudio, el Modified Early Warning Score de los pacientes se clasificó como sin y con deterioro clínico, de 0 a 4 y de 5 a 9, respectivamente. Se consideró que había deterioro clínico cuando presentaban insuficiencia respiratoria aguda, shock y paro cardiorrespiratorio. Resultados: el Modified Early Warning Score promedio fue de 3,34. En cuanto al deterioro clínico de los pacientes, se observó que en el 43% de los casos el tiempo de deterioro fue menor a 24 horas y que el 65,9% ocurrió en urgencias. El deterioro más frecuente fue la insuficiencia respiratoria aguda (69,9%) y el resultado fue alta hospitalaria (70,3%). Conclusión: los pacientes con COVID-19 que presentaban Modified Early Warning Score 4 se asociaron a las categorías de clasificación de riesgo urgente, muy urgente y emergente y tuvieron más deterioro clínico, como insuficiencia respiratoria y shock, y murieron, lo que demuestra que el Protocolo de Clasificación de Riesgo priorizó correctamente a los pacientes con riesgo vital.

Objective: to evaluate the association of the risk classification categories with the Modified Early Warning Score and the outcomes of COVID-19 patients in the emergency service Method: a crosssectional study carried out with 372 patients hospitalized with a COVID-19 diagnosis and treated at the Risk Classification Welcoming area from the Emergency Room. In this study, the patients' Modified Early Warning Score was categorized into without and with clinical deterioration, from 0 to 4 and from 5 to 9, respectively. Clinical deterioration was considered to be acute respiratory failure, shock and cardiopulmonary arrest Results: the mean Modified Early Warning Score was 3.34. In relation to the patients' clinical deterioration, it was observed that, in 43%, the time for deterioration was less than 24 hours and that 65.9% occurred in the Emergency Room. The most frequent deterioration was acute respiratory failure (69.9%) and the outcome was hospital discharge (70.3%). Conclusion: COVID-19 patients who had a Modified Early Warning Scores > 4 were associated with the urgent, very urgent and emergency risk classification categories, had more clinical deterioration, such as respiratory failure and shock, and evolved more to death, which shows that the Risk Classification Protocol correctly prioritized patients at risk of life.

Objetivo: avaliar a associação das categorias de classificação de risco com o Modified Early Warning Score e os desfechos dos pacientes com COVID-19 no serviço de emergência Método: estudo transversal, realizado com 372 pacientes internados com diagnóstico de COVID-19 atendidos no Acolhimento com Classificação de Risco no Pronto-Atendimento. Neste estudo, o Modified Early Warning Score dos pacientes foi categorizado em sem e com deterioração clínica, de 0 a 4 e de 5 a 9, respectivamente. Foram consideradas deteriorações clínicas a insuficiência respiratória aguda, choque e parada cardiorrespiratória. Resultados: o Modified Early Warning Score médio foi de 3,34. Em relação à deterioração clínica dos pacientes, observou-se que em 43% o tempo para deterioração foi menor de 24 horas e que 65,9% delas ocorreu no pronto-socorro. A deterioração mais frequente foi a insuficiência respiratória aguda (69,9%) e o desfecho foi o de alta hospitalar (70,3%). Conclusão: pacientes com COVID-19 que tiveram Modified Early Warning Score 4 foram associados às categorias da classificação de risco urgente, muito urgente e emergente e tiveram mais deterioração clínica, como a insuficiência respiratória e o choque, e evoluíram mais a óbito, o que demonstra que o Protocolo de Classificação de Risco priorizou corretamente os pacientes com risco de vida.

Nursing Training for Early Clinical Deterioration Risk Assessment: Protocol for an Implementation Study.

BACKGROUND: During the hospitalization period, it is possible to observe considerable changes in the vital parameters of patients, which may require emergency interventions or intensive treatment. The alteration of signs and symptoms that lead to physiological instability that can worsen the clinical picture with progression to shock, respiratory failure, or cardiorespiratory arrest is currently defined as clinical deterioration. Identifying signs of clinical deterioration at an early stage can lead to substantial decreases in mortality rates, the need for emergency interventions, and unscheduled treatments in intensive care units. Identifying and appropriately referring patients who show signs of clinical deterioration can be facilitated by applying early warning systems that provide rapid responses. The nursing team is usually the first to identify clinical changes in patients. Although the literature demonstrates that early recognition of clinical deterioration is the key to early intervention and leads to better outcomes, we only sometimes pursue the most appropriate intervention. OBJECTIVE: This study aims to implement and evaluate an evidence-based professional training program designed for nurses and coordinated by a nurse using the "just-in-time" methodology and the National Early Warning Score 2 (NEWS2) to assess the risk of early clinical deterioration and appropriate referral in inpatient units of a public university hospital in southeastern Brazil. METHODS: This intervention protocol is structured according to the recommendations of the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) Declaration 2013. The type of training to be offered, "Just-in-Time Training," consists of a teaching modality that facilitates the delivery of a time-based and work-based education, with greater emphasis on providing on-the-job learning as needed. A qualitative stage will also be conducted through focus groups and interviews with nurses to verify the factors that influence the professional practice related to the early evaluation of the clinic. A script of previously tested questions will guide and standardize the different groups. The data will define the intervention's elements: the strategy, the type of training, the location, the teaching methodology, and the teaching material. RESULTS: The study has received authorization from the ethics committee, and participants will be recruited in July 2023. Data collection should be completed in October of the same year. The results obtained at the end of this research will be shared with the participating nursing team through the presentation of reports. In addition, the research results will be submitted to scientific journals and presented at international scientific conferences. CONCLUSIONS: This study will support nurses and possibly other clinicians to improve their approach to early recognition of clinical deterioration in patients. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials RBR-5hq9y3k; https://ensaiosclinicos.gov.br/rg/RBR-5hq9y3k. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/47293.

Modified Early Warning Score: Clinical Deterioration of Mexican Patients Hospitalized with COVID-19 and Chronic Disease.

The objective was to evaluate the Modified Early Warning Score in patients hospitalized for COVID-19 plus chronic disease. METHODS: Retrospective observational study, 430 hospitalized patients with COVID-19 and chronic disease. Instrument, Modified Early Warning Score (MEWS). Data analysis, with Cox and logistic regression, to predict survival and risk. RESULTS: Of 430 patients, 58.6% survived, and 41.4% did not. The risk was: low 53.5%, medium 23.7%, and high 22.8%. The MEWS score was similar between survivors 3.02, p 0.373 (95% CI: -0.225-0.597) and non-survivors 3.20 (95% CI: -0.224-0.597). There is a linear relationship between MEWS and mortality risk R 0.920, ANOVA 0.000, constant 4.713, and coefficient 4.406. The Cox Regression p 0.011, with a risk of deterioration of 0.325, with a positive coefficient, the higher the risk, the higher the mortality, while the invasive mechanical ventilation coefficient was negative -0.757. By providing oxygen and ventilation, mortality is lower. CONCLUSIONS: The predictive value of the modified early warning score in patients hospitalized for COVID-19 and chronic disease is not predictive with the MEWS scale. Additional assessment is required to prevent complications, especially when patients are assessed as low-risk.

Early warning systems and end-user decision-making: A risk formalism tool to aid communication and understanding.

In this work, we introduce a formalism to highlight the role of decision-making implicit in the setup of early warning systems (EWSs) and its consequences with respect to loss avoidance for end users. The formalism, a close relative of the cost/loss approach, combines EWS verification scores with traditional expressions of risk from the point of view of the user. This formalism articulates in mathematical format many well-known issues surrounding EWS usage, offering a conceptual anchor for concepts that otherwise may seem to wobble among the multidisciplinary perspectives participating in the EWS chain. This decision model is visually represented in a variation of the popular "performance diagram" used in forecast and warning verification. Our diagram adds to this the perspective of a generic user, in an effort to gain insight into how choices made regarding EWS settings may determine which users benefit from warnings and which do not. Although these results are based on a conceptual model, they are useful to better understand the actual benefits experienced by users and to highlight aspects that may temper unrealistic expectations on EWSs. The recent United Nations initiative to extend EWSs for natural hazards to all nations within 5 years will make EWSs more common and more public. The approach proposed here can be a tool to promote greater transparency and improve the necessary dialog between warning issuers and users in order to reduce loss.

Advancing school dropout early warning systems: the IAFREE relational model for identifying at-risk students.

Introduction: There is a global effort to address the school dropout phenomenon. The urgency to act on it comes from the harmful evidence that school dropout has on societal and individual levels. Early Warning Systems (EWS) for school dropout at-risk student identification have been developed to anticipate and help schools have a better chance of acting on it. However, several studies point to a doubt that Correct EWS may come too late because they use only publicly available and general student and school information. We hypothesize that having a tool to assess more subjective and inter-relational factors would help anticipate where and when to act to prevent school dropout. This study aimed to develop a multidimensional measure for assessing relational factors for predicting school dropout (SD) risk in the Brazilian context. Methods: We performed several procedures, including (a) the specialized literature review, (b) the item development of the Relational Factors for the Risk of School Dropout Scale (IAFREE in Portuguese), (c) the content validity analysis, (d) a pilot study, and (e) the administration of the IAFREE to a large Brazilian sample of high school and middle school students (N = 15,924). Results: After the theoretical steps, we found content validity for five relational dimensions for SD (Student-School, Student-School Professionals, Student-Family, Student-Community, and Student-Student) that include 12 facets of risk factors. At the empirical stage, confirmatory analysis corroborated the proposed theoretical model with 12 first-order risk factors and 5 s-order dimensions (36 items). Further, through the Item Response Theory analysis, we assessed the individual item parameters of the items, providing a brief measure without losing psychometric quality (IAFREE-12). Discussion: We discuss how this model may fill gaps in Correct EWS models and how to advance it. The IAFREE is a good measure for scholars investigating the risk of SD. These results are important for implementing an early warning system for SD that looks into the complexity of the school dropout phenomenon.

Towards a leptospirosis early warning system in northeastern Argentina.

Leptospirosis is a zoonotic disease with a high burden in Latin America, including northeastern Argentina, where flooding events linked to El Niño are associated with leptospirosis outbreaks. The aim of this study was to evaluate the value of using hydrometeorological indicators to predict leptospirosis outbreaks in this region. We quantified the effects of El Niño, precipitation, and river height on leptospirosis risk in Santa Fe and Entre Ríos provinces between 2009 and 2020, using a Bayesian modelling framework. Based on several goodness of fit statistics, we selected candidate models using a long-lead El Niño 3.4 index and shorter lead local climate variables. We then tested predictive performance to detect leptospirosis outbreaks using a two-stage early warning approach. Three-month lagged Niño 3.4 index and one-month lagged precipitation and river height were positively associated with an increase in leptospirosis cases in both provinces. El Niño models correctly detected 89% of outbreaks, while short-lead local models gave similar detection rates with a lower number of false positives. Our results show that climatic events are strong drivers of leptospirosis incidence in northeastern Argentina. Therefore, a leptospirosis outbreak prediction tool driven by hydrometeorological indicators could form part of an early warning and response system in the region.

Opportune warning of COVID-19 in a Mexican health care worker cohort: Discrete beta distribution entropy of smartwatch physiological records.

We present a statistical study of heart rate, step cadence, and sleep stage registers of health care workers in the Hospital General de México "Dr. Eduardo Liceaga" (HGM), monitored continuously and non-invasively during the COVID-19 contingency from May to October 2020, using the Fitbit Charge 3® Smartwatch device. The HGM-COVID cohort consisted of 115 participants assigned to areas of COVID-19 exposure. We introduce a novel biomarker for an opportune signal for the likelihood of SARS-CoV-2 infection based on the Shannon Entropy of the Discrete Generalized Beta Distribution fit of rank ordered smartwatch registers. Our statistical test indicated infection for 94% of patients confirmed by positive polymer chain reaction (PCR+) test, 47% before the test, and 47% in coincidence. These results required innovative data preprocessing for the definition of a new biomarker index. The statistical method parameters are data-driven, confidence estimates were calibrated based on sensitivity tests using appropriately derived surrogate data as a benchmark. Our surrogate tests can also provide a benchmark for comparing results from other anomaly detection methods (ADMs). Biomarker comparison of the negative Immunoglobulin G Antibody (IgG-) subgroup with the PCR+ subgroup showed a statistically significant difference (p < 0.01, effect size = 1.44). The distribution of the uninfected population had a lower median and less dispersion than the PCR+ population. A retrospective study of our results confirmed that the biomarker index provides an early warning of the likelihood of COVID-19, even several days before the onset of symptoms or the PCR+ test request. The method can be calibrated for the analysis of different SARS-CoV-2 strains, the effect of vaccination, and previous infections. Furthermore, our biomarker screening could be implemented to provide general health profiles for other population sectors based on physiological signals from smartwatch wearable devices.

20-Month monitoring of SARS-CoV-2 in wastewater of Curitiba, in Southern Brazil.

The COVID-19 pandemic resulted in the collapse of healthcare systems and led to the development and application of several approaches of wastewater-based epidemiology to monitor infected populations. The main objective of this study was to carry out a SARS-CoV-2 wastewater based surveillance in Curitiba, Southern Brazil Sewage samples were collected weekly for 20 months at the entrance of five treatment plants representing the entire city and quantified by qPCR using the N1 marker. The viral loads were correlated with epidemiological data. The correlation by sampling points showed that the relationship between the viral loads and the number of reported cases was best described by a cross-correlation function, indicating a lag between 7 and 14 days amidst the variables, whereas the data for the entire city presented a higher correlation (0.84) with the number of positive tests at lag 0 (sampling day). The results also suggest that the Omicron VOC resulted in higher titers than the Delta VOC. Overall, our results showed that the approach used was robust as an early warning system, even with the use of different epidemiological indicators or changes in the virus variants in circulation. Therefore, it can contribute to public decision-makers and health interventions, especially in vulnerable and low-income regions with limited clinical testing capacity. Looking toward the future, this approach will contribute to a new look at environmental sanitation and should even induce an increase in sewage coverage rates in emerging countries.

Avaliação da relação entre a qualidade da anotação dos parâmetros fisiológicos, o Escore para Alerta Precoce e a adoção do Plano de Ação em enfermaria de um Hospital Universitário / Assessment of the relationship between the quality of the recording of physiological parameters, the Early Warning Score, and the adoption of the Action Plan in the ward of a University Hospital

Introdução: Em pacientes em enfermarias, eventos adversos evitáveis podem decorrer de deterioração clínica despercebida, frequentemente antecedida por alterações nos sinais vitais, fornecendo oportunidade para intervenção precoce. A adoção de Equipe de Resposta Rápida (ERR) pode melhorar esse desfecho, porém é altamente dependente do monitoramento dos parâmetros fisiológicos e da notificação da ERR. Objetivo: Avaliar a qualidade das informações em prontuários e da resposta assistencial a pacientes em enfermarias com agravamento do estado clínico, resultando em óbito ou transferência para UTI em um Hospital Universitário e fornecer dados para comparação de resultados após implantação da ERR. Material e Métodos: Estudo documental retrospectivo, entre junho de 2013 e julho de 2014, em 128 prontuários de pacientes com piora clínica que resultou em óbito ou admissão em UTI ("evento"). Foram coletados os parâmetros fisiológicos, a pontuação no Escore para Alerta Precoce e o Plano de Ação registrado em 11 momentos que antecederam o "evento", resultando em 11 escores. A relação entre a pontuação do Escore de Alerta Precoce e a execução do Plano de Ação foi classificada como "adequada", "inadequada" ou "ausente". Resultados: Quanto mais se afastava momento de ocorrência do "evento", maior foi o número de dados faltantes, ocasionando Escores de Alerta Precoce não calculáveis. O número de casos adequados foi menor quanto mais distante estava o "evento" do momento da aferição dos parâmetros fisiológicos. Conclusão: Os tempos de resposta foram inadequados ao Plano de Ação. A falha em socorrer pacientes em deterioração clínica é complexa e multifatorial, mas acredita-se que no presente relato isto se deveu, pelo menos em parte, à anotação inadequada dos parâmetros fisiológicos. Esforços devem ser envidados no sentido de reforçar a importância do registro dos parâmetros fisiológicos, de reconhecer, de intervir e de comunicar agravos, essenciais para o correto funcionamento das alças aferente e eferentes das ERR.

Introduction: Preventable adverse events may result from unnoticed clinical deterioration in inpatients, which are often preceded by changes in warning signs, providing an opportunity for early intervention. The adoption of the Rapid Response Team (ERR) can improve the outcome; however, it is highly dependent on monitoring of the physiological parameters and on notification of the ERR. Objective: To evaluate the quality of information in medical records and the care response to patients in wards with worsening of the clinical status, which resulting in death or transfer to the ICU in a University Hospital and provide data for future comparison of results after ERR deployment. Material and Methods: Documentary retrospective study, between June 2013 and July 2014, of 128 medical records of patients with clinical worsening who died in death or admission to the ICU ("event"). The physiological parameters, the score on the Early Warning Score and the Action Plan recorded in 11 moments that preceded the "event" were collected, resulting in 11 scores. The relationship between the Early Warning Score and Action Plan execution was classified as "adequate", "inadequate" or "absent". Results: The further away from the moment of occurrence of the "event", greater the number of missing data, causing non- calculable Early Warning Scores. The number of adequate cases was smaller the further away the "event" was from the moment of measurement of the physiological parameters. Conclusion: Response times were inadequate to the Action Plan. Failure to rescue patients in the clinic is a complex and multifactorial, but it is believed that in the present report this was due, at least in part, to inadequate recording of physiological parameters. Efforts should be made to reinforce the importance of recording physiological parameters, recognizing, intervening, and communicating injuries, which are essential for the correct functioning of the afferent and efferent loops of the ERR.

Multicenter validation of Early Warning Scores for detection of clinical deterioration in COVID-19 hospitalized patients.

Objective: Investigate the predictive value of NEWS2, NEWS-C, and COVID-19 Severity Index for predicting intensive care unit (ICU) transfer in the next 24 h. Design: Retrospective multicenter study. Setting: Two third-level hospitals in Argentina. Patients: All adult patients with confirmed COVID-19, admitted on general wards, excluding patients with non-intubated orders. Interventions: Patients were divided between those who were admitted to ICU and non-admitted. We calculated the three scores for each day of hospitalization. Variables: We evaluate the calibration and discrimination of the three scores for the outcome ICU admission within 24, 48 h, and at hospital admission. Results: We evaluate 13,768 days of hospitalizations on general medical wards of 1318 patients. Among these, 126 (9.5%) were transferred to ICU. The AUROC of NEWS2 was 0.73 (95%CI 0.68-0.78) 24 h before ICU admission, and 0.52 (95%CI 0.47-0.57) at hospital admission. The AUROC of NEWS-C was 0.73 (95%CI 0.68-0.78) and 0.52 (95%CI 0.47-0.57) respectively, and the AUROC of COVID-19 Severity Index was 0.80 (95%CI 0.77-0.84) and 0.61 (95%CI 0.58-0.66) respectively. COVID-19 Severity Index presented better calibration than NEWS2 and NEWS-C. Conclusion: COVID-19 Severity index has better calibration and discrimination than NEWS2 and NEWS-C to predict ICU transfer during hospitalization.

Objetivo: Investigar el valor predictivo de los scores NEWS2, NEWS-C y COVID-19 Severity Index para predecir la transferencia de urgencia a la unidad de cuidados intensivos (UCI) en las próximas 24 horas. Diseño: Estudio multicéntrico retrospectivo. Ámbito: Dos hospitales de tercer nivel en Argentina. Pacientes: Pacientes adultos con COVID-19, ingresados en salas generales, excluyendo pacientes con órdenes de no intubar. Intervenciones: Se dividió a los pacientes entre los que ingresaron en la UCI y los que no ingresaron. Calculamos las tres puntuaciones para cada día de hospitalización. Variables: Evaluamos la calibración y discriminación de las tres puntuaciones para predecir el traslado de urgencia a UCI en las 24, 48 h previas al pase a UCI y al ingreso hospitalario. Resultados: Evaluamos 13.768 días de hospitalización en internación general de 1.318 pacientes, de los cuales 126 (9,5%) fueron trasladados a UCI. El AUROC del NEWS2 fue de 0,73 (IC 95% 0,68-0,78) 24 h antes del ingreso en UCI y de 0,52 (IC 95% 0,47-0,57) al ingreso hospitalario. El AUROC de NEWS-C fue de 0,73 (IC 95% 0,68-0,78) y 0,52 (IC 95% 0,47-0,57) respectivamente, y el AUROC del COVID-19 Severity Index fue de 0,80 (IC 95% 0,77-0,84) y 0,61 (IC 95% 0,58-0,66) respectivamente. El COVID-19 Severity Index presentó una mejor calibración que NEWS2 y NEWS-C. Conclusión: El COVID-19 Severity Index presentó una mejor calibración y discriminación que NEWS2 y NEWS-C para predecir la transferencia de la UCI durante la hospitalización.

Integrating earthquake early warnings into business continuity and organisational resilience: lessons learned from Mexico City.

Earthquake early warning (EEW) is becoming a popular tool for mitigating earthquake-induced losses. However, the current literature separates EEW technical components and their operational and behavioural implications. This paper investigates how EEW can be integrated into business continuity practices, organisational resilience, and disaster risk reduction (DRR). A mixed methods approach is applied to analyse EEW perceptions in the case-study context of Mexico City, Mexico, which is characterised by a high level of seismic hazard and social and physical exposure/vulnerability. The dataset includes evidence from 15 semi-structured interviews with representatives of the public and private sectors, such as governments and enterprises, and 78 valid questionnaires compiled by local organisations, including civil protection and education institutions. The results reveal inconsistencies between technical EEW methodologies and their integration into three core domains of organisational practice: accountability, governance, and jurisdiction; standardisation of plans and procedures; training and education. Finally, open challenges for future research are highlighted.

Desempenho do Escore Pediátrico de Alerta (EPA) de deterioração clínica / Desempeño del Sistema de Alerta Precoz Infantil (SAPI) de deterioración clínica / Pediatric Alert Score (EPA) performance in clinical deterioration

Resumo Objetivo Avaliar a acurácia, utilidade, reprodutibilidade e aplicabilidade do Escore Pediátrico de Alerta (EPA) na identificação da deterioração clínica em crianças e adolescentes hospitalizados. Métodos Estudo de teste diagnóstico, prospectivo, realizado entre outubro/2018 a outubro/2019, para medir a acurácia diagnóstica do EPA em uma amostra de 240 crianças, e sua reprodutibilidade e aplicabilidade em uma amostra de 60 crianças. Os dados foram processados e analisados no MedCalc e VassarStats.net. Resultados No ponto de corte ≥ 3, o escore apresentou sensibilidade de 73,6%, especificidade de 95,7%, valor preditivo positivo de 83%, valor preditivo negativo de 92,7, área sob a curva ROC de 93,6%, prevalência estimada pelo teste de 19,6%, razão de probabilidade positiva 17,1, probabilidade pós-teste positivo de 77,8%, kappa simples de 0,946. Conclusão O estudo fornece evidências sobre a elevada acurácia, utilidade e reprodutibilidade do EPA na identificação da deterioração clínica em um cenário hospitalar pediátrico brasileiro, e considerou o instrumento aplicável no contexto da pesquisa.

Resumen Objetivo Evaluar la precisión, utilidad, reproducibilidad y aplicabilidad del Sistema de Alerta Precoz Infantil (SAPI) en la identificación del deterioro clínico en niños y adolescentes hospitalizados. Métodos Estudio de prueba diagnóstica, prospectiva, realizada entre octubre de 2018 y octubre de 2019, para medir la precisión diagnóstica del SAPI en una muestra de 240 niños y su reproducibilidad y aplicabilidad en una muestra de 60 niños. Los datos fueron procesados y analizados en MedCalc y VassarStats.net. Resultados En el punto de corte ≥ 3, el puntaje presentó una sensibilidad del 73,6 %, especificidad del 95,7 %, valor predictivo positivo del 83 %, valor predictivo negativo de 92,7, área bajo la curva ROC del 93,6 %, prevalencia estimada por la prueba del 19,6 %, razón de probabilidad positiva 17,1, probabilidad posprueba positiva del 77,8 %, kappa simple de 0,946. Conclusión El estudio presenta evidencias sobre la elevada precisión, utilidad y reproducibilidad del SAPI en la identificación del deterioro clínico en un escenario hospitalario pediátrico brasileño, por lo que el instrumento se consideró aplicable en el contexto de la investigación.

Abstract Objective To assess the Pediatric Alert Score (EPA) accuracy, usefulness, reproducibility and applicability in identifying clinical deterioration in hospitalized children and adolescents. Methods This is a prospective diagnostic test study, carried out between October/2018 and October/2019, to measure EPA diagnostic accuracy in a sample of 240 children, and its reproducibility and applicability in a sample of 60 children. Data were processed and analyzed on MedCalc and VassarStats.net. Results At cut-off point ≥ 3, the score had a sensitivity of 73.6%, specificity of 95.7%, positive predictive value of 83%, negative predictive value of 92.7, area under the ROC curve of 93.6%, estimated prevalence of 19.6%, positive probability ratio of 17.1, positive post-test probability of 77.8%, simple Kappa of 0.946. Conclusion The study provides evidence on EPA high accuracy, usefulness and reproducibility in identifying clinical deterioration in a Brazilian pediatric hospital setting, and considered the instrument applicable in the context of the research.

National Early Warning Score 2 ­ versão brasileira: validade preditiva para adultos com COVID-19* / National Early Warning Score 2 ­ versión brasileña: validez predictiva para adultos con COVID-19 / National Early Warning Score 2 ­ Brazilian version: predictive validity for adults with COVID-19

Objetivo: realizar a validade preditiva do National Early Warning Score 2 ­ versão brasileira (NEWS 2 ­ BR) nos desfechos alta e óbito em pacientes com COVID-19. Método: estudo transversal com análise de validade preditiva. Variáveis sociodemográficas, clínicas, desfechos e os componentes do escore foram coletados em prontuário eletrônico e analisados por meio da estatística descritiva e inferencial. Resultados: incluíram-se 400 pacientes, com mediana de idade de 61 anos. O escore na admissão teve mediana de 5 pontos, com amplitude de 0 a 21. Houve associação entre escores mais altos com o desfecho óbito e escores mais baixos com a alta. A validade preditiva do NEWS 2 ­ BR para o óbito foi realizada pela análise de curva ROC e o ponto de corte de maior acurácia foi de seis pontos. Conclusão: a versão brasileira do NEWS 2 é um escore válido para avaliação de pacientes com COVID-19.

Objective: perform the predictive validity of National Early Warning Score 2 ­ Brazilian version (NEWS 2 ­ BR) in discharge and death outcomes in patients with COVID-19. Method: cross-sectional study with predictive validity analysis. Social-demographical and clinical variables, outcomes and the score components were collected with an electronic health record and analyzed through descriptive and inferential statistics. Outcomes: 400 patients were included, with median age of 61 years. The score, at the moment of admission, had a median of 5 points, with a range from 0 to 21. There is an association between the highest scores and the death outcome and the lowest scores and the discharge outcome. The predictive validity of NEWS 2 ­ BRfor death was established by the analysis of the ROC curve and the most accurate cut-off point was six points. Conclusion: The Brazilian version of NEWS 2 is a valid score to assess patients with COVID-19.

Objetivo: realizar la validez predictiva del National Early Warning Score 2 ­ versión brasileña (NEWS 2 ­ BR) en los resultados alta y fallecimiento en pacientes con COVID-19. Método: estudio transversal con análisis de validez predictiva. Variables sociodemográficas, clínicas, resultados y los componentes del score fueron recolectados en prontuario electrónico y analizados por medio de la estadística descriptiva e inferencial. Resultados: se incluyeron 400 pacientes, con mediana de edad de 61 años. El score en la admisión tuvo mediana de 5 puntos, con amplitud de 0 a 21. Hubo asociación entre scores más altos con el resultado fallecimiento y scores más bajos con el alta. La validez predictiva del NEWS 2 ­ BR para el fallecimiento fue realizada por el análisis de curva ROC y el punto de corte de mayor precisión fue de seis puntos. Conclusión: la versión brasileña del NEWS 2 es un score válido para la evaluación de pacientes con COVID-19.

Design of early warning system for mental health problems based on data mining and database / Projeto de sistema de alerta precoce para problemas de saúde mental com base na mineração de dados e banco de dados / Diseño de un sistema de alerta temprana de problemas de salud mental basado en la minería de datos y en la base de datos

ABSTRACT Introduction: Data mining technology is mainly employed in the era of big data to evaluate the acquired information. Subsequently, reasoning about the data inductively is fully automated to discover possible patterns. Objective: Recently, data mining technology in the national mental health database has deepened and can be effectively used to solve various mental health early warning problems. Methods: For example, it can be applied to mine psychological data and extract the most important features and information. Results: This paper presents the design of an early warning system for mental health problems based on data mining techniques to offer some thoughts on early warning of mental health problems, including data preparation, data mining, results in analysis, and decision tree algorithm. Conclusion: The experimental results indicate that the results of the early warning system in this paper can achieve an accuracy rate of more than 96% with a high accuracy rate. Level of evidence II; Therapeutic studies - investigating treatment outcomes.

RESUMO Introdução: A tecnologia de mineração de dados é empregada principalmente na era da big data para avaliar as informações adquiridas. Posteriormente, raciocinar indutivamente sobre os dados de forma totalmente automatizada para descobrir possíveis padrões. Objetivo: Recentemente, a tecnologia de mineração de dados no banco de dados nacional de saúde mental tem se aprofundado e pode ser efetivamente utilizada para resolver vários problemas de alerta precoce da saúde mental. Métodos: Por exemplo, ela pode ser aplicada para a mineração de dados psicológicos e extrair as características e informações mais importantes. Resultados: Este documento apresenta o projeto de um sistema de alerta precoce para problemas de saúde mental baseado em técnicas de mineração de dados, com o objetivo de oferecer algumas reflexões sobre alerta precoce de problemas de saúde mental, incluindo preparação de dados, mineração de dados, análise de resultados e algoritmo de árvore de decisão. Conclusão: Os resultados experimentais indicam que os resultados do sistema de alerta precoce neste trabalho podem alcançar uma taxa de precisão de mais de 96% com uma alta taxa de precisão. Nível de evidência II; Estudos terapêuticos - investigação dos resultados do tratamento.

Resumen Introducción: La tecnología de minería de datos se emplea principalmente en la era de la big data para evaluar la información adquirida. Posteriormente, razonar inductivamente sobre los datos de forma totalmente automatizada para descubrir posibles patrones. Objetivo: Recientemente, la tecnología de minería de datos en la base de datos nacional de salud mental se ha profundizado y puede ser utilizada eficazmente para resolver varios problemas de alerta temprana de salud mental. Métodos: Por ejemplo, puede aplicarse para minar datos psicológicos y extraer las características e información más importantes. Resultados: Este trabajo presenta el diseño de un sistema de alerta temprana de problemas de salud mental basado en técnicas de minería de datos, con el objetivo de ofrecer algunas reflexiones sobre la alerta temprana de problemas de salud mental, incluyendo la preparación de los datos, la minería de datos, el análisis de los resultados y el algoritmo de árbol de decisión. Conclusión: Los resultados experimentales indican que los resultados del sistema de alerta temprana de este documento pueden alcanzar un índice de precisión superior al 96% con un alto índice de precisión. Nivel de evidencia II; Estudios terapéuticos - investigación de los resultados del tratamiento.

Performance of risk scores in patients with acute exacerbations of COPD / Desempenho de escores de risco em pacientes com exacerbações agudas da DPOC

ABSTRACT Objective: Acute exacerbations of COPD (AECOPD) are common causes of hospitalization. Various scoring systems have been proposed to classify the risk of clinical deterioration or mortality in hospitalized patients with AECOPD. We sought to investigate whether clinical deterioration and mortality scores at admission can predict adverse events occurring during hospitalization and after discharge of patients with AECOPD. Methods: We performed a retrospective study of patients admitted with AECOPD. The National Early Warning Score 2 (NEWS2), the NEWS288-92%, the Dyspnea, Eosinopenia, Consolidation, Acidemia, and atrial Fibrillation (DECAF) score, and the modified DECAF (mDECAF) score were calculated at admission. We assessed the sensitivity, specificity, and overall performance of the scores for the following outcomes: in-hospital mortality; need for invasive mechanical ventilation or noninvasive ventilation (NIV); long hospital stays; hospital readmissions; and future AECOPD. Results: We included 119 patients admitted with AECOPD. The median age was 75 years, and 87.9% were male. The NEWS288-92% was associated with an 8.9% reduction in the number of individuals classified as requiring close, continuous observation, without an increased risk of death in the group of individuals classified as being low-risk patients. The NEWS288-92% and NEWS2 scores were found to be adequate in predicting the need for acute NIV and longer hospital stays. The DECAF and mDECAF scores were found to be better at predicting in-hospital mortality than the NEWS2 and NEWS288-92%. Conclusions: The NEWS288-92% safely reduces the need for clinical monitoring in patients with AECOPD when compared with the NEWS2. The NEWS2 and NEWS288-92% appear to be good predictors of the length of hospital stay and need for NIV, but they do not replace the DECAF and mDECAF scores as predictors of mortality.

RESUMO Objetivo: As exacerbações agudas da DPOC (EADPOC) são causas comuns de hospitalização. Vários escores foram propostos para classificar o risco de deterioração clínica ou mortalidade em pacientes hospitalizados com EADPOC. Buscamos investigar se escores de deterioração clínica e mortalidade no momento da admissão podem prever eventos adversos durante a hospitalização e após a alta de pacientes com EADPOC. Métodos: Realizamos um estudo retrospectivo a respeito de pacientes admitidos com EADPOC. O National Early Warning Score 2 (NEWS2), o NEWS288-92%, o escore Dyspnea, Eosinopenia, Consolidation, Acidemia, and atrial Fibrillation (DECAF, Dispneia, Eosinopenia, Consolidação, Acidemia e Fibrilação atrial) e o escore DECAF modificado (DECAFm) foram calculados no momento da admissão. Avaliamos a sensibilidade, a especificidade e o desempenho geral dos escores quanto aos seguintes desfechos: mortalidade hospitalar; necessidade de ventilação mecânica invasiva ou ventilação não invasiva (VNI); longas internações hospitalares; readmissões hospitalares e futuras AECOPD. Resultados: Incluímos 119 pacientes admitidos com EADPOC. A mediana da idade foi de 75 anos, e 87,9% eram do sexo masculino. O NEWS288-92% associou-se a uma redução de 8,9% no número de indivíduos classificados em pacientes com necessidade de observação atenta e contínua, sem aumento do risco de morte no grupo de indivíduos classificados em pacientes de baixo risco. O NEWS288-92% e o NEWS2 foram considerados adequados para prever a necessidade de VNI aguda e internações hospitalares mais longas. O DECAF e o DECAFm foram considerados melhores em prever a mortalidade hospitalar do que o NEWS2 e o NEWS288-92%. Conclusões: Em comparação com o NEWS2, o NEWS288-92% reduz com segurança a necessidade de monitoramento clínico em pacientes com EADPOC. O NEWS2 e o NEWS288-92% aparentemente são bons preditores do tempo de internação hospitalar e da necessidade de VNI, mas não substituem o DECAF e o DECAFm como preditores de mortalidade.

Focalidad de Aedes aegypti e indicadores climáticos en Nueva Gerona Cuba (2006-2022)

Introducción: Las enfermedades transmitidas por mosquitos resultan particularmente sensibles a las condiciones meteorológicas. Objetivo: Modelar la focalidad de Aedes aegypti e indicadores climáticos en Nueva Gerona, Cuba. Métodos: Estudio descriptivo de corte transversal realizado en el período de 2006 a 2022 en Nueva Gerona, Isla de la Juventud. Se empleó una curva de expectativa según meses y análisis de indicadores climáticos para establecer el momento más oportuno para acometer acciones de supresión vectorial. Una vez identificado, se procedió a la modelación espacial y al análisis del clima para el mismo período. Resultados: La curva de expectativa facilitó muestras de mayor focalidad de Aedes aegypti a partir del mes de junio, por lo que se definió el período de marzo a junio como el más oportuno para intensificar las acciones de supresión de la población vectorial. Los mapas mostraron varias zonas calientes en las que se encuentran involucrados con mayor riesgo los consejos populares de Pueblo Nuevo, Abel Santamaría, 26 de Julio y la localidad de Nazareno. Las precipitaciones acumuladas comenzaron en marzo (24,3 mm), abril (55,4 mm), mayo (163,4 mm) y junio (393,8 mm). Las temperaturas y la humedad relativa incrementaron de un mes a otro. Predominaron los vientos del Este. Conclusiones: La modelación de la focalidad de Aedes aegypti definió temporo-espacialmente y como sistema de alerta temprana que el período entre marzo y junio constituía el más oportuno para la realización de las acciones que llevarían hacia la supresión vectorial, a tenor del comportamiento de indicadores climáticos que ejercieron efectos favorecedores sobre la infestación.

Introduction: Mosquito-borne diseases are particularly sensitive to weather conditions. Objective: To model Aedes aegypti focality and climate indicators in Nueva Gerona, Cuba. Methods: A descriptive cross-sectional study was conducted from 2006 to 2022 in Nueva Gerona, Isla de la Juventud. An expectation curve by months and analysis of climate indicators was used to decide on the most appropriate moment to undertake vector suppression actions. Once identified, spatial modeling and weather analysis were carried out for the same period. Results: The expectation curve provided evidence of greater Aedes aegypti focality from June onwards; therefore, the period from March to June was defined as the most appropriate to intensify vector population suppression actions. The maps showed several hot spots with the highest risk that include the people's councils of Pueblo Nuevo, Abel Santamaría, 26 de Julio and the locality of Nazareno. Cumulative rainfall began in March (24.3 mm), April (55.4 mm), May (163.4 mm) and June (393.8 mm). Temperatures and relative humidity increased by month. Easterly winds predominated. Conclusions: Modeling Aedes aegypti focality defined temporo-spatially and as an early warning system that the period between March and June were the most appropriate for conducting vector suppression actions, based on climate indicators that exerted favoring effects on infestation.

Escores de alerta precoce em pacientes com suspeita ou diagnóstico de sepse: uma revisão integrativa / Early warning scores in patients with suspected or diagnosed sepsis: an integrative review / Puntuaciones de alerta temprana en pacientes con sospecha o diagnóstico de sepsis: una revisión integradora

Objetivo: analisar publicações científicas sobre a utilização de escores de alerta precoce, nos serviços terciários, como ferramentas de detecção da deterioração clínica em paciente com suspeita ou diagnóstico de sepse. Método: revisão integrativa realizada na PubMed, Scopus, Web of Science e Biblioteca Virtual em Saúde entre fevereiro e março de 2021. Incluídos artigos em inglês, espanhol e português, sem delimitação de tempo na busca. Resultados: identificou-se diferentes escores para detecção precoce da deterioração clínica em pacientes com suspeita ou diagnóstico de sepse. As ferramentas mais frequentes nos serviços terciários foram: National Early Warning Score, Sequential Organ Failure Assessment Score e Systemic Inflammatory Response Syndrome (n=6) (50%), sendo a maioria nos Departamentos de Emergências (n=5) (41,6%). Considerações finais: National Early Warning Score foi o escore mais utilizado para pacientes com suspeita ou diagnóstico de sepse com maior acurácia para a predição de mortalidade hospitalar e admissão em Unidade de Terapia Intensiva.

Objective: to examine scientific publications on the use of early warning scores in tertiary services as tools for detecting clinical deterioration in patients with suspected or diagnosed sepsis. Method: this integrative review was conducted in PubMed, Scopus, Web of Science and the Virtual Health Library between February and March 2021. Articles in English, Spanish, and Portuguese were included with no time limits on the search. Results: different scores were found for early detection of clinical deterioration in patients with suspected or diagnosed sepsis. The most frequent tools in tertiary services were the National Early Warning Score, Sequential Organ Failure Assessment Score and Systemic Inflammatory Response Syndrome (n = 6) (50%), most of them in Emergency Departments (n = 5) (41.6 %). Final remarks: the National Early Warning Score was the most used for patients with suspected or diagnosed sepsis and was the most accurate in predicting hospital mortality and admission to the Intensive Care Unit.

Objetivo: analizar publicaciones científicas sobre la utilización de puntuaciones de alerta temprana, en servicios terciarios, como herramientas para detección de deterioro clínico en pacientes con sospecha o diagnóstico de sepsis. Método: revisión integradora en PubMed, Scopus, Web of Science y Biblioteca Virtual en Salud entre febrero y marzo de 2021. Fueron incluidos artículos en inglés, español y portugués, sin límite de tiempo en la búsqueda. Resultados: se identificaron diferentes puntuaciones para detección temprana de deterioro clínico en pacientes con sospecha o diagnóstico de sepsis. Las herramientas frecuentes en los servicios terciarios fueron: National Early Warning Score, Sequential Organ Failure Assessment Score y Systemic Inflammatory Response Syndrome (n=6) (50%), la mayoría en Servicios de Emergencia (n=5) (41,6 %). Consideraciones finales: National Early Warning Score fue la puntuación más utilizada para pacientes con sospecha o diagnóstico de sepsis con mejor precisión para predecir la mortalidad hospitalaria e ingreso a la Unidad de Cuidados Intensivos.