RESUMO
BACKGROUND AND AIMS: In Sri Lanka, as in most low-to-middle-income countries (LMICs), early warning systems (EWSs) are not in use. Understanding observation-reporting practices and response to deterioration is a necessary step in evaluating the feasibility of EWS implementation in a LMIC setting. This study describes the practices of observation reporting and the recognition and response to presumed cardiopulmonary arrest in a LMIC. PATIENTS AND METHODS: This retrospective study was carried out at District General Hospital Monaragala, Sri Lanka. One hundred and fifty adult patients who had cardiac arrests and were reported to a nurse responder were included in the study. RESULTS: Availability of six parameters (excluding mentation) was significantly higher at admission (P < 0.05) than at 24 and 48 h prior to cardiac arrest. Patients had a 49.3% immediate return of spontaneous circulation (ROSC) and 35.3% survival to hospital discharge. Nearly 48.6% of patients who had ROSC did not receive postarrest intensive care. Intubation was performed in 46 (62.2%) patients who went on to have ROSC compared with 28 (36.8%) with no ROSC (P < 0.05). Defibrillation, performed in eight (10.8%) patients who had ROSC and eight (10.5%) in whom did not, was statistically insignificant (P = 0.995). CONCLUSIONS: Observations commonly used to detect deterioration are poorly reported, and reporting practices would need to be improved prior to EWS implementation. These findings reinforce the need for training in acute care and resuscitation skills for health-care teams in LMIC settings as part of a program of improving recognition and response to acute deterioration.
RESUMO
OBJECTIVE: This study describes the availability of core parameters for Early Warning Scores (EWS), evaluates the ability of selected EWS to identify patients at risk of death or other adverse outcome and describes the burden of triggering that front-line staff would experience if implemented. DESIGN: Longitudinal observational cohort study. SETTING: District General Hospital Monaragala. PARTICIPANTS: All adult (age >17 years) admitted patients. MAIN OUTCOME MEASURES: Existing physiological parameters, adverse outcomes and survival status at hospital discharge were extracted daily from existing paper records for all patients over an 8-month period. STATISTICAL ANALYSIS: Discrimination for selected aggregate weighted track and trigger systems (AWTTS) was assessed by the area under the receiver operating characteristic (AUROC) curve.Performance of EWS are further evaluated at time points during admission and across diagnostic groups. The burden of trigger to correctly identify patients who died was evaluated using positive predictive value (PPV). RESULTS: Of the 16 386 patients included, 502 (3.06%) had one or more adverse outcomes (cardiac arrests, unplanned intensive care unit admissions and transfers). Availability of physiological parameters on admission ranged from 90.97% (95% CI 90.52% to 91.40%) for heart rate to 23.94% (95% CI 23.29% to 24.60%) for oxygen saturation. Ability to discriminate death on admission was less than 0.81 (AUROC) for all selected EWS. Performance of the best performing of the EWS varied depending on admission diagnosis, and was diminished at 24 hours prior to event. PPV was low (10.44%). CONCLUSION: There is limited observation reporting in this setting. Indiscriminate application of EWS to all patients admitted to wards in this setting may result in an unnecessary burden of monitoring and may detract from clinician care of sicker patients. Physiological parameters in combination with diagnosis may have a place when applied on admission to help identify patients for whom increased vital sign monitoring may not be beneficial. Further research is required to understand the priorities and cues that influence monitoring of ward patients. TRIAL REGISTRATION NUMBER: NCT02523456.