open access publication

Article, 2023

Development and External Validation of the International Early Warning Score for Improved Age- and Sex-Adjusted In-Hospital Mortality Prediction in the Emergency Department

Critical Care Medicine, ISSN 1530-0293, 0090-3493, Volume 51, 7, Pages 881-891, 10.1097/ccm.0000000000005842

Contributors

Candel, Bart Gerard Jan (Corresponding author) [1] [2] Nissen, Søren Kabell 0000-0003-3722-908X [3] [4] Nickel, Christian Hans [5] [6] Raven, Wouter 0000-0003-1154-011X [2] Thijssen, Wendy [7] Gaakeer, Menno Iskander 0000-0003-4973-004X [8] Lassen, Annmarie Touborg 0000-0003-4942-6152 [3] Brabrand, Mikkel 0000-0002-3340-8251 [3] [4] [9] Steyerberg, Ewout Willem 0000-0002-7787-0122 [2] [10] De Jonge, Evert 0000-0003-1431-8039 [2] De Groot, Bas [11]

Affiliations

  1. [1] Máxima Medisch Centrum
    2. [NORA names: Netherlands; Europe, EU; OECD];
  2. [2] Leiden University Medical Center
    3. [NORA names: Netherlands; Europe, EU; OECD];
  3. [3] Odense University Hospital
    4. [NORA names: Region of Southern Denmark; Hospital; Denmark; Europe, EU; Nordic; OECD];
  4. [4] University of Southern Denmark
    5. [NORA names: SDU University of Southern Denmark; University; Denmark; Europe, EU; Nordic; OECD];
  5. [5] University Hospital of Basel
    6. [NORA names: Switzerland; Europe, Non-EU; OECD];

Abstract

OBJECTIVES: Early Warning Scores (EWSs) have a great potential to assist clinical decision-making in the emergency department (ED). However, many EWS contain methodological weaknesses in development and validation and have poor predictive performance in older patients. The aim of this study was to develop and externally validate an International Early Warning Score (IEWS) based on a recalibrated National Early warning Score (NEWS) model including age and sex and evaluate its performance independently at arrival to the ED in three age categories (18-65, 66-80, > 80 yr). DESIGN: International multicenter cohort study. SETTING: Data was used from three Dutch EDs. External validation was performed in two EDs in Denmark. PATIENTS: All consecutive ED patients greater than or equal to 18 years in the Netherlands Emergency department Evaluation Database (NEED) with at least two registered vital signs were included, resulting in 95,553 patients. For external validation, 14,809 patients were included from a Danish Multicenter Cohort (DMC). MEASUREMENTS AND MAIN RESULTS: Model performance to predict in-hospital mortality was evaluated by discrimination, calibration curves and summary statistics, reclassification, and clinical usefulness by decision curve analysis. In-hospital mortality rate was 2.4% ( n = 2,314) in the NEED and 2.5% ( n = 365) in the DMC. Overall, the IEWS performed significantly better than NEWS with an area under the receiving operating characteristic of 0.89 (95% CIs, 0.89-0.90) versus 0.82 (0.82-0.83) in the NEED and 0.87 (0.85-0.88) versus 0.82 (0.80-0.84) at external validation. Calibration for NEWS predictions underestimated risk in older patients and overestimated risk in the youngest, while calibration improved for IEWS with a substantial reclassification of patients from low to high risk and a standardized net benefit of 5-15% in the relevant risk range for all age categories. CONCLUSIONS: The IEWS substantially improves in-hospital mortality prediction for all ED patients greater than or equal to18 years.

Keywords

Danish, Denmark, Dutch emergency departments, ED patients, Early, Early Warning Score, Evaluation Database, International, National Early Warning Score, Netherlands, Netherlands Emergency Department Evaluation Database, Warning Score, age, age categories, analysis, area, arrival, benefits, calibration, calibration curve, categories, characteristics, clinical decision-making, clinical use, cohort, consecutive ED patients, curve analysis, curves, data, database, decision, decision curve analysis, decision-making, department, development, discrimination, emergency, emergency department, external validation, externalities, high risk, in-hospital mortality, in-hospital mortality prediction, in-hospital mortality rate, methodological weaknesses, model, model performance, mortality, mortality prediction, mortality rate, multicenter cohort, older patients, operating characteristics, overestimate risk, patients, performance, poor predictive performance, potential, prediction, predictive performance, range, rate, reclassification, reclassification of patients, risk, risk range, scores, sex, signs, study, to18, to18 years, use, validity, vital signs, weakness, years

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