UMEM Educational Pearls

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

Keywords: NEWS, MEWS, IEWS, international Early Warning Score, mortality (PubMed Search)

Posted: 6/27/2023 by Quincy Tran, MD (Updated: 4/29/2024)
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Settings: Retrospective data from 3 Dutch EDs (development of the score), 2 Denmark ED (for validation of the score). The novel score (International Early Warning Score) will be composed of the National Early Warning Score (NEWS) + Age +Sex

Components of the National Early Warning Score:

Respiratory rate,
oxygen saturation,
supplemental oxygen (yes/no),
Temperature,
Systolic blood pressure,
heart rate,
level of consciousness (Alert vs. not).

Participants: All adult patients in the Netherlands Emergency department Evaluation Database (NEED) and Danish Multicenter Cohort (DMC).

Outcome measurement: in-hospital mortality, including death in EDs.

Study Results:

95553 (2314, 2.5% died) patients were used for development of the score, 14809 patients (365, 2.5% died) were in the validation cohort.
The IEWS provides higher AUROC (0.87, 95% CI 0.85-0.88) than the NEWS (AUROC 0.82, 95% CI 0.80-0.84) in the validation cohort.
The IEWS for the age group 18-65 years (AUROC 0.86, 95% CI 0.80-0.91) had the most improvement, compared to NEWS (AUROC 0.82, 95% CI 0.75-0.89).

Discussion:

The study excluded patients whom did not have 2 sets of vital signs, thus, “very sick” or “not sick” patients would be excluded.
This novel score was not compared with the updated NEWS2, which incorporates hypercapnia and confusion. Additionally, this novel score was also not compared with another popular score, Modified Early Warning Score (MEWS). Both the NEWS and MEWS scores have been studied extensively in the literature, thus, have been adopted in clinical use.

Conclusion:

This multicenter study showed that IEWS perform better than the NEWS for predicting in-hospital mortality for ED patients.

References

Candel BGJ, Nissen SK, Nickel CH, Raven W, Thijssen W, Gaakeer MI, Lassen AT, Brabrand M, Steyerberg EW, de Jonge E, de Groot B. Development and External Validation of the International Early Warning Score for Improved Age- and Sex-Adjusted In-Hospital Mortality Prediction in the Emergency Department. Crit Care Med. 2023 Jul 1;51(7):881-891. doi: 10.1097/CCM.0000000000005842. Epub 2023 Mar 23. PMID: 36951452; PMCID: PMC10262984.