TY - JOUR
T1 - Development and External Validation of the International Early Warning Score for Improved Age and Sex Adjusted In-Hospital Mortality Prediction in the Emergency Department
AU - Candel, Bart Gerard Jan
AU - Nissen, Søren Kabell
AU - Nickel, Christian H.
AU - Raven, Wouter
AU - Thijssen, Wendy
AU - Gaakeer, Menno I.
AU - Lassen, Annmarie Touborg
AU - Brabrand, Mikkel
AU - Steyerberg, Ewout W.
AU - Jonge, Evert de
AU - Groot, Bas de
PY - 2023/7/1
Y1 - 2023/7/1
N2 - 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.
AB - 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.
KW - Aged
KW - Cohort Studies
KW - Early Warning Score
KW - Emergency Service, Hospital
KW - Hospital Mortality
KW - Humans
KW - ROC Curve
KW - Vital Signs
UR - https://journals.lww.com/ccmjournal/Fulltext/9900/Development_and_External_Validation_of_the.116.aspx
U2 - 10.1097/ccm.0000000000005842
DO - 10.1097/ccm.0000000000005842
M3 - Journal article
C2 - 36951452
SN - 0090-3493
VL - 51
SP - 881
EP - 891
JO - Critical Care Medicine
JF - Critical Care Medicine
IS - 7
ER -