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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 12  |  Page : 1773-1778

If early warning systems are used, would it be possible to estimate early clinical deterioration risk and prevent readmission to intensive care?


1 Department of Anesthesiology And Reanimation, Biruni University Faculty of Medicine, Istanbul, Turkey
2 Department of Anesthesiology And Reanimation, Mengücek Gazi Training And Research Hospital, Erzincan, Turkey

Date of Submission18-Dec-2019
Date of Acceptance07-Jun-2021
Date of Web Publication09-Dec-2021

Correspondence Address:
Dr. I Kupeli
Department of Anesthesiology And Reanimation, Biruni University Faculty of Medicine, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_682_19

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   Abstract 


Background: Although the intensive care unit (ICU) admission criteria are specified clearly, it is difficult to make the decision of discharge from ICU. Aims: The purpose of this study is to test whether or not early warning scores will allow us to estimate early clinical deterioration within 24 hours and predict readmission to intensive care. A total of 1330 patients were included in the retrospective study. Patients and Methods: All the patients' age, gender, ICU hospitalization reasons and Acute Physiological and Chronic Health Evaluation (APACHE II) scores were recorded. National Early Warning Score (NEWS) and VitalpacTM early warning score (VIEWS) scores were calculated using the physiological and neurological examination records. Discharge NEWS and VIEWS values of the patients who were readmitted to intensive care 24 hours after discharge were compared with the patients who were not readmitted to intensive care. The statistical analysis was performed using the IBM SPSS version 21 package software. Results: Age average of all the patients was 64.3 ± 20.8 years. The number of the patients who were readmitted to intensive care was 118 (8.87%). When examining the factors that affect early clinical deterioration, it was found that advanced age, high APACHE II scores, higher NEWS and VIEWS scores, lower DAP values and the patient's transfer from the ward were significantly predictive (P < 0.05). Conclusions: In this study, high NEWS and VIEWS are strong scoring systems that can be used in estimating early clinical deterioration risk and are easy-to-use and less time consuming.

Keywords: Early clinical deterioration, early warning scores, intensive care, readmission


How to cite this article:
Kupeli I, Subasi F. If early warning systems are used, would it be possible to estimate early clinical deterioration risk and prevent readmission to intensive care?. Niger J Clin Pract 2021;24:1773-8

How to cite this URL:
Kupeli I, Subasi F. If early warning systems are used, would it be possible to estimate early clinical deterioration risk and prevent readmission to intensive care?. Niger J Clin Pract [serial online] 2021 [cited 2022 Aug 14];24:1773-8. Available from: https://www.njcponline.com/text.asp?2021/24/12/1773/332086




   Introduction Top


While considering the concerns about limited resources and optimal resource allocation, it is necessary to determine the admission and discharge criteria of intensive care unit (ICU) clearly, increase patient safety and also increase the number of patients receiving care. Although the ICU admission criteria are specified clearly,[1] it is often difficult to make the decision of discharge from ICU.[1]

It is known that discharging a patient from ICU before she/he is fully ready (early discharge) causes early ICU readmission and the increased ICU mortality.[2],[3],[4],[5]

In order to prevent early ICU discharge, a variety of indices and clinical criteria are offered to determine the most appropriate patient (1). However, it is difficult to apply these complex criteria in clinical practice. Vitalpac™ early warning score (VIEWS) is basically an early warning system aiming to estimate mortality of emergency service patients within the first 24 hours and was not used in evaluating intensive care discharge.[6]

On the other hand, the National Early Warning Score (NEWS) was suggested to detect early clinical deterioration in patients hospitalized[7] and only one study evaluated its practicality for intensive care discharge. However, it was stressed that there was a need for further studies on this matter.[1]

Both of the scoring systems consist of simple physiological parameters obtained from present vital signs and neurological findings and are easy to evaluate. The aim of this study was to increase the reliability on the use of these two identical early warning scores together.

The purpose of this study is to seek an answer to the following question; if one of the two scoring systems was used in intensive care discharge which was evaluated retrospectively, would it be possible to prevent these patients' readmission by detecting the most appropriate patient for discharge?


   Materials and Methods Top


The present study was designed as a retrospective study. It was started after receiving an ethics committee approval from Erzincan Binali Yildirim University Clinical Trials Ethics Committee. ClinicalTrials.gov ID: NCT03912701.

The patients older than 18 years who were discharged and the patients who were readmitted to intensive care within the first 24 hours between 1 January 2015 and 1 January 2019 were included in the study. The patients who were younger than 18 years, were admitted to postoperative intensive care and pregnant were excluded from the study.

All demographic data of the patients, including their age, gender, reason of ICU hospitalization, Acute Physiological and Chronic Health Evaluation (APACHE) II score and ICU discharge were recorded using their file records. NEWS and VIEWS scores were calculated using physiological and neurological examination records. NEWS and VIEWS values of the patients, who were readmitted to intensive care 24 hours after being discharged, during the discharge were compared with the patients who were not readmitted to intensive care.

There are seven parameters constituting these scoring systems: respiratory rate, oxygen saturation, oxygen need, body temperature, heart rate, systolic blood pressure and consciousness level. Higher scores signify significant early clinical deterioration and severity. Those with >5 are accepted to be high risk.[1]

Primary goal of the study is to test whether or not NEWS and VIEWS scores of the patients who are screened retrospectively will allow us to estimate early clinical deterioration within 24 hours and predict readmission to intensive care.

Secondary goals of the present study are to evaluate the correlation between readmission to intensive care within 24 hours after being discharged from intensive care and morbidity/mortality.

The study was designed based on the hypothesis that early clinical deterioration can be estimated after intensive care discharge and it is possible to prevent these patients from being discharged before full recovery and reduce readmission to intensive care.

Statistical analysis

The results were presented as numbers for categorical variables and mean ± standard deviation for continuous variables. Comparison of the categorical variables between the groups was performed using Chi-square or Fisher exact test. The normality of distribution for continuous variables was confirmed with the Kolmogorov–Smirnov test. For comparison of continuous independent variables between the two groups, the Student's t-test or Mann–Whitney U test was used depending on whether the statistical hypotheses were fulfilled or not. The statistical level of significance for all the tests was considered to be 0.05. The statistical analysis was performed using the IBM SPSS version 21 package software (IBM Software, New York, United States).


   Results Top


A total of 1330 patients were included in the study. Age average of all the patients was 64.3 ± 20.8 years and the number of women/men was 611/719. It was determined that APACHE II was 46.13 ± 26.0, NEWS was 2.36 ± 1.8; VIEWS was 3.12 ± 2.1 and DAP was 68.55 ± 16.5. The number of the patients who were readmitted to intensive care was 118 (8.87%) and 99 of them (83.9%) were exitus. 705 of the patients condition worsened in the ward and were readmitted to intensive care [Table 1].
Table 1: Descriptive Statistics

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[Table 2] shows the patients' initial admission diagnoses and early clinical deterioration reasons.
Table 2: Initial Admission And Readmission Reasons

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When considering the factors affecting early clinical deterioration that would require readmission to intensive care, which is the primary goal of the present study, it was determined that advanced age, high APACHE II score, low DAP values, the patient's transfer from the ward [Table 3], high NEWS and VIEWS scores were significantly effective AUC; 0,931; 0,930, respectively [Table 3] and [Figure 1].
Figure 1: Area Under Curves of NEWS and VIEWS (AUC; 0,931; 0,930, respectively)

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Table 3: Factors Affecting Early Clinical Deterioration

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When considering the effect of readmission to intensive care on morbidity and mortality, which is the secondary goal of the present study, it was determined that mortality rates were high. It was found that mortality was significantly affected by advanced age, high APACHE II scores, high readmission APACHE II scores (p: 0.001). NEWS and VIEWS scores did not predict mortality. (p: 0.084) [Table 4].
Table 4: Factors Affecting Mortality

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   Discussion Top


In our study aiming to test the practicality of early warning systems such as NEWS and VIEWS in intensive care discharge; the NEWS and VIEWS scores during the discharge of 118 patients, who were readmitted to intensive care within the first 24 hours, were significantly higher than those who were not readmitted. These scoring systems were found to be an independent predictor of clinical deterioration within 24 hours after transfer. Also, in this presented study showed that these scoring systems were not the only parameter in predicting early clinical deterioration and other factors were also effective on early clinical deterioration.

Although the Society of Intensive Care Medicine has prepared a guideline for admission to intensive care unit, triage and discharge; evidences in the guideline are too weak.[1] Thus, ICU discharge decision is still up to the decision of intensive care staff. ICU readmission rate within 24-48 hours is accepted to be the main indicator of ICU quality and ICU performance. In the literature, readmission rates are 5.5%[8],[9],[10] to 14.8%[1] and in our study, ICU readmission rate was 8.87%, which was similar to the literature. Because there is only one intensive care unit in our hospital, it was seen that the most common admission reasons were cerebrovascular event, in-car traffic accident, falling. On the other hand, it was determined that the most common readmission reasons were hypotension, cardiac arrest, and hypoxia.

Early warning score system is based on the idea that irregularities in simple physiological observations can identify hospitalized patients under a high deterioration risk. Prodromal warning signs such as increase of respiratory rate or decrease of blood pressure appear before a critical disease and early diagnosis of such events offers an opportunity for reducing mortality. Early warning score system allows the user to record more than one parameters and respond at the same time and thus, slight changes in vital signs can be used in starting early emergency management to reverse the patients' abnormal physiological decline or demand her/his admission to a critical care area. Early warning scores were found to be an excellent indicator of cardiac arrest, ICU transfer and death in ICU, as well as 30-day mortality and duration of ICU hospitalization.[11]

In this study, the National Early Warning Score (NEWS), which is the most widely used EWS presented by the Royal College of Physicians (RCPL) in 2012,[1] and the 'VitalPac Early Warning Score (VIEWS) defined by Prytherch et al.,[6] In 2010 were preferred. In parallel with the literature, the results of the present study showed that NEWS and VIEWS scores were significantly higher in the patients who were readmitted to intensive care (Respectively, NEWS 2.0 and 5.5 and VIEWS 2.7 and 6.5).[1],[10]

Age, ICU hospitalization reasons, comorbidities, number of organ failure, high acute physiological scores during admission, ICU discharge during night shift and duration of ICU hospitalization are among the risk factors of clinical deterioration, which results in readmission.[1],[2],[10],[12],[13],[14],[15],[16],[17] Also the present study revealed that advanced age (73.5 ± 14.3) and high APACHE II scores (59.0 ± 20.9) were among the risk factors of early clinical deterioration. Additionally, the present study pointed out that low diastolic artery pressures and patients who were admitted to intensive care from the service due to worsening were under a significantly higher risk of early clinical deterioration.

ICU patients are physiologically unstable patients and they usually suffer from multiple organ failure. Due to the limited ICU resources concerning personnel and beds; patients are generally discharged earlier right after stabilization and even before attaining a full stabilization.[10] Early ICU discharge or discharging the patient before she/he is fully ready has a potential of increasing the frequency of readmission and mortality rate.[3],[9] Similarly in the present study, 83.9% of the patients who were readmitted to intensive care were exitus. On the other hand, increasing mortality were found to be associated with advanced age, high APACHE II scores in both hospitalizations. Although the NEWS and VIEWS scores were high in patients with exitus, this difference was not significant (p: 0.084).

Estimation values of early warning scores are important. It has been found that they prevent ICU admissions by helping anaesthetists make decisions and early warning scores have an excellent predictive value and affect patient outcomes in the environment of hospitalized patients. However, they can neither be used in isolation or replace clinical decision.[11] RCPL (Royal College of Physicians of Londra) suggests that a patient with 5-6 NEWS scores should be evaluated urgently in terms of acute physiological deterioration and the ICU specialist should not be impetuous for the patient's discharge in ≥6 NEWS values.[1]

In our unit, no early warning system is used in these patients. Average NEWS and VIEWS scores of the general population and early clinical deterioration group were 2.0 and 5.5, and 2.7 and 6.5, respectively. Thus, these patients probably had physiological irregularities before they were discharged and were not appropriate for discharge. Due to that problem, our intensive care team brought the concern about patient safety before deciding to take the patient out of ICU. This result has shown that our unit requires more resources and more beds and also the current practice should be changed in order to increase the safety of ICU discharge.

The present study has some limitations. Firstly, it is known that comorbidity and regularly used drugs affect prognosis in patients aged 65 years and over. In the present study, these factors were not considered. Similarly, no detailed evaluation was made for the deceased patients in terms of cause of death and final diagnosis. Secondly, since our hospital has only one intensive care unit and this unit is general intensive care, this study cannot be generalized to specific sub-specialties. Reanimation should only be supported by prospective studies carried out in specific intensive care units such as neurology, internal medicine and chest diseases. Finally, this is a retrospective study based on the assumption that healthcare professionals record physiological parameters during discharge correctly. Human factors such as miscalculations, measurement durations recorded wrongly and prejudices against lower-upper limit values could have emerged.


   Conclusions Top


Discharge NEWS and VIEWS values of the patients, who were readmitted to intensive care within first 24 hours after being discharged, were significantly higher than the patients who were not readmitted. It was determined that the early warning systems were an indicator of early clinical deterioration only following the transfer but did not predict mortality and morbidity. In addition, the study showed that these scoring systems were not the only effective parameter for predicting early clinical deterioration; also, advanced age, high APACHE II scores, low DAP values and being currently hospitalized in the service were also effective on early clinical deterioration. Although early warning systems are useful tools, we believe that when used alone, they cannot replace clinical decisions and experiences in managing patients.

Financial support and sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Uppanisakorn S, Bhurayanontachai R, Boonyarat J, Kaewpradit J. National Early Warning Score (NEWS) at ICU discharge can predict early clinical deterioration after ICU transfer. J Crit Care 2018;43:225-9.  Back to cited text no. 1
    
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Kaben A, Corrêa F, Reinhart K, Settmacher U, Gummert J, Kalff R, et al. Readmission to a surgical intensive care unit: Incidence, outcome and risk factors. Crit Care 2008;12:R123.  Back to cited text no. 2
    
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Nguyen MC, Strosberg DS, Jones TS, Bhakta A, Jones EL, Lyaker MR, et al. Mortality and readmission of outcomes after discharge from the surgical intensive care unit to long-term, acute-care hospitals. Surgery 2017;161:1367-75.  Back to cited text no. 3
    
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Roehrig C, Rosa RG, Ascoli AM, Madeira L, Rutzen W, Maccari J, et al. Comparison of unplanned intensive care unit readmission scores: A prospective cohort study. Intensive Care Med Exp 2015;3(Suppl 1):A472.  Back to cited text no. 4
    
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Elliott M, Worrall-Carter L, Page K. Intensive care readmission: A contemporary review of the literature. Intensive Crit Care Nurs 2014;30:121-37.  Back to cited text no. 5
    
6.
Prytherch DR, Smith GB, Schmidt PE, Featherstone PI. ViEWS—Towards a national early warning score for detecting adult inpatient deterioration. Resuscitation 2010;81:932-7.  Back to cited text no. 6
    
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McGinley A, Pearse RM. A national early warning score for acutely ill patients. BMJ 2012;345:e5310.  Back to cited text no. 7
    
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Renton J, Pilcher DV, Santamaria JD, Stow P, Bailey M, Hart G, et al. Factors associated with increased risk of readmission to intensive care in Australia. Intensive Care Med 2011;37:1800-8.  Back to cited text no. 8
    
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Kramer AA, Higgins TL, Zimmerman JE. Intensive care unit readmissions in U.S. hospitals: Patient characteristics, risk factors, and outcomes. Crit Care Med 2012;40:3-10.  Back to cited text no. 9
    
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Klepstad PK, Nordseth T, Sikora N, Klepstad P. Use of National Early Warning Score for observation for increased risk for clinical deterioration during post-ICU care at a surgical ward. Ther Clin Risk Manag 2019;15:315-22.  Back to cited text no. 10
    
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Downey CL, Tahir W, Randell R, Brown JM, Jayne DG. Strengths and limitations of early warning scores: A systematic review and narrative synthesis. Int J Nurs Stud 2017;76:106-19.  Back to cited text no. 11
    
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Goldfrad C, Rowan K. Consequences of discharges from intensive care at night. Lancet 2000;355:1138-42.  Back to cited text no. 12
    
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Brunetti MA, Glatz AC, McCardle K, Mott AR, Ravishankar C, Gaynor JW. Unplanned readmission to the pediatric cardiac intensive care unit: Prevalence, outcomes, and risk factors. World J Pediatr Congenit Heart Surg 2015;6:597-603.  Back to cited text no. 13
    
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Cardoso FS, Karvellas CJ, Kneteman NM, Meeberg G, Fidalgo P, Bagshaw SM. Respiratory rate at intensive care unit discharge after liver transplant is an independent risk factor for intensive care unit readmission within the same hospital stay: A nested case-control study. J Crit Care 2014;29:791-6.  Back to cited text no. 14
    
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Jo YS, Lee YJ, Park JS, Yoon HI, Lee JH, Lee CT, et al. Readmission to medical intensive care units: Risk factors and prediction. Yonsei Med J 2015;56:543-9.  Back to cited text no. 15
    
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Kang YA. Risk factors and outcomes associated with readmission to the intensive care unit after cardiac surgery. AACN Adv Crit Care 2016;27:29-39.  Back to cited text no. 16
    
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Kogan A, Cohen J, Raanani E, et al. Readmission to the intensive care unit after “fast-track” cardiac surgery: Risk factors and outcomes. Ann Thorac Surg 2003;76:503-7.  Back to cited text no. 17
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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