Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
BMC Emergency Medicine
Published in: BMC Emergency Medicine 1/2017

Open Access 01-12-2017 | Research article

The effectiveness of physiologically based early warning or track and trigger systems after triage in adult patients presenting to emergency departments: a systematic review

Authors: Francesca Wuytack, Pauline Meskell, Aislinn Conway, Fiona McDaid, Nancy Santesso, Fergal G. Hickey, Paddy Gillespie, Adam J. N. Raymakers, Valerie Smith, Declan Devane

Published in: BMC Emergency Medicine | Issue 1/2017

Login to get access

Abstract

Background

Changes to physiological parameters precede deterioration of ill patients. Early warning and track and trigger systems (TTS) use routine physiological measurements with pre-specified thresholds to identify deteriorating patients and trigger appropriate and timely escalation of care. Patients presenting to the emergency department (ED) are undiagnosed, undifferentiated and of varying acuity, yet the effectiveness and cost-effectiveness of using early warning systems and TTS in this setting is unclear. We aimed to systematically review the evidence on the use, development/validation, clinical effectiveness and cost-effectiveness of physiologically based early warning systems and TTS for the detection of deterioration in adult patients presenting to EDs.

Methods

We searched for any study design in scientific databases and grey literature resources up to March 2016. Two reviewers independently screened results and conducted quality assessment. One reviewer extracted data with independent verification of 50% by a second reviewer. Only information available in English was included. Due to the heterogeneity of reporting across studies, results were synthesised narratively and in evidence tables.

Results

We identified 6397 citations of which 47 studies and 1 clinical trial registration were included. Although early warning systems are increasingly used in EDs, compliance varies. One non-randomised controlled trial found that using an early warning system in the ED may lead to a change in patient management but may not reduce adverse events; however, this is uncertain, considering the very low quality of evidence. Twenty-eight different early warning systems were developed/validated in 36 studies. There is relatively good evidence on the predictive ability of certain early warning systems on mortality and ICU/hospital admission. No health economic data were identified.

Conclusions

Early warning systems seem to predict adverse outcomes in adult patients of varying acuity presenting to the ED but there is a lack of high quality comparative studies to examine the effect of using early warning systems on patient outcomes. Such studies should include health economics assessments.
Appendix
Available only for authorised users
Literature
1.
Goldhill DR, McNarry AF. Physiological abnormalities in early warning scores are related to mortality in adult inpatients. Br J Anaesth. 2004;92(6):882–4.CrossRefPubMed
2.
Buist M, Bernard S, Nguyen TV, Moore G, Anderson J. Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study. Resuscitation. 2004;62(2):137–41.CrossRefPubMed
3.
Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest. 1990;98(6):1388–92.CrossRefPubMed
4.
Smith AF, Wood J. Can some in-hospital cardio-respiratory arrests be prevented? A prospective survey. Resuscitation. 1998;37(3):133–7.CrossRefPubMed
5.
Franklin C, Mathew J. Developing strategies to prevent inhospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med. 1994;22(2):244–7.CrossRefPubMed
6.
Rivers EP, Coba V, Whitmill M. Early goal-directed therapy in severe sepsis and septic shock: a contemporary review of the literature. Curr Opin Anaesthesiol. 2008;21(2):128–40.CrossRefPubMed
7.
Department of Health. National Early Warning Score: National Clinical Guideline no.1. Dublin: Department of Health; 2013.
8.
Royal College of Physicians. National Early Warning Score (NEWS): Standardising the assessment of acute-illness severity in the NHS. Report of a working party. London: Royal College of Physicians; 2012.
9.
National Institute for Health and Care Excellence. Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital (CG50). London: NICE; 2007.
10.
Mitchell IA, McKay H, Van Leuvan C, Berry R, McCutcheon C, Avard B, et al. A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients. Resuscitation. 2010;81(6):658–66.CrossRefPubMed
11.
12.
13.
Courtney DM, Neumar RW, Venkatesh AK, Kaji AH, Cairns CB, Lavonas E, et al. Unique characteristics of emergency care research: scope, populations, and infrastructure. Acad Emerg Med. 2009;16(10):990–4.CrossRefPubMed
14.
Roland D, Coats TJ. An early warning? Universal risk scoring in emergency medicine. Emerg Med J. 2011;28(4):263.CrossRefPubMed
15.
Subbe CP, Kruger M, Rutherford P & Gemmel L. Validation of a modified early warning score in medical admissions. QJM - Monthly Journal of the Association of Physicians. 2001;94:521–526.
16.
Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:1–8. doi:10.​1136/​bmj.​b2535.
17.
Macaskill P, Gatsonis C, Deeks JJ, Harbord RM, Takwoingi Y. Chapter 10: Analysing and Presenting Results. Handbook for Systematic Reviews of Diagnostic Test Accuracy Version 1.0. The Cochrane Collaboration; 2010. Available from: http://​srdta.​cochrane.​org/​.
18.
Gu M, Fu Y, Li C, Chen M, Zhang X, Xu J, et al. The value of modified early warning score in predicting early mortality of critically ill patients admitted to emergency department. Chinese Crit Care Med. 2015;27(8):687–90.
19.
Considine J, Lucas E, Wunderlich B. The uptake of an early warning system in an Australian emergency department: a pilot study. Crit Care Resusc. 2012;14(2):135–41.PubMed
20.
Griffiths JR, Kidney EM. Current use of early warning scores in UK emergency departments. Emerg Med J. 2012;29(1):65–6.CrossRefPubMed
21.
Australian Commission on Safety and Quality in Health Care (the Commission). Recognising and responding to clinical deterioration, survey of recognition and response systems in australia. 2011.
22.
Coughlan E, Deasy C, McDaid F, Geary U, Ward M, O'Sullivan R, et al. An introduction to the emergency department adult clinical escalation protocol: ED-ACE. Resuscitation. 2015;96:33.CrossRef
23.
Christensen D, Jensen NM, Maaloe R, Rudolph SS, Belhage B, Perrild H. Low compliance with a validated system for emergency department triage. Dan Med Bull. 2011;58(6):A4294.PubMed
24.
Johnson KD, Winkelman C, Burant CJ, Dolansky M, Totten V. The factors that affect the frequency of vital sign monitoring in the emergency department. JEN: Journal of Emergency Nursing. 2014;40(1):27–35.
25.
Austen C, Patterson C, Poots A, Green S, Weldring T, Bell D. Using a local early warning scoring system as a model for the introduction of a national system. Acute Med. 2012;11(2):66–73.PubMed
26.
Hudson P, Ekholm J, Johnson M, Langdon R. Early identification and management of the unstable adult patient in the emergency department. J Clin Nurs. 2015;24(21–22):3138–46.CrossRefPubMed
27.
Wilson SJ, Wong D, Clifton D, Fleming S, Way R, Pullinger R, et al. Track and trigger in an emergency department: an observational evaluation study. Emerg Med J. 2013;30(3):186–91.
28.
Shuk-Ngor S, Chi-Wai O, Lai-Yee W, Chung JYM, Graham CA. Is the modified early warning score able to enhance clinical observation to detect deteriorating patients earlier in an Accident & Emergency Department? Australas Emerg Nurs J. 2015;18(1):24–32.
29.
Albright CM, Ali TN, Lopes V, Rouse DJ, Anderson BL. The sepsis in obstetrics score: a model to identify risk of morbidity from sepsis in pregnancy. Am J Obstet Gynecol. 2014;211(1):39.e1–8.
30.
Christensen D, Jensen NM, Maaløe R, Rudolph SS, Belhage B, Perrild H. Nurse-administered early warning score system can be used for emergency department triage. Dan Med Bull. 2011;58(6):A4221.PubMed
31.
Cattermole GN, Mak SKP, Liow CHE, Ho MF, Hung KYG, Keung KM, et al. Derivation of a prognostic score for identifying critically ill patients in an emergency department resuscitation room. Resuscitation. 2009;80(9):1000–5.CrossRefPubMed
32.
Geier F, Popp S, Greve Y, Achterberg A, Glockner E, Ziegler R, et al. Severity illness scoring systems for early identification and prediction of in-hospital mortality in patients with suspected sepsis presenting to the emergency department. Wien Klin Wochenschr. 2013;125(17–18):508–15.CrossRefPubMed
33.
Olsson T, Lind L. Comparison of the rapid emergency medicine score and APACHE II in nonsurgical emergency department patients. Acad Emerg Med. 2003;10(10):1040–8.
34.
Olsson T, Terent A, Lind L. Rapid emergency medicine score: a new prognostic tool for in-hospital mortality in nonsurgical emergency department patients. J Intern Med. 2004;255(5):579–87.
35.
Cattermole GN, Liow ECH, Graham CA, Rainer TH. THERM: the resuscitation management score. A prognostic tool to identify critically ill patients in the emergency department. Emerg Med J. 2014;31(10):803–7.
36.
Liu FY, Qin J, Wang RX, Fan XL, Wang J, Sun CY, et al. A prospective validation of national early warning score in emergency intensive care unit patients at Beijing. Hong Kong Journal of Emergency Medicine. 2015;22(3):137–44.
37.
Bulut M, Cebicci H, Sigirli D, Sak A, Durmus O, Top AA, et al. The comparison of modified early warning score with rapid emergency medicine score: A prospective multicentre observational cohort study on medical and surgical patients presenting to emergency department. Emerg Med J [Internet]. 2014;31(6):[476–81 pp.]. Available from: http://​emj.​bmj.​com/​content/​31/​6/​476.​full.​pdf.
38.
Çildir E, Bulut M, Akalin H, Kocabaş E, Ocakoǧlu G, Aydin ŞA. Evaluation of the modified MEDS, MEWS score and Charlson comorbidity index in patients with community acquired sepsis in the emergency department. Intern Emerg Med. 2013;8(3):255–60.CrossRefPubMed
39.
Considine J, Rawet J, Currey J. The effect of a staged, emergency department specific rapid response system on reporting of clinical deterioration. Australas Emerg Nurs J. 2015;18(4):218–26.CrossRefPubMed
40.
Corfield AR, Lees F, Houston G, Zealley I, Dickie S, Ward K, et al. Early warning scores in sepsis: utility of a single early warning score in the emergency department? Intensive Care Med. 2012;38:S296–S7.
41.
Dundar ZD, Ergin M, Karamercan MA, Ayranci K, Colak T, Tuncar A, et al. Modified early warning score and VitalPac early warning score in geriatric patients admitted to emergency department. Eur J Emerg Med; 2015. doi:10.​1097/​MEJ.​0000000000000274​. [ahead of print].
42.
Eick C, Rizas KD, Meyer-Zürn CS, Groga-Bada P, Hamm W, Kreth F, et al. Autonomic nervous system activity as risk predictor in the medical emergency department: a prospective cohort study. Crit Care Med. 2015;43(5):1079–86.
43.
Heitz CR, Gaillard JP, Blumstein H, Case D, Messick C, Miller CD. Performance of the maximum modified early warning score to predict the need for higher care utilization among admitted emergency department patients. J Hosp Med. 2010;5(1):E46–52.
44.
Ho LO, Li H, Shahidah N, Koh ZX, Sultana P, Ong MEH. Poor performance of the modified early warning score for predicting mortality in critically ill patients presenting to an emergency department. World J Emerg Med. 2013;4(4):273–7.
45.
Howell MD, Donnino MW, Talmor D, Clardy P, Ngo L, Shapiro NI. Performance of severity of illness scoring systems in emergency department patients with infection. Acad Emerg Med. 2007;14(8):709–14.
46.
Jo S, Lee JB, Jin YH, Jeong TO, Yoon JC, Jun YK, et al. Modified early warning score with rapid lactate level in critically ill medical patients: the ViEWS-L score. Emerg Med J. 2013;30(2):123–9.
47.
Jo S, Jeong T, Lee JB, Jin Y, Yoon J, Park B. Validation of modified early warning score using serum lactate level in community-acquired pneumonia patients. The National Early Warning Score-Lactate score. Am J Emerg Med. 2016;34(3):536–41.CrossRefPubMed
48.
Jones AE, Fitch MT, Kline JA. Operational performance of validated physiologic scoring systems for predicting in-hospital mortality among critically ill emergency department patients. Crit Care Med. 2005;33(5):974–8.
49.
Keep JW, Messmer AS, Sladden R, Burrell N, Pinate R, Tunnicliff M, et al. National early warning score at emergency department triage may allow earlier identification of patients with severe sepsis and septic shock: a retrospective observational study. Emerg Med J. 2016;33(1):37–41.CrossRefPubMed
50.
Subbe CP, Slater A, Menon D, Gemmell L. Validation of physiological scoring systems in the accident and emergency department. Emerg Med J. 2006;23:841–5.
51.
Vorwerk C, Loryman B, Coats TJ, Stephenson JA, Gray LD, Reddy G, et al. Prediction of mortality in adult emergency department patients with sepsis. Emerg Med J. 2009;26(4):254–8.
52.
Williams J, Greenslade J, Chu K, Brown A, Lipman J. Severity scores in emergency department patients with presumed infection: a prospective validation study. Crit Care Med. 2016;44(3):539–47.
53.
Alam N, Vegting IL, Houben E, van Berkel B, Vaughan L, Kramer MH, et al. Exploring the performance of the National Early Warning Score (NEWS) in a European emergency department. Resuscitation. 2015;90:111–5.CrossRefPubMed
54.
Armagan E, Yilmaz Y, Olmez OF, Simsek G, Gul CB. Predictive value of the modified early warning score in a turkish emergency department. Eur J Emerg Med. 2008;15(6):338–40.CrossRefPubMed
55.
Correia N, Rodrigues RP, Sá MC, Dias P, Lopes L, Paiva A. Improving recognition of patients at risk in a Portuguese general hospital: results from a preliminary study on the early warning score. Int J Emerg Med. 2014;7(1):Article number 22.CrossRefPubMed
56.
Graham CA, Choi KM, Ki CW, Leung YK, Leung PH, Mak P, et al. Evaluation and validation of the use of modified early warning score (MEWS) in emergency department observation ward...2007 Society for Academic Emergency Medicine annual meeting. Acad Emerg Med. 2007;14:S199–200.
57.
Hock Ong ME, Lee Ng CH, Goh K, Liu N, Koh ZX, Shahidah N, et al. Prediction of cardiac arrest in critically ill patients presenting to the emergency department using a machine learning score incorporating heart rate variability compared with the modified early warning score. Crit Care. 2012;16(3): R108.
58.
Junhasavasdikul D, Theerawit P, Kiatboonsri S. Association between admission delay and adverse outcome of emergency medical patients. Emerg Med J. 2013;30(4):320–3.
59.
Nguyen HB, Van Ginkel C, Batech M, Banta J, Corbett SW. Comparison of predisposition, insult/infection, response, and organ dysfunction, acute physiology and chronic health evaluation II, and mortality in emergency department sepsis in patients meeting criteria for early goal-directed therapy and the. J Crit Care. 2012;27(4):362–9.
60.
Wang AY, Fang CC, Chen SC, Tsai SH, Kao WF. Periarrest modified early warning score (MEWS) predicts the outcome of in-hospital cardiac arrest. J Formos Med Assoc. 2016;115(2):76–82.
61.
Wilson SJ, Wong D, Pullinger RM, Way R, Clifton DA, Tarassenko L. Analysis of a data-fusion system for continuous vital sign monitoring in an emergency department. Eur J Emerg Med. 2016;23(1):28–32.CrossRefPubMed
62.
Naidoo DK, Rangiah S, Naidoo SS. An evaluation of the triage early warning score in an urban accident and emergency department in KwaZulu-Natal. South African Family Practice. 2014;56(1):69–73.
63.
Burch VC, Tarr G, Morroni C. Modified early warning score predicts the need for hospital admission and inhospital mortality. Emerg Med J. 2008;25(10):674–8.
64.
Challen K, Goodacre SW. Predictive scoring in non-trauma emergency patients: a scoping review. Emerg Med J. 2011;28(10):827–37.
65.
66.
Hosmer D, Lemeshow S. Applied logistic regression. 2 ed. New York: John Wiley & Sons, Inc.; 2000.
67.
Abbott TE, Torrance HD, Cron N, Vaid N, Emmanuel J. A single-centre cohort study of National Early Warning Score (NEWS) and near patient testing in acute medical admissions. Eur J Intern Med. 2016;35:78–82.CrossRefPubMed
68.
Nickel CH, Kellett J, Cooksley T, Bingisser R, Henriksen DP, Brabrand M. Combined use of the National Early Warning Score and D-dimer levels to predict 30-day and 365-day mortality in medical patients. Resuscitation. 2016;106:49–52.CrossRefPubMed
69.
70.
Higgins J, Green S. Cochrane Handbook for systematic Reviews of Interventions Version 5.1.0 [updated March 2011]: The Cochrane Collaboration; 2011. Available from: www.​cochrane-handbook.​org.
71.
72.
Drummond MF, Jefferson TO. Guidelines for authors and peer reviewers of economic submissions to the BMJ. The BMJ economic evaluation working party. BMJ : British Medical Journal. 1996;313(7052):275–83.CrossRefPubMedPubMedCentral
73.
Philips Z, Ginnelly L, Sculpher M, Claxton K, Golder S, Riemsma R, et al. Review of guidelines for good practice in decision-analytic modelling in health technology assessment. Health Technol Assess 2004;8(36):iii-iv, ix-xi, 1-158.
74.
75.
Corfield AR, Lees F, Zealley I, Houston G, Dickie S, Ward K, et al. Utility of a single early warning score in patients with sepsis in the emergency department. Emergency medicine journal : EMJ. 2014;31(6):482–7.CrossRefPubMed
Metadata
Title
The effectiveness of physiologically based early warning or track and trigger systems after triage in adult patients presenting to emergency departments: a systematic review
Authors
Francesca Wuytack
Pauline Meskell
Aislinn Conway
Fiona McDaid
Nancy Santesso
Fergal G. Hickey
Paddy Gillespie
Adam J. N. Raymakers
Valerie Smith
Declan Devane
Publication date
01-12-2017
Publisher
BioMed Central
Published in
BMC Emergency Medicine / Issue 1/2017
Electronic ISSN: 1471-227X
DOI
https://doi.org/10.1186/s12873-017-0148-z

Other articles of this Issue 1/2017

BMC Emergency Medicine 1/2017 Go to the issue

Research article

Hypoxia and hypotension in patients intubated by physician staffed helicopter emergency medical services - a prospective observational multi-centre study

Research article

Assessment of client satisfaction on emergency department services in Hawassa University Referral Hospital, Hawassa, Southern Ethiopia

Correspondence

Aerial medical evacuation of health workers with suspected Ebola virus disease in Guinea Conakry-interest of a negative pressure isolation pod-a case series

Research article

The effectiveness of prehospital hypertonic saline for hypotensive trauma patients: a systematic review and meta-analysis

Research article

Educational standards for training paramedics in ultrasound: a scoping review

Research article

Reasons for encounter by different levels of urgency in out-of-hours emergency primary health care in Norway: a cross sectional study