Frequency of alterations in qSOFA, SIRS, MEWS and NEWS scores during the emergency department stay in infectious patients: a prospective study

Gideon H P Latten; Judith Polak; Audrey H H Merry; Jean W M Muris; Jan C Ter Maaten; Tycho J Olgers; Jochen W L Cals; Patricia M Stassen

doi:10.1186/s12245-021-00388-z

Frequency of alterations in qSOFA, SIRS, MEWS and NEWS scores during the emergency department stay in infectious patients: a prospective study

Int J Emerg Med. 2021 Nov 27;14(1):69. doi: 10.1186/s12245-021-00388-z.

Authors

Gideon H P Latten¹, Judith Polak², Audrey H H Merry³, Jean W M Muris⁴, Jan C Ter Maaten⁵, Tycho J Olgers⁵, Jochen W L Cals⁴, Patricia M Stassen⁶

Affiliations

¹ Emergency Department, Zuyderland Medical Centre, Henri Dunantstraat 5, 6419 PC, Heerlen, The Netherlands. g.latten@zuyderland.nl.
² Emergency Department, Zuyderland Medical Centre, Henri Dunantstraat 5, 6419 PC, Heerlen, The Netherlands.
³ Zuyderland Academy, Zuyderland Medical Centre, Heerlen, The Netherlands.
⁴ Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands.
⁵ Department of Internal Medicine, section acute internal medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.
⁶ Department of Internal Medicine, division general medicine, section acute medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands.

Abstract

Background: For emergency department (ED) patients with suspected infection, a vital sign-based clinical rule is often calculated shortly after the patient arrives. The clinical rule score (normal or abnormal) provides information about diagnosis and/or prognosis. Since vital signs vary over time, the clinical rule scores can change as well. In this prospective multicentre study, we investigate how often the scores of four frequently used clinical rules change during the ED stay of patients with suspected infection.

Methods: Adult (≥ 18 years) patients with suspected infection were prospectively included in three Dutch EDs between March 2016 and December 2019. Vital signs were measured in 30-min intervals and the quick Sequential Organ Failure Assessment (qSOFA) score, the Systemic Inflammatory Response Syndrome (SIRS) criteria, the Modified Early Warning Score and the National Early Warning Score (NEWS) score were calculated. Using the established cut-off points, we analysed how often alterations in clinical rule scores occurred (i.e. switched from normal to abnormal or vice versa). In addition, we investigated which vital signs caused most alterations.

Results: We included 1433 patients, of whom a clinical rule score changed once or more in 637 (44.5%) patients. In 6.7-17.5% (depending on the clinical rule) of patients with an initial negative clinical rule score, a positive score occurred later during ED stay. In over half (54.3-65.0%) of patients with an initial positive clinical rule score, the score became negative later on. The respiratory rate caused most (51.2%) alterations.

Conclusion: After ED arrival, alterations in qSOFA, SIRS, MEWS and/or NEWS score are present in almost half of patients with suspected infection. The most contributing vital sign to these alterations was the respiratory rate. One in 6-15 patients displayed an abnormal clinical rule score after a normal initial score. Clinicians should be aware of the frequency of these alterations in clinical rule scores, as clinical rules are widely used for diagnosis and/or prognosis and the optimal moment of assessing them is unknown.

Keywords: Clinical rules; Emergency department; Infection.