Outcome prediction value of National Early Warning Score in septic patients with community-acquired pneumonia in emergency department: A single-center retrospective cohort study

doi:10.5847/wjem.j.1920-8642.2020.04.002

Abstract

Abstract:

BACKGROUND:To evaluate the accuracy of National Early Warning Score (NEWS) in predicting clinical outcomes (28-day mortality, intensive care unit [ICU] admission, and mechanical ventilation use) for septic patients with community-acquired pneumonia (CAP) compared with other commonly used severity scores (CURB65, Pneumonia Severity Index [PSI], Sequential Organ Failure Assessment [SOFA], quick SOFA [qSOFA], and Mortality in Emergency Department Sepsis [MEDS]) and admission lactate level.

METHODS: Adult patients diagnosed with CAP admitted between January 2017 and May 2019 with admission SOFA ≥2 from baseline were enrolled. Demographic characteristics were collected. The primary outcome was the 28-day mortality after admission, and the secondary outcome included ICU admission and mechanical ventilation use. Outcome prediction value of parameters above was compared using receiver operating characteristics (ROC) curves. Cox regression analyses were carried out to determine the risk factors for the 28-day mortality. Kaplan-Meier survival curves were plotted and compared using optimal cut-off values of qSOFA and NEWS.

RESULTS: Among the 340 enrolled patients, 90 patients were dead after a 28-day follow-up, 62 patients were admitted to ICU, and 84 patients underwent mechanical ventilation. Among single predictors, NEWS achieved the largest area under the receiver operating characteristic (AUROC) curve in predicting the 28-day mortality (0.861), ICU admission (0.895), and use of mechanical ventilation (0.873). NEWS+lactate, similar to MEDS+lactate, outperformed other combinations of severity score and admission lactate in predicting the 28-day mortality (AUROC 0.866) and ICU admission (AUROC 0.905), while NEWS+lactate did not outperform other combinations in predicting mechanical ventilation (AUROC 0.886). Admission lactate only improved the predicting performance of CURB65 and qSOFA in predicting the 28-day mortality and ICU admission.

CONCLUSIONS: NEWS could be a valuable predictor in septic patients with CAP in emergency departments. Admission lactate did not predict well the outcomes or improve the severity scores. A qSOFA ≥2 and a NEWS ≥9 were strongly associated with the 28-day mortality, ICU admission, and mechanical ventilation of septic patients with CAP in the emergency departments.

Key words: Community-acquired pneumonia, Sepsis, National Early Warning Score (NEWS), Intensive care unit, Emergency departments

Hai-jiang Zhou, Tian-fei Lan, Shu-bin Guo. Outcome prediction value of National Early Warning Score in septic patients with community-acquired pneumonia in emergency department: A single-center retrospective cohort study[J]. World Journal of Emergency Medicine, 2020, 11(4): 206-215.

Figures/Tables 8

Figure 1.

Table 1

Baseline characteristics of enrolled patients with community-acquired pneumonia in emergency departments

Parameters	All cohort	Death	Survival	P	ICU admission	Non-ICU admission	P	MV	Non-MV	P
n (%)	340	90 (26.5)	250 (73.5)		62 (18.2)	278 (81.8)		84 (24.7)	256 (75.3)
Age (years)	76 (61-84)	78 (67-85)	75 (61-83)	0.159	81 (71-88)	74 (61-83)	0.004	77 (66-84)	76 (61-84)	0.637
Male, n (%)	214 (62.9)	57 (63.3)	157 (62.8)	0.928	41 (66.1)	173 (62.2)	0.565	55 (65.5)	159 (62.1)	0.579
Comorbidities, n (%)
COPD	40 (11.9)	12 (13.3)	28 (11.2)	0.590	16 (25.8)	24 (8.6)	<0.001	14 (15.7)	26 (10.5)	0.194
CDVD	49 (14.4)	18 (20.0)	31 (12.4)	0.078	14 (22.6)	35 (12.6)	0.034	14 (15.7)	34 (13.8)	0.650
CBVD	88 (26.2)	28 (31.1)	60 (24.0)	0.187	18 (29.0)	70 (25.2)	0.531	20 (22.5)	68 (27.5)	0.352
Diabetes	78 (22.9)	31 (34.4)	47 (18.8)	0.002	24 (38.7)	54 (19.4)	0.001	15 (16.9)	62 (25.1)	0.112
CRD	30 (8.9)	9 (10.0)	21 (8.4)	0.646	8 (12.9)	22 (7.9)	0.210	9 (10.1)	21 (8.5)	0.648
HBD	26 (7.6)	5 (5.6)	21 (8.4)	0.384	6 (9.7)	20 (7.2)	0.596	6 (6.7)	18 (7.3)	0.864
Healthy	28 (8.3)	6 (6.7)	22 (8.81)	0.528	8 (12.9)	20 (7.2)	0.139	7 (7.9)	21 (8.5)	0.852
Laboratory results
WBC (×10⁹/L)	10.0 (6.8-14.1)	11.0 (6.7-16.0)	9.9 (6.8-13.9)	0.433	11.7 (7.4-16.2)	9.8 (6.6-13.9)	0.051	10.4 (6.7-15.8)	9.7 (6.8-13.9)	0.244
HGB (g/L)	126 (115-138)	123 (111-135)	127 (117-138)	0.166	124±22	127 (116-138 )	0.463	126 (115-137)	126 (116-137)	0.781
HCT (%)	36.9 (31.8-40.8)	34.8±9.1	37.3 (32.8-40.9)	0.054	35.7±9.3	37.3 (32.5-40.7)	0.474	35.4±9.2	37.2 (32.7-40.7)	0.356
PLT (×10⁹/L)	184 (131-251)	163 (123-249)	191 (135-251)	0.291	155 (123-230)	191 (136-254)	0.106	155 (117-241)	192 (141-251)	0.109
ALB (g/L)	36.2 (32.1-39.1)	34.0±5.9	36.8 (33.0-39.3)	0.001	34.2±6.0	36.5 (32.5-39.1)	0.032	34.0±6.0	36.7 (32.8-39.3)	0.002
Creatinine (μmol/L)	80.5 (61.1-113.3)	92.0 (63.3-140.0)	76.0 (60.4-106.8)	0.015	94.3 (74.2-153.6)	75.9 (60.2-106.0)	<0.001	92.5 (71.2-149.2)	75.5 (59.9-104.0)	<0.001
BUN (mmol/L)	7.4 (5.3-11.0)	8.7 (6.0-13.5)	6.8 (5.1-10.4)	0.009	10.1 (6.7-16.2)	6.8 (5.1-10.4)	<0.001	9.5 (6.5-15.0)	6.8 (5.0-10.3)	<0.001
AST (U/L)	30 (20-54)	33 (23-69)	30 (20-53)	0.156	35 (23-65)	30 (20-53)	0.223	36 (23-81)	29 (20-53)	0.097
ALT (U/L)	20 (13-37)	18 (12-36)	21 (14-37)	0.285	16 (11-32)	21 (14-37)	0.217	17 (12-45)	21 (14-36)	0.694
TBIL (μmol/L)	14.8 (9.7-23.0)	15.6 (10.3-23.5)	14.4 (9.5-22.8)	0.303	15.4 (9.5-23.9)	14.8 (9.8-22.9)	0.739	16.1 (10.6-25.0)	14 (9.5-22.3)	0.164
DBIL (μmol/L)	6.4 (4.0-10.5)	6.9 (4.4-11.4)	6.1 (3.9-10.0)	0.077	6.1 (4.3-11.6)	6.4 (4.0-10.4)	0.448	7.0 (4.4-12.3)	6.1 (3.9-9.7)	0.037
K⁺(mmol/L)	3.8 (3.5-4.2)	3.9 (3.5-4.4)	3.8 (3.5-4.2)	0.248	4.0 (3.6-4.4)	3.8 (3.5-4.2)	0.049	4.0 (3.6-4.5)	3.8 (3.5-4.1)	0.006
PaO₂/FiO₂	304 (263-356)	284 (245-328)	315 (274-364)	<0.001	285 (241-329)	311 (268-362)	0.005	285 (244-326)	313 (272-363)	<0.001
Vital signs
SBP (mmHg)	132 (119-139)	121 (96-135)	134 (125-143)	<0.001	122 (96-135)	132 (122-142)	<0.001	122 (100-135)	134 (125-143)	<0.001
DBP (mmHg)	68 (65-76)	63 (55-70)	70 (66-78)	<0.001	65±12	69 (65-76)	<0.001	65 (55-71)	70 (66-78)	<0.001
HR (times/minute)	86 (78-95)	87 (79-106)	86 (78-94)	0.008	86 (79-107)	86 (78-94)	0.018	86 (79-104)	86 (78-94)	0.033
Severity scores
CURB65	2 (2-3)	3 (3-4)	2 (1-3)	<0.001	4 (3-4)	2 (2-3)	<0.001	3 (3-4)	2 (1-3)	<0.001
PSI	130±40	157±35	119 (90-143)	<0.001	174 (150-192)	121±36	<0.001	161±37	120±36	<0.001
SOFA	3 (2-5)	5.5 (4-8)	3 (2-4)	<0.001	7 (6-9)	3 (2-4)	<0.001	6 (4-9)	3 (2-4)	<0.001
qSOFA	2 (1-2)	2 (2-3)	1 (1-2)	<0.001	3 (2-3)	1 (1-2)	<0.001	3 (2-3)	1 (1-2)	<0.001
MEDS	11 (8-14)	14.5 (13-16.3)	10 (8-11)	<0.001	16 (13-17)	10 (8-11)	<0.001	14 (12-16)	10 (8-11)	<0.001
NEWS	6 (5-10)	11 (9-13)	6 (4-8)	<0.001	12 (9-14)	6 (4-8)	<0.001	11 (9-13)	6 (4-8)	<0.001
Lactate (mmol/L)	1.4 (1.1-2.1)	1.8 (1.3-3.2)	1.3 (1.0-1.8)	<0.001	2.5 (1.6-4.2)	1.3 (1.1-1.8)	<0.001	2.0 (1.3-4.2)	1.4 (1.1-1.8)	<0.001

Table 1

Figure 2.

Figure 3.

Figure 4.

Table 2

Table 3

Figure 5.

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Parameters	β	Wald	P	aHR	95% CI
Parameters	β	Wald	P	aHR	Lower	Upper
MEDS	0.181	26.933	<0.001	1.199	1.120	1.284
NEWS	0.204	34.123	<0.001	1.227	1.146	1.314
HCT	-0.027	4.708	0.030	0.974	0.951	0.997

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