Original article
Pancreas, biliary tract, and liver
National Early Warning Score Accurately Discriminates the Risk of Serious Adverse Events in Patients With Liver Disease

https://doi.org/10.1016/j.cgh.2017.12.035Get rights and content

Background & Aims

The National Early Warning Score (NEWS) is used to identify deteriorating adult hospital inpatients. However, it includes physiological parameters frequently altered in patients with cirrhosis. We aimed to assess the performance of the NEWS in acute and chronic liver diseases.

Methods

We collected vital signs, recorded in real time, from completed consecutive admissions of patients 16 years or older to a large acute-care hospital in Southern England, from January 1, 2010, through October 31, 2014. Using International Classification of Diseases, 10th revision, codes, we categorized patients as having primary liver disease, secondary liver disease, or none. For patients with liver disease, 2 analysis groups were developed: the first was based on clinical group (such as acute or chronic, alcohol-induced, or associated with portal hypertension), and the second was based on a summary of liver-related, hospital-level mortality indicator diagnoses. For each, we compared the abilities of the NEWS and 34 other early warning scores to discriminate 24-hour mortality, cardiac arrest, or unanticipated admission to the intensive care unit using the area under the receiver operating characteristic (AUROC) curve and early warning score efficiency curve analyses.

Results

The NEWS identified patients with primary, nonprimary, and no diagnoses of liver disease with AUROC values of 0.873 (95% CI, 0.860–0.886), 0.898 (95% CI, 0.891–0.905), and 0.879 (95% CI, 0.877–0.881), respectively. High AUROC values were also obtained for all clinical subgroups; the NEWS identified patients with alcohol-related liver disease with an AUROC value of 0.927 (95% CI, 0.912–0.941). The NEWS identified patients with liver diseases with higher AUROC values than other early warning scoring systems.

Conclusions

The NEWS accurately discriminates patients at risk of death, admission to the intensive care unit, or cardiac arrest within a 24-hour period for a range of liver-related diagnoses. Its widespread use provides a ready-made, easy-to-use option for identifying patients with liver disease who require early assessment and intervention, without the need to modify parameters, weightings, or escalation criteria.

Section snippets

Patients and Methods

The Isle of Wight, Portsmouth, and Southeast Hampshire research ethics committees approved our study (ref. 08/02/1394).

Study Population

Categorizing patient episodes using the 4 clinical subgroups, 773 patients (1197 episodes) were discharged with a primary diagnosis of liver disease and 2525 (3953 episodes) were discharged with a nonprimary (comorbid) diagnosis. In the same period, if patient episodes were categorized using the 3 SHMI groups, 1216 patients (2016 episodes) were discharged with a primary diagnosis of liver disease and 4957 (6459 episodes) were discharged with a nonprimary (comorbid) diagnosis. After excluding

Discussion

In the United Kingdom, the Royal College of Physicians recommended that NEWS is deployed to standardize assessment of acute illness severity in hospitals. Our study was designed to test the hypothesis that NEWS might not accurately predict serious events in patients with liver disease owing to pre-existing altered physiology associated with the underlying condition. This hypothesis was disproven and we were encouraged to find that NEWS remained a highly accurate discriminator of adverse events

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    Conflicts of interest These authors disclose the following: Paul E. Schmidt, Richard J. Aspinall, and Paul Meredith are employed by Portsmouth Hospitals NHS Trust. Gary B. Smith and David R. Prytherch were employees of Portsmouth Hospitals NHS Trust until March 31, 2011, and July 31, 2016, respectively. Paul E. Schmidt, and the wives of Gary B. Smith and David R. Prytherch, were shareholders in The Learning Clinic Ltd at the time of the study. Gary B. Smith, David R. Prytherch, and Paul E. Schmidt were unpaid research advisors to The Learning Clinic Ltd until May 2016. Gary B. Smith and David R. Prytherch have received reimbursement of travel expenses from The Learning Clinic Ltd. for attending symposia in the United Kingdom. The remaining author discloses no conflicts.

    VitalPAC is a trade name of The Learning Clinic Limited. Vitalpac is part of System C Healthcare (www.systemc.com). VitalPAC is a collaborative development of The Learning Clinic Ltd and Portsmouth Hospitals NHS Trust. At the time of the study, Portsmouth Hospitals NHS Trust had a royalty agreement with The Learning Clinic Ltd to pay for the use of Portsmouth Hospitals NHS Trust intellectual property within the VitalPAC product.

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