Comparing 11 early warning scores and three shock indices in early sepsis prediction in the emergency department

BACKGROUND:This study aimed to evaluate the discriminatory performance of 11 vital signbased early warning scores (EWSs) and three shock indices in early sepsis prediction in the emergency department (ED).METHODS:We performed a retrospective study on consecutive adult patients with an infection over 3 months in a public ED in Hong Kong. The primary outcome was sepsis (Sepsis-3 definition)within 48 h of ED presentation. Using c-statistics and the De Long test, we compared 11 EWSs,including the National Early Warning Score 2 (NEWS2), Modified Early Warning Score, and Worthing Physiological Scoring System (WPS), etc., and three shock indices (the shock index [SI], modified shock index [MSI], and diastolic shock index [DSI]), with Systemic Inflammatory Response Syndrome(SIRS) and quick Sequential Organ Failure Assessment (q SOFA) in predicting the primary outcome,intensive care unit admission, and mortality at different time points.RESULTS:We analyzed 601 patients, of whom 166 (27.6%) developed sepsis. NEWS2 had the highest point estimate (area under the receiver operating characteristic curve [AUROC] 0.75,95%CI 0.70–0.79) and was significantly better than SIRS, q SOFA, other EWSs and shock indices,except WPS, at predicting the primary outcome. However, the pooled sensitivity and specificity of NEWS2≥5 for the prediction of sepsis were 0.45 (95%CI 0.37–0.52) and 0.88 (95%CI 0.85–0.91),respectively. The discriminatory performance of all EWSs and shock indices declined when used to predict mortality at a more remote time point.CONCLUSION:NEWS2 compared favorably with other EWSs and shock indices in early sepsis prediction but its low sensitivity at the usual cut-off point requires further modification for sepsis screening.