• Abi Beane, De Silva Ambepitiyawaduge Pubudu AP Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka. , Nirodha De Silva, Jayasingha A Sujeewa, R M Dhanapala Rathnayake, P Chathurani Sigera, Priyantha Lakmini Athapattu, Palitha G Mahipala, Aasiyah Rashan, Sithum Bandara Munasinghe, Kosala Saroj Amarasiri Jayasinghe, Arjen M Dondorp, and Rashan Haniffa.
• Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka.
• BMJ Open. 2018 Apr 27; 8 (4): e019387.

ObjectiveThis study describes the availability of core parameters for Early Warning Scores (EWS), evaluates the ability of selected EWS to identify patients at risk of death or other adverse outcome and describes the burden of triggering that front-line staff would experience if implemented.DesignLongitudinal observational cohort study.SettingDistrict General Hospital Monaragala.ParticipantsAll adult (age >17 years) admitted patients.Main Outcome MeasuresExisting physiological parameters, adverse outcomes and survival status at hospital discharge were extracted daily from existing paper records for all patients over an 8-month period.Statistical AnalysisDiscrimination for selected aggregate weighted track and trigger systems (AWTTS) was assessed by the area under the receiver operating characteristic (AUROC) curve.Performance of EWS are further evaluated at time points during admission and across diagnostic groups. The burden of trigger to correctly identify patients who died was evaluated using positive predictive value (PPV).ResultsOf the 16 386 patients included, 502 (3.06%) had one or more adverse outcomes (cardiac arrests, unplanned intensive care unit admissions and transfers). Availability of physiological parameters on admission ranged from 90.97% (95% CI 90.52% to 91.40%) for heart rate to 23.94% (95% CI 23.29% to 24.60%) for oxygen saturation. Ability to discriminate death on admission was less than 0.81 (AUROC) for all selected EWS. Performance of the best performing of the EWS varied depending on admission diagnosis, and was diminished at 24 hours prior to event. PPV was low (10.44%).ConclusionThere is limited observation reporting in this setting. Indiscriminate application of EWS to all patients admitted to wards in this setting may result in an unnecessary burden of monitoring and may detract from clinician care of sicker patients. Physiological parameters in combination with diagnosis may have a place when applied on admission to help identify patients for whom increased vital sign monitoring may not be beneficial. Further research is required to understand the priorities and cues that influence monitoring of ward patients.Trial Registration NumberNCT02523456.© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

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