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COMMENTARY
Year : 2020  |  Volume : 152  |  Issue : 4  |  Page : 332-334

Predicting outcomes in patients with community-acquired pneumonia using weighted track & trigger early warning systems: Lessons learnt & insights for future use


Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati 517 507, Andhra Pradesh, India

Date of Submission03-Feb-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Alladi Mohan
Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati 517 507, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmr.IJMR_261_20

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How to cite this article:
Mohan A, Bhargav K M. Predicting outcomes in patients with community-acquired pneumonia using weighted track & trigger early warning systems: Lessons learnt & insights for future use. Indian J Med Res 2020;152:332-4

How to cite this URL:
Mohan A, Bhargav K M. Predicting outcomes in patients with community-acquired pneumonia using weighted track & trigger early warning systems: Lessons learnt & insights for future use. Indian J Med Res [serial online] 2020 [cited 2021 May 14];152:332-4. Available from: https://www.ijmr.org.in/text.asp?2020/152/4/332/305162

Community-acquired pneumonia (CAP) remains a common and serious illness despite the availability of potent new antimicrobials and effective vaccines[1],[2]. Worldwide, among adults, pneumonia is the most common infectious cause of death and the second-leading cause of overall life years lost. As per the World Health Organization, Global Burden of Disease study[1] lower respiratory tract infections, including CAP account for 94.5 million disability-adjusted life years and 1.6 million deaths annually in adults aged over 59 yr[1]. Severe CAP is associated with significant mortality (16-36%) in spite of the availability of effective antibiotic therapy[3],[4]. Extrapolating the data from a prospective population-based cohort study[5] in adults hospitalized with pneumonia in Louisville, Kentucky, to the entire country, the authors[5] reported that >1.5 million adults were hospitalized annually, 100,000 deaths occurred during hospitalization and approximately 1 of 3 patients hospitalized with CAP died within one year in the United States of America (USA). These data underscore the importance of meticulous initial assessment of patients with CAP to ensure the institution of appropriate level of treatment and care required.

In immunocompetent patients with CAP, clinical prediction rules, such as the confusion, elevated blood urea nitrogen, respiratory rate and blood pressure plus age ≥65 yr (CURB-65) score[6] and pneumonia severity index (PSI)[7], among others have been used in conjunction with clinical judgement to determine the need for hospitalization and the level of in-patient treatment intensity like admission into intensive care unit (ICU) and/or mortality. Published data suggest that in comparison to CURB-65, PSI identifies a larger proportion of patients who can be treated in the outpatient setting and has a higher discriminative power in predicting mortality[8].

Several physiologically-based early warning scores (EWS), such as, modified early warning score (MEWS)[9], standardized early warning scoring system (SEWS)[10], global MEWS[11], VitalPAC™ early warning score (ViEWS)[12] and the ViEWS-L[13] which includes serum lactate as an additional component, were developed to address this issue. The National Early Warning Score (NEWS)[14] includes six routinely recorded physiological parameters routinely namely, respiratory rate, oxygen saturation, temperature, systolic blood pressure, pulse rate, level of consciousness and a weighting score of 2 to be added for any patient requiring supplemental oxygen; and its modification NEWS-L[15] includes serum lactate as an additional component, have also been evaluated for predicting adverse outcomes.

In the study by Kaya et al[16], the performances of CURB-65, PSI, NEWS and NEWS-L were compared in patients (n=250, mean age 72.3±14.3 yr; 58.4% males) diagnosed to have pneumonia in the emergency department. Receiver operating characteristic (ROC) curves were used for comparing the performance of these scores in predicting mortality, need for admission into hospital and ICU. The authors reported that NEWS-L [cut-off value >13.7; sensitivity 85.1%, specificity 96.4%, area under the curve (AUC) 0.96; 95% confidence intervals (CI) 0.928-0.981)] was the most successful tool for predicting 30-day mortality followed by NEWS, CURB-65 and PSI, respectively. NEWS-L (cut-off value >7.7; sensitivity 69.1%, specificity 63.4%, AUC 0.72; 95% CI 0.659-0.774) was also observed to have the highest AUC for deciding on the need for admission to the hospital followed by NEWS, CURB-65 and PSI. For predicting the need for ICU care, NEWS and NEWS-L had the highest AUC (0.86 each) followed by CURB-65 (0.85); NEWS-L had the highest sensitivity (90%) and CURB-65 had the highest specificity (94.7%). The authors concluded that NEWS-L score was most useful to predict mortality, need for hospitalization, ICU care[16].

Evidence is available suggesting that abnormal vital signs precede critical events such as death, cardiopulmonary arrest and need for shifting to an ICU[17],[18]. These EWSs have been validated most often in ICUs in the USA, United Kingdom and Europe; seldom have these been derived/validated in countries like Turkey, where the present study[16] was conducted. Therefore, there is a continuing need for evolving and validating early warning systems that are applicable to the institutional/hospital setup where these are intended to be practically used in day-to-day practice.

There are some caveats which concern the results of the present study[16]. It is a single-centre study, with a short follow up period (30-day mortality was reported). NEWS and NEWS-L belong to the category of weighted 'track and trigger systems'[19],[20] where points are allocated in a weighted manner to derangements in common clinically documented physiological variables from an arbitrarily agreed normal range. The sum total of the allocated points constitutes the EWS. The present study[16] documented the various scores at a single time point, at the time of initial presentation. Further, a significant number (39%) of patients had chronic obstructive pulmonary disease and their supplemental oxygen requirement could have influenced the performance of NEWS and NEWS-L scores.

EWS mandate the collection and processing of accurate, reliable data which requires clinicians, nursing, paramedical staff, rapid response team with appropriate training, skills, experience and dedication. In developing countries, not all critically ill patients have access to quality critical care or monitoring[21]. Further, lack of resources required for providing critical care is a major concern as well. The present study[16] provides clinically interesting information identifying patients at risk and offers potential for instituting an effective response that can change the outcomes. The observations from this study need to be validated in adequately powered studies for assessing key outcome measures across a spectrum of emergency room settings and ICUs for establishing the utility of the emerging EWS.

Conflicts of Interest: None.

 
   References Top

1.
The Global Burden of the Disease. Available from: http://www.who.int/topics/global_burden_of_disease/en/, accessed on October 10, 2019.  Back to cited text no. 1
    
2.
Gupta D, Agarwal R, Aggarwal AN, Singh N, Mishra N, Khilnani GC, et al. Guidelines for diagnosis and management of community- and hospital-acquired pneumonia in adults: Joint ICS/NCCP(I) recommendations. Lung India 2012; 29 : S27-62.  Back to cited text no. 2
    
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Liapikou A, Ferrer M, Polverino E, Balasso V, Esperatti M, Piñer R, et al. Severe community-acquired pneumonia: Validation of the infectious diseases Society of America/American Thoracic Society guidelines to predict an intensive care unit admission. Clin Infect Dis 2009; 48 : 377-85.  Back to cited text no. 4
    
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Ramirez JA, Wiemken TL, Peyrani P, Arnold FW, Kelley R, Mattingly WA, et al. University of Louisville Pneumonia Study Group. Adults hospitalized with pneumonia in the United States: Incidence, epidemiology, and mortality. Clin Infect Dis 2017; 65 : 1806-12.  Back to cited text no. 5
    
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Lim WS, van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI, et al. Defining community acquired pneumonia severity on presentation to hospital: An international derivation and validation study. Thorax 2003; 58 : 377-82.  Back to cited text no. 6
    
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Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997; 336 : 243-50.  Back to cited text no. 7
    
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Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and infectious diseases Society of America. Am J Respir Crit Care Med 2019; 200 : e45-67.  Back to cited text no. 8
    
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Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified early warning score in medical admissions. QJM 2001; 94 : 521-6.  Back to cited text no. 9
    
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Paterson R, MacLeod DC, Thetford D, Beattie A, Graham C, Lam S, et al. Prediction of in-hospital mortality and length of stay using an early warning scoring system: Clinical audit. Clin Med (Lond) 2006; 6 : 281-4.  Back to cited text no. 10
    
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Harrison GA, Jacques T, McLaws ML, Kilborn G. Combinations of early signs of critical illness predict in-hospital death-the SOCCER study (signs of critical conditions and emergency responses). Resuscitation 2006; 71 : 327-34.  Back to cited text no. 11
    
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Jo S, Lee JB, Jin YH, Jeong TO, Yoon JC, Jun YK, et al. Modified early warning score with rapid lactate level in critically ill medical patients: The ViEWS-L score. Emerg Med J 2013; 30 : 123-9.  Back to cited text no. 13
    
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Royal College of Physicians. National Early Warning Score (NEWS): Standardising the assessment of acute-illness severity in the NHS. Report of a working party. London: RCP, 2012.  Back to cited text no. 14
    
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Jo S, Yoon J, Lee JB, Jin Y, Jeong T, Park B. Predictive value of the national early warning score-lactate for mortality and the need for critical care among general emergency department patients. J Crit Care 2016; 36 : 60-8.  Back to cited text no. 15
    
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Kaya AE, Ozkan S, Usul E, Arslan ED. Comparison of pneumonia severity scores for patients diagnosed with pneumonia in emergency department. Indian J Med Res 2020; 152 : 368-77.  Back to cited text no. 16
    
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Romero-Brufau S, Huddleston JM, Naessens JM, Johnson MG, Hickman J, Morlan BW, et al. Widely used track and trigger scores: Are they ready for automation in practice? Resuscitation 2014; 85 : 549-52.  Back to cited text no. 20
    
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Mohan A, Bollineni S. Predicting mortality in critically ill obstetric patients requiring intensive care unit admission in India. Indian J Med Sci 2007; 61 : 175-7.  Back to cited text no. 21
    




 

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