Current best evidence for clinical care (more info)
OBJECTIVES: Although the National Early Warning Score (NEWS) and its latest version NEWS2 are recommended for monitoring deterioration in patients admitted to hospital, little is known about their performance in COVID-19 patients. We aimed to compare the performance of the NEWS and NEWS2 in patients with COVID-19 versus those without during the first phase of the pandemic.
DESIGN: A retrospective cross-sectional study.
SETTING: Two acute hospitals (Scarborough and York) are combined into a single dataset and analysed collectively.
PARTICIPANTS: Adult (=18 years) non-elective admissions discharged between 11 March 2020 and 13 June 2020 with an index or on-admission NEWS2 electronically recorded within ±24 hours of admission to predict mortality at four time points (in-hospital, 24 hours, 48 hours and 72 hours) in COVID-19 versus non-COVID-19 admissions.
RESULTS: Out of 6480 non-elective admissions, 620 (9.6%) had a diagnosis of COVID-19. They were older (73.3 vs 67.7 years), more often male (54.7% vs 50.1%), had higher index NEWS (4 vs 2.5) and NEWS2 (4.6 vs 2.8) scores and higher in-hospital mortality (32.1% vs 5.8%). The c-statistics for predicting in-hospital mortality in COVID-19 admissions was significantly lower using NEWS (0.64 vs 0.74) or NEWS2 (0.64 vs 0.74), however, these differences reduced at 72hours (NEWS: 0.75 vs 0.81; NEWS2: 0.71 vs 0.81), 48 hours (NEWS: 0.78 vs 0.81; NEWS2: 0.76 vs 0.82) and 24hours (NEWS: 0.84 vs 0.84; NEWS2: 0.86 vs 0.84). Increasing NEWS2 values reflected increased mortality, but for any given value the absolute risk was on average 24% higher (eg, NEWS2=5: 36% vs 9%).
CONCLUSIONS: The index or on-admission NEWS and NEWS2 offers lower discrimination for COVID-19 admissions versus non-COVID-19 admissions. The index NEWS2 was not proven to be better than the index NEWS. For each value of the index NEWS/NEWS2, COVID-19 admissions had a substantially higher risk of mortality than non-COVID-19 admissions which reflects the increased baseline mortality risk of COVID-19.
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Strengths: • Large dataset used. • Both medical and surgical admission compared. Weaknesses: • While Covid-19 can affect the surgical population, the significance of that is much less compared to medical patients. • Mortality of surgical patients mainly depends on the surgical factors than covid-19 issues. • Oxygen supplementation in surgical patients is used routinely. Many surgical patients will need ventilation for surgical indications. • Subgroup analysis between medical and surgical patients missing. • No explanation was given why c-statistics predicted lower mortality in covid-19 patients. • Progression of NEWS should have been used. • Increasing oxygen requirements surprisingly did not have any impact on NEWS/NEWS2 values. Impression: Timely survey of the impact of NEWS on Covid-19. But this should have included mainly surgical patients or the authors should have done subgroup analysis to differentiate impact between medical and surgical patients.