Value of triage early warning score for trauma patients in an emergency department

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1 中 南 大 学 学 报 ( 医 学 版 ) J Cent South Univ (Med Sci) 2015, 40(5) DOI: /j.issn Value of triage early warning score for trauma patients in an emergency department TIAN Lingyun 1,2, FANG Zhengqing 2, XIAO Hongling 2, LI Li 3, LI Yinglan 1 (1. Department of Nursing, Xiangya Hospital, Central South University, Changsha ; 2. School of Nursing, Anhui University of Chinese Medicine, Hefei ; 3. Department of Emergency, Xiangya Hospital, Central South University, Changsha , China) ABSTRACT KEY WORDS Objective: To evaluate the predictive accuracy of the triage early warning score (TEWS) in the prognosis and emergency treatment for trauma patients admitted to the emergency department (ED). Methods: A total of 456 trauma patients (>12 years old) admitted to ED at an education and research hospital in approximately 4 months were prospectively studied. The TEWS was recorded in all patients. The primary end-point was during 28 days and the emergency responses (such as cardiopulmonary resuscitation/ electrical defibrillation, mechanical ventilation) in the ED. Results: Patients with TEWS less than or equal to 9, from 10 to 13, or greater or equal to 14 had mortality rates of 0.98%, 52.63%, or 80%, respectively. An increase in 1 point within the range of 17-point TEWS would be associated with an odds ratio (OR) of 2.14 for death [95% confidence interval (CI): to 2.604]. In predicting mortality rates during 28 days, the cut-point was greater than 8, the sensitivity was 87.10% (95% CI: 70.2% to 96.4%), the specificity was 92.47% (95% CI: 89.5% to 94.8%), and the areas under the receiver operating characteristic curves (AUCROC) was (95% CI: to 0.951). The AUCROC of TEWS in predicting the emergency responses for CPR/ electrical defibrillation application or mechanical ventilation was (95% CI: to 0.983) or (95% CI: to 0.923), respectively. Conclusion: TEWS is effective in predicting the prognosis and emergency treatment for trauma patients admitted to ED. trauma patients; emergency department; warning score; mortality; cardiopulmonary resuscitation/ electrical defibrillation; mechanical ventilation; prospective observational study 分 流 早 期 预 警 评 分 在 急 诊 创 伤 患 者 中 的 应 用 价 值 田 凌 云 1,2, 方 正 清 2, 肖 洪 玲 2, 李 丽 3 1, 李 映 兰 (1. 中 南 大 学 湘 雅 医 院 护 理 部, 长 沙 ;2. 安 徽 中 医 药 大 学 护 理 学 院, 合 肥 ; 3. 中 南 大 学 湘 雅 医 院 急 诊 科, 长 沙 ) Date of reception: First author: TIAN Lingyun, @qq.com Corresponding author: LI Yinglan, yuyan0202@sina.com

2 550 中 南 大 学 学 报 ( 医 学 版 ), 2015, 40(5) [ 摘 要 ] 目 的 : 评 估 分 流 早 期 预 警 评 分 (triage early warning score,tews) 在 急 诊 创 伤 患 者 中 预 后 及 急 诊 科 应 急 处 置 预 测 的 准 确 性 方 法 : 在 一 所 教 育 和 研 究 型 三 甲 医 院 进 行 为 期 约 4 个 月 的 前 瞻 性 研 究, 符 合 纳 入 标 准 的 创 伤 患 者 均 进 行 TEWS, 观 测 结 局 指 标 为 28 d 病 死 率 急 诊 科 应 急 处 置 方 式 ( 使 用 心 肺 复 苏 术 / 电 除 颤 和 机 械 通 气 ) 结 果 : 纳 入 研 究 的 对 象 TEWS 9 分,10~13 分, 14 分 的 病 死 率 分 别 为 0.98%,52.63% 和 80%,TEWS 每 增 加 1 分, 则 死 亡 相 对 危 险 度 为 2.14 (95% CI: 1.759~2.604) TEWS 预 测 患 者 28 d 病 死 率 时, 最 佳 截 断 值 >8 分, 敏 感 度 为 87.10% (95% CI:0.2%~96.4%), 特 异 度 为 92.47% (95% CI:89.5%~94.8%),ROC 曲 线 下 面 积 为 (95% CI:0.902~0.951); 对 急 诊 科 预 测 的 患 者 使 用 心 肺 复 苏 术 / 电 除 颤 应 急 处 置 时,ROC 曲 线 下 面 积 为 (95% CI:0.949~0.983); 对 急 诊 科 预 测 的 患 者 使 用 机 械 通 气 应 急 处 置 时,ROC 曲 线 下 面 积 为 0.897(95% CI:0.865~0.923) 结 论 :TEWS 能 有 效 地 预 测 急 诊 科 创 伤 患 者 的 预 后 及 急 诊 科 内 应 急 处 置 方 式 的 使 用 [ 关 键 词 ] 创 伤 患 者 ; 急 诊 科 ; 预 警 评 分 ; 病 死 率 ; 心 肺 复 苏 术 / 电 除 颤 ; 机 械 通 气 ; 前 瞻 性 研 究 Trauma and unintentional injuries are the leading causes of death for all individuals less than 44 years of age which result in a major cost burden for the healthcare system [1]. In China, trauma is the number one reason of death among young adults [2], and study has also pointed out that the largest death population in the emergency department (ED) is trauma patients [3]. Over the past decade, scoring systems have been utilized to assess injury severity and provided an objective measure for treatment and appropriate allocation of healthcare resources [4]. Easy-to-use trauma scoring systems inform physicians of the severity of trauma in patients and help them decide the course of trauma management. When the patient is in the ED, trauma scoring systems can be used to prepare the patient for surgery, to call on medical staff for trauma support and to inform the family of the severity of the patient s condition in the early stage [5]. Many trauma scoring systems have been developed and used. For instance, the Acute Physiology and Chronic Health Evaluation (APACHE II) is a validated scale that assesses the severity of illness among non-surgical, surgical and intensive care hospital patients [6]. The Trauma Injury Severity Score (TRISS) is a validated score that can be retrospectively used to measure the effectiveness of trauma care [7]. The Revised Trauma Score (RTS) is calculated by the summation of fixed codes, based on physiological parameters, multiplied by previously published weight coefficients [8]. However, calculation of these trauma scoring systems is too complicated to use in the ED, especially in developing countries. For hospitals and healthcare systems in the developing countries, many of codes and variables are extremely difficult to reliably collect [9]. The Triage Early Warning Score (TEWS) is a validated composite triage score and is a component of the larger South African Triage Scale (SATS) [10-12]. It is based on the Modified Early Warning Score (MEWS) with the South African s special burden of disease (more than 1/3 patients of ED are trauma patients) [13]. The TEWS includes mobility (capacity for action), trauma, AVPU components (alert, responds to voice, responds to pain, unresponsive or confused) and vital sign (temperature, systolic blood pressure, respiratory rate, heart rate). To calculate TEWS for an individual emergency case, a higher total score indicates more physiological derangement and is used as a proxy for more severe illness or injury. The TEWS is very user friendly [14], which can be taught quickly to inexperienced staff [15] and uses simple clinical parameters, making it useful at all levels of emergency service delivery in a developing setting [16]. Unlike the scoring system mentioned above, TEWS can be much more readily handled in developing countries and is therefore a potential candidate to assist these countries in measuring the success of an emergency care system or intervention [18]. The aims of this study are: to evaluate TEWS as a risk stratification tool to predict mortality during 28 days in traumatically injured patients; and to evaluate TEWS in predicting emergency treatment of trauma patients in the ED. 1 Materials and methods 1.1 Study design and setting A prospective observational study was carried out on trauma patients admitted to the ED of Xiangya Hospital of Central South University in Changsha, China, between May 12th and August 31st Patients under 12 years of age or patients who were declared dead on arrival were excluded. 1.2 Datum collection Demographic and physiological details were all collected prospectively by 3 co-authors who had received formal training to do so. The following information was collected when a patient was admitted to the ED instantly: time and

3 Value of triage early warning score for trauma patients in an emergency department TIAN Lingyun, et al. 551 date of admission, sex, age, temperature ( ), respiratory rate (breaths per minute), blood pressure (mmhg), heart rate (beats per minute), conscious level using the AVPU score [AVPU reliably assesses the central nervous system as to whether a patient is alert ( A ), only responding to voice ( V ), only responding to pain ( P ), unresponsive ( U ) or confused], mobility (walking or with help or stretcher/ immobile when patient admitted to the ED), or in trauma, etc. Completeness of data was checked by 2 of the investigators. As the purpose of the study was to evaluate the scoring method, all raw data were converted to TEWS during the datum collection for use in this paper, such as a patient with mobility (capacity for action) stretcher (2), temperature 36.2 (0), respiratory rate 16 breaths per minute (1), heart rate 105 beats per minute (1), systolic blood pressure 145 mmhg (0), AVPU alert (0), trauma yes (1). The total TEWS is Outcome measurement The primary outcome measurement was the mortality during 28 days and the secondary outcome measurement was cardiopulmonary resuscitation (CPR)/ electrical defibrillation and mechanical ventilation (endotracheal intubation or tracheotomy) application in the ED. CPR/ electrical defibrillation and mechanical ventilation application were at the discretion of emergency medical specialists and nurses in the ED, who were unaware of the TEWS of the patients. 1.4 Ethical considerations Before the datum collection, permission for the study was granted by Ethics Review Committees of Xiangya Hospital, Central South University. 1.5 Statistical analysis Continuous variables were described by means ± deviation (x±s). Similarly, categorical variables were described by frequency and percentage. Parametric tests were used for the comparisons between groups: χ 2 test in the case of categorical variables and the t test, t -tests or Kruskal-Wallis test in the case of continuous variables. TEWS was calculated as shown in Table 1. Sensitivities and specificities with 95% confidence intervals (95%CI) were calculated for each cut-point of the TEWS and receiver operating characteristic (ROC) curves were plotted. The area under the ROC curves (AUCROC), with 95% CI was obtained to evaluate the accuracy of TEWS of mortality during 28 days, CPR/ electrical defibrillation and mechanical ventilation application. Statistical analysis was performed using SPSS 13.0 and MedCalc software. P<0.05 was considered statistically significant. Table 1 Triage early warning scores Items Mobility Walking With help Stretcher/immobile Respiratory rate/min 1 < > 29 Heart rate/min 1 < > 129 Systolic blood < pressure/mmhg Temperature/ Feels cold OR<35.0 Feels normal OR Feels hot OR> AVPU Confused Alert Reacts to voice Reacts to pain Unresponsive Trauma No Yes 2 Results 2.1 Physiological parameters for trauma patients During the study, 456 patients were observed. The mean age was (45.79±16.20) years. A total of 121 (26.54%) patients were female and 335 (73.46%) were male. Of the patients, 425 (93.20%) lived and 31(6.80%) died. The most common cause of death was due to serious craniocerebral trauma (n=17, 54.84%). One hundred and eighty eight (41.23%) patients suffered from closed trauma, 90.35% open trauma, and 44 (9.65%) closed trauma and open trauma. The average TEWS was 5.85±2.38. Table 2 presents the demographic and physiological

4 552 中 南 大 学 学 报 ( 医 学 版 ), 2015, 40(5) characteristics for trauma patients (the dead group and the living group). Patients who died had significantly lower systolic blood pressure (95% CI: to 69.26, P<0.001), lower respiratory rate (95% CI: 4.63 to 14.63, P<0.001), and higher TEWS (95% CI: 6.27 to 4.29, P<0.001). Patients who died more commonly had reduced conscious level (P<0.001), and more likely to have closed trauma (P=0.049). More men died than woman (P=0.009). There was no significant difference in age (95%CI: to 0.87, P=0.094), temperature(95%ci: 0.20 to 0.63, P=0.298), pulse rate (95% CI: to 18.91, P=0.892), mobility (P=0.211), and open trauma (P=0.532) between the dead group and the living group. Table 2 Baseline characteristics for trauma patients Groups n Age (x±s, years) Sex/[No.(%)] female male Systolic blood pressure/ (x±s, mmhg) Characteristics Temperature/ (x±s, ) Respiratory rate/ (x±s, min 1 ) Heart rate/ (x±s, min 1 ) TEWS/ All ± (26.54) 335(73.46) ± ± ± ± ±2.38 Living ± (98.35) 306(91.34) ± ± ± ± ±1.92 Dead ± (1.65) 29(8.66) 77.48± ± ± ± ±2.65 P < < <0.001 Groups All 288 Living 287 Characteristics (x±s) Conscious level/[no.(%)] Mobility/[No.(%)] Closed trauma/[no.(%)] Open traum/[no.(%)] Alert Voice Confused Pain Unresponsive Walking With help Stretcher/ Immobile 55 (63.16) (12.06) (99.65) Dead 1 (0.35) 55 (100) 29 (6.36) 24 (82.76) 0(0) 5 (17.24) 70 (15.35) 54 (77.14) 16 (22.86) 14(3.07) 9 (1.97) 5(35.71) 9 (100) 30 (6.58) 30 (100) 417 (91.45) 386 (92.57) 9(64.29) 0(0) 0(0) 31 No Yes No Yes 268 (58.77) 255 (95.15) 188 (41.23) 170 (90.43) 44 (9.65) 42 (95.45) P < (7.43) 13 (4.85) 18 (9.57) 2 (4.55) 412 (90.35) 383 (92.96) 29 (7.04) 2.2 Characteristics of treatment and disposition for trauma patients Table 3 displays the characteristics of treatment and disposition for trauma patients. There was significant difference in TEWS for patients who was applied CPR/ electrical defibrillation (95%CI: 7.03 to 5.21; P<0.001), and mechanical ventilation (95%CI: 5.08 to 3.52; P<0.001) between the dead group and the living group. The difference in TEWS for patients who was disposed at the emergency intensive care unit (EICU), resuscitation room and observation room was statistically significant (P<0.001) between the dead group and the living group. 2.3 Distribution of patient mortality by each incremental TEWS The study team looked at the distribution of patient mortality by each incremental TEWS (0 17). Based on this distribution, we used natural cut-offs to develop the TEWS groupings. A higher TEWS was associated with increased mortality (P<0.001, Table 4). Patients with TEWS less than or equal to 9, from 10 to 13, and greater than or equal to 14 had mortalities of 0.98%, 52.63%, and 80%, respectively. An increase of 1 point within the 17-point TEWS was associated with an OR of 2.14 for death (95% CI: 1.76 to 2.60).

5 Value of triage early warning score for trauma patients in an emergency department TIAN Lingyun, et al. 553 Table 3 Characteristics of treatment and disposition for trauma patients Parameters n TEWS (x±s) 95% CI P Emergency treatment CPR/electrical defibrillation Yes ±2.20 No ± to 5.21 <0.001 mechanical ventilation Yes ±0.38 No ± to 3.52 <0.001 Disposition at ED EICU ± to 7.78 resuscitation room ± to 6.40 <0.001 observation room ± to TEWS in predicting mortality during 28 days for trauma patients Table 5 shows the sensitivities and specificities with 95% confidence intervals for TEWS in predicting mortality during 28 days. Optimal discrimination using TEWS was found at a score >8 which gave a sensitivity of 87.10% (95% CI: 70.2% to 96.4%) and specificity of 92.47% (95%CI: 89.5% to 94.8%), and the youden index was The performance accuracy was further illustrated by the ROC curve (Figure 1). The AUCROC of TEWS was (95% CI: to 0.951). Table 4 TEWS score characteristics for trauma patients TEWS living/no. Dead /No. Mortality/% < > Total Table 5 Sensitivities and specificities (in percentages) with 95% CI for TEWS at select cut to points in predicting mortality during 28 days Cut to point Sensitivity 95% CI Specificity 95% CI to to 0.9 > to to 10.7 > to to 40.0 > to to 63.5 > to to 80.6 > to to 90.3 >8* to to 94.8 > to to 97.3 > to to 98.7 > to to 99.5 > to to 99.9 > to to > to to > to to *Optimal discrimination score

6 554 中 南 大 学 学 报 ( 医 学 版 ), 2015, 40(5) Sensitivity/% Specificity 2.5 TEWS in predicting emergency treatment for trauma patients in the ED TEWS in predicting CPR/ electrical defibrillation Table 6 shows the sensitivities and specificities with 95% CI for TEWS at select cut-points in predicting CPR/ electrical defibrillation. Optimal discrimination using TEWS was found at a score >8 which gave sensitivity of 95.00% (95% CI: 75.1 to 99.9) and specificity of 90.83% (95% CI: 87.7 to 93.4), and the performance accuracy was further illustrated by the ROC curve (Figure 2). The AUCROC of TEWS was (95% CI: to 0.983). Figure 1 ROC curve for TEWS on mortality during 28 days Table 6 Sensitivities and specificities (in percentages) with 95% CI for TEWS at select cut-points in predicting CPR/ electrical defibrillation Cut-point Sensitivity 95% CI Specificity 95% CI to to 0.8 > to to 79.4 > to to 88.9 >8* to to 93.4 > to to 96.1 > to to 98.2 > to to 99.4 > to to 99.9 > to to > to to > to to *Optimal discrimination score Sensitivity/% TEWS in predicting mechanical ventilation Table 7 shows the sensitivities and specificities with 95%CI for TEWS at select cut-points in predicting mechanical ventilation. Optimal discrimination using TEWS was found at a score >6 which gave sensitivity of 87.50% (95% CI: 75.9 to 94.8) and specificity of 80.50% (95% CI: 76.3 to 84.3). The performance accuracy was further illustrated by the ROC curve (Figure 3). The AUCROC of TEWS was (95% CI: to 0.923) Specificity Figure 2 ROC curve for TEWS on CPR/electrical defibrillation

7 Value of triage early warning score for trauma patients in an emergency department TIAN Lingyun, et al. 555 Table 7 Sensitivities and specificities (in percentages) with 95%CI for TEWS at select cut to points in predicting mechanical ventilation Criterion Sensitivity 95%CI Specificity 95%CI to to 0.9 > to to 11.4 > to to 41.9 > to to 66.8 >6* to to 84.3 > to to 92.1 > to to 96.5 > to to 98.4 > to to 99.6 > to to 99.8 > to to > to to > to to > to to *Optimal discrimination score Sensitivity/% Figure 3 ROC curve for TEWS on mechanical ventilation 3 Discussion Specificity TEWS is the simple-to-use clinical parameters that may facilitate the rapid triaging of medical, non-medical, and trauma emergencies [18]. At the present, it is the first time that TEWS is applied to predict the prognosis and emergency treatment of trauma patients in the ED in our study. In this study, the TEWS of dead patients was higher than the living patients and the difference between the 2 groups was statistically significant (P<0.001). Further, we found patients with TEWS less than or equal to 9 points, from 10 to 13 points, and greater than or equal to 14 points had mortalities of 0.98%, 52.63%, and 80%, respectively, which was proved that a higher TEWS is associated with increased mortality. The TEWS scores of patients disposed in the EICU, resuscitation room, and observation room was 7.09±2.38, 6.14±2.41, and 4.24±1.30, respectively, and the difference among the 3 dispositions was statistically significant (P<0.001). To a certain extent, the scoring system might help to triage trauma patients quickly and reduce the congestion of emergency triage station. In predicting mortality for trauma patients, the AUCROC of TEWS which gave sensitivity of 87.10% and specificity of 92.47% was Generally, clinical experts think that when the AUCROC of a diagnostic test is 0.8 or higher, the predicting model will be reliable, and can be applied clinically [19]. That is to say it is reliable for TEWS in predicting the prognosis of trauma patients and could be used in clinical work. The best clinical cut-off point of TEWS is >8, which was closely related to mortality during 28 days in trauma patients. In the study, we chose the emergency treatment (CPR/ electrical defibrillation and mechanical ventilation) for trauma patients in the ED as the outcomes, which rarely adopted in the previous related studies. Sometimes the condition of severe trauma is complex, therefore, how to judge the severity of trauma quickly and accurately,

8 556 中 南 大 学 学 报 ( 医 学 版 ), 2015, 40(5) and how to preset rules for examination, diagnosis, deterministic treatment as soon as possible, have become the key to the successful rescue. The previous study [20] indicates that respiratory care without being timely is the common failure for the trauma treatment. If there is a scoring system that could predict emergency treatment for trauma patients in the ED, it might help medical staff to pay attention to critically ill patients in advance and rescue patients promptly when patient needs CPR/ electrical defibrillation or mechanical ventilation. Our results showed that the AUCROC of TEWS was and in predicting CPR/ electrical defibrillation application and mechanical ventilation application for trauma patients respectively, suggesting that the TEWS is reliable in predicting the emergency treatment of trauma patients. The best clinical cut-off point of TEWS was higher than 8 or 6 in predicting CPR/ electrical defibrillation application or mechanical ventilation application for trauma patients respectively, which suggests that the medical staff should pay close attention to the changes of the patient's condition when the TEWS of trauma patients is higher than 6. Past study [20] has also suggested that the lack of communication efficiency between doctors and nurses would cause the failure for the trauma patients treatment. Currently, most scoring systems are always exclusively adopted by doctors for assessing the trauma patients. The nurses rarely take the initiative to assess the patient with scoring system in China for the complexity of the commonly used scoring tools, such as the Acute Physiology and Chronic Health Evaluation (APACHE II), the Trauma Injury Severity Score (TRISS) or the Revised Trauma Score (RTS). Based on the simplicity and accuracy of the TEWS, it should be popularized among nurses, which may help them to predict the disease severity of patients and timely give emergency disposal for patients with unstable conditions. TEWS can also improve the communication about the disease severity of patients between nurses and doctors. Our study was limited by several factors. First, data in the study were collected from May to August, so the sample size was slightly small. Moreover, the study is based on data from a single hospital, so it needs further clinical validation study on the TEWS application to the other hospital and other areas in our country. Finally, we only evaluated the accuracy of the TEWS, lacking of comparison between TEWS and other scoring system used in trauma patients. In a word, the TEWS is able to identify trauma patients at risk and is feasible in predicting the prognosis and emergency treatment for trauma patients in the ED. 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