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To determine the MEW Score of the patients on admission who are transferred to Intensive Care Unit / Special Care Unit or who died during hospital stay in a medical ward at a tertiary care hospital in Karachi.
Deterioration of patients in hospital is frequently preceded by documented deterioration of physiological parameters 1,2. Failure of clinical staff to respond to worsening of respiratory or cerebral functions and increase levels of medical intervention will put patients at risk of cardio-respiratory arrest 3,4. Inappropriate action in response to observed abnormal physiological and biochemical variables might lead to avoidable death 5. Sub-optimal care prior to admission to a critical care unit can lead to increased mortality 6. The number of patients that can be monitored and treated in intensive care units and high dependency units is restricted because of resource limitations. The selection of patients who might benefit from critical care is therefore crucial 7.
Studies have shown that abnormalities in basic physiological observations are present in patients before they are admitted to the intensive or high dependency units or have a cardiac arrests 8,9.On these grounds early warning scoring system should work to help patients at risk of critical illness. Early warning scoring systems are widely used in the United Kingdom and are recommended by the National Institute for Health and Clinical Excellence to help identify patients at risk in General wards 14.
Early warning score is a tool for bedside evaluation of a patient based on five physiological parameters: systolic blood pressure (SBP), pulse rate (PR), respiratory rate (RR), temperature, AVPU OR GCS. MEWS was originally developed with two specific aims: to facilitate timely recognition of the patients with established or impending critical illness and to empower nurses and junior medical staff to secure experienced help through operation of a trigger threshold which if, reached, required mandatory attendance by a more senior staff. A study that assessed the validity of Modified Early Warning Score System found that a score of 9 was associated with admission to the intensive care or high dependency units or death in 100% cases ,whereas a score 0-2 was associated with the same outcomes in 7.9% of cases 7. Another study found that mortality increased with the number of physiological abnormalities 10 . Therefore, MEWS works as a screening tool to identify patients at risk of deterioration and in need of more advanced intervention. There are other scoring systems used in the hospital, ICU and surgical wards like acute physiology and chronic health evaluation score (APACHE II) and Mortality Prediction Model (MDM) and Simplified Acute Physiology Score (SAPS). None of the available scoring system appears to be suitable for bedside assessment of ward patients in a routine fashion. MEWS is used in general wards to assess patients in a routine way without using laboratory tests. The huge advantage of the MEW Score is that it simply collates the results of classic vital signs and can be used by anyone at the bedside 12.In a study done in Italy, total of 1107 patients were admitted to the ,966 were discharged,102 were deceased and 39 were transferred to higher level care. The range of admission scores varied from 0 to 10 with high preponderance of low values. In comparison with the lowest score(MEWS= 0),risk of death was incremental as MEWS goes up and so with the risk of death and transfer to ICU/SCU 11 . Early identification of medical patients who are at higher risk for getting transferred to ICU or special care unit from the wards is very important. This can be done by measuring physiological parameters like B.P, pulse, respiratory rate, temperature and AVPU/GCS .Hence MEWS has all these physiological parameters incorporated in it.
1. To calculate the MEW SCORE of medical patients on admission who are transferred to special care unit/Intensive care unit or who died during the hospital stay.
2. To determine the outcome of the transferred patients to ICU/SCU ( discharge or mortality).
1) MEWS SCORE: Modified Early Warning Score is a tool for bedside evaluation of a patient based on five physiological parameters: systolic blood pressure (SBP), pulse rate (PR), AVPU, respiratory rate (RR) and temperature 10. MEW Score is determined by assigning a number between 0 and 3 to each of the 5 parameters .The sum of the scores of the five vital signs from the reference table yields the patient's total MEW Score. Mortality and morbidity is increased as the score goes higher.
Key Table 13
41 - 50
51 - 100
Temperature (°C )
Reacting to pain
Reacting to voice
Reacting to voice
Reacting to pain
Systolic BP (mm Hg)
Its a form of track and trigger scoring system. All patients' vital signs are measured and each variable given a score. The higher the score the more abnormal vital signs are. The system monitors: Blood pressure , Pulse , Respiratory rate, Temperature and GCS or AVPU.MEW Score ≥5 is associated with impending clinical instability (11).
Unexposed group:Mew Score of 0-1.
Exposed group:Mew Score of 2-3,4-5 and .>5.
Outcome of the transferred patients to ICU/SCU: Mortality and discharge.
MATERIAL AND METHODS:
STUDY DESIGN: prospective observational cohort study
SETTING: Department of Medicine, Aga Khan University Hospital Karachi
DURATION: 6 months after approval of synopsis
From the previous study, 62.5% patients had MEW score on admission were >5 who were transferred to the SCU/ICU during the hospital stay and 15.4% patients had MEW score between 2 to 5. To estimate the sample size, with a bound on error of 0.09 (9%) with a 95% CIs, the maximum sample size came out as to be 112 patients. From previous studies overall 13, 7-25% patients died during SCU/ICU stay, with a bound on error of 0.09 (9%) with a 95% CIs, the maximum sample size came out as to be 89 is required to achieve this objective. Sample size calculated for the MEW score of transferred to the SCU/ICU patients was larger than the mortality of transferred to ICU patients. Therefore, a sample of 112 was targeted to cover both the objectives.
SAMPLE SELECTION: Non-probability, purposive sampling.
1. Patients, age>13 yrs old.
2. All patients admitted to medical special care unit /ICU directly from emergency room.
3. All patients admitted from emergency room and then transferred to medical special care unit/ICU.
1. Surgical patients.
2. Burn and trauma patients.
3. Terminally ill and DNR patients.
4. Day care patients.
All patients admitted to medical units who fulfill the inclusion criteria will be enrolled in the study after taking informed written consent from the patient or their next of kin (if patient is unable to give consent).Demographic details (age, gender), the vital signs such as pulse, blood pressure, temperature, respiratory rate, GCS or AVPU on admission would be filled in by a nurse taking care of the patients will be recorded. All patients will be followed for their outcome (discharged and mortality). Patients will be divided into 4 categories based on their total scores :0-1,2-3, 4-5 and over 5.All data will be taken by principal investigator and filled in Proforma attached as ANNEXURE-I.
A descriptive analysis done for demographic characteristics are presented as mean ± standard deviation for quantitative variables i.e., age, blood pressure, heart rate, respiratory rate and temperature and number (Percentage) for qualitative variables like gender. The MEW score of each patient who will be transferred to ICU/SCU will be calculated. MEW score will be categorised into 0-1, 2-3, 4-5 and more than 5. Number (percentages) will be calculated for each MEW score. All patients will be followed for their outcome; mortality or hospital discharge.
All analyses will be conducted by using the Statistical package for social science SPSS (Release 17.0, standard version, copyright © SPSS; 1989-02). Age could be a confounding variable ;hence we will categorize patients into less than 40 yrs old or more than 40 yrs old. Information bias could be there in data collection. Hence one designated person would collect the data on pre-designed proforma.
To determine the MEW SCORE of the patients on admission who are transferred to ICU/SCU or who died during hospital stay in a medical ward at a tertiary care hospital in Karachi.
Date of admission
Mode of admission
Directly from Emergency room
From the ward to ICU/SCU
MEW SCORE on admission
MEW SCORE of a Transferred Patient to ICU/ SCU
MEW SCORE of a Patient who died during hospital stay