Service Line: Rapid Response Service Version: 1.0 Publication Date: October 3, 2017 Report Length: 10 Pages

CADTH RAPID RESPONSE REPORT: SUMMARY OF ABSTRACTS Tools for the Early Identification of Adult Inpatients at Risk for Deterioration: Clinical Effectiveness and Guidelines Service Line: Rapid Response Service Version: 1.0 Publication Date: October 3, 2017 Report Length: 10 Pages

Authors: Michelle Clark, Charlene Argáez Cite As: Tools for the early identification of adult inpatients at risk for deterioration: clinical effectiveness and guidelines. Ottawa: CADTH; 2017 Oct. (CADTH rapid response report: summary of abstracts). Acknowledgments: Disclaimer: The information in this document is intended to help Canadian health care decision-makers, health care professionals, health systems leaders, and policy-makers make well-informed decisions and thereby improve the quality of health care services. While patients and others may access this document, the document is made available for informational purposes only and no representations or warranties are made with respect to its fitness for any particular purpose. The information in this document should not be used as a substitute for professional medical advice or as a substitute for the application of clinical judgment in respect of the care of a particular patient or other professional judgment in any decision-making process. The Canadian Agency for Drugs and Technologies in Health (CADTH) does not endorse any information, drugs, therapies, treatments, products, processes, or services. While care has been taken to ensure that the information prepared by CADTH in this document is accurate, complete, and up-to-date as at the applicable date the material was first published by CADTH, CADTH does not make any guarantees to that effect. CADTH does not guarantee and is not responsible for the quality, currency, propriety, accuracy, or reasonableness of any statements, information, or conclusions contained in any third-party materials used in preparing this document. The views and opinions of third parties published in this document do not necessarily state or reflect those of CADTH. CADTH is not responsible for any errors, omissions, injury, loss, or damage arising from or relating to the use (or misuse) of any information, statements, or conclusions contained in or implied by the contents of this document or any of the source materials. This document may contain links to third-party websites. CADTH does not have control over the content of such sites. Use of third-party sites is governed by the third-party website owners own terms and conditions set out for such sites. CADTH does not make any guarantee with respect to any information contained on such third-party sites and CADTH is not responsible for any injury, loss, or damage suffered as a result of using such third-party sites. CADTH has no responsibility for the collection, use, and disclosure of personal information by third-party sites. Subject to the aforementioned limitations, the views expressed herein are those of CADTH and do not necessarily represent the views of Canada s federal, provincial, or territorial governments or any third party supplier of information. This document is prepared and intended for use in the context of the Canadian health care system. The use of this document outside of Canada is done so at the user s own risk. This disclaimer and any questions or matters of any nature arising from or relating to the content or use (or misuse) of this document will be governed by and interpreted in accordance with the laws of the Province of Ontario and the laws of Canada applicable therein, and all proceedings shall be subject to the exclusive jurisdiction of the courts of the Province of Ontario, Canada. The copyright and other intellectual property rights in this document are owned by CADTH and its licensors. These rights are protected by the Canadian Copyright Act and other national and international laws and agreements. Users are permitted to make copies of this document for non-commercial purposes only, provided it is not modified when reproduced and appropriate credit is given to CADTH and its licensors. About CADTH: CADTH is an independent, not-for-profit organization responsible for providing Canada s health care decision-makers with objective evidence to help make informed decisions about the optimal use of drugs, medical devices, diagnostics, and procedures in our health care system. SUMMARY OF ABSTRACTS Tools for the Early Identification of Adult Inpatients at Risk for Deterioration 2

Research Questions 1. What is the clinical effectiveness regarding tools or indicators for early identification of deteriorating or worsening condition among adult hospitalized patients? 2. What are the evidence-based guidelines and best practice regarding tools or indicators for early identification of deteriorating or worsening condition among adult hospitalized patients? Key Findings One health technology assessment, six systematic reviews, one randomized controlled trial, and one evidence-based guideline were identified regarding tools or indicators for early identification of deteriorating or worsening conditions among adult hospitalized patients. Methods This report makes use of a literature search developed for a previous CADTH report. The original literature search was conducted in November 2011 on key resources including PubMed, The Cochrane Library, University of York Centre for Reviews and Dissemination (CRD) databases, Canadian and major international health technology agencies, as well as a focused Internet search. No filters were applied to limit retrieval by study type. Where possible, retrieval was limited to the human population. The initial search was also limited to English-language documents published between January 1, 2008 and November 7, 2011. For the current report, database searches were rerun on September 19, 2017 to capture any articles published since the initial search date. The search of major health technology agencies was also updated to include documents published since November 2011. Selection Criteria One reviewer screened citations and selected studies based on the inclusion criteria presented in Table 1. Table 1: Selection Criteria Population Interventions Comparators Adult patients in hospital Interventions for early recognition of deterioration: May include scoring tools such as: Early Warning Score, Modified Early Warning Score, VitalPac Early Warning Score, score-to-door time benchmarking tool Outreach programs Screening tools Interventions compared with each other or with usual care or no intervention Outcomes Q1: Clinical effectiveness, impact on length of stay Q2: Guidelines Study Designs Health technology assessments, systematic reviews, meta-analyses, randomized controlled trials, nonrandomized studies, evidence-based guidelines SUMMARY OF ABSTRACTS Tools for the Early Identification of Adult Inpatients at Risk for Deterioration 3

Results Rapid Response reports are organized so that the higher quality evidence is presented first. Therefore, health technology assessment reports, systematic reviews, and meta-analyses are presented first. These are followed by randomized controlled trials and evidence-based guidelines. Due to the volume of relevant literature, non-randomized studies have been included in the appendix. One health technology assessment, six systematic reviews, one randomized controlled trial, and one evidence-based guideline were identified regarding tools or indicators for early identification of deteriorating or worsening conditions among adult hospitalized patients. Non-randomized studies and additional references of potential interest are provided in the appendix. Overall Summary of Findings One health technology assessment 1 was identified that examined the implementation of electronic early warning score systems in hospitals. Some evidence was identified that suggested that the use of these systems resulted in reduced mortality rates. Length of stay was reduced in both intensive care units (ICUs) and general hospital wards and the accuracy of vital sign measurement was improved. 1 One systematic review (SR) 4 examined the impact of the use of the Early Warning Score (EWS) on patient outcomes. The studies included in the review found a range of differences on in-hospital mortality rates from significantly improved to no significant difference. 4 There was no significant difference reported in serious adverse events; however, there was a reduction in events following the use of the EWS. Two SRs identified 11 5 and 13 6 different early warning systems that were based on a combination of clinical evaluation and vital signs. The authors determined that the systems were able to predict cardiac arrest and death within 48 hours; however, the methods of the included studies were too varied to allow them to make a conclusion about their overall effectiveness. 5-6 One SR 7 identified studies that examined single parameter and aggregate weighted scoring systems and the authors determined that aggregate scoring systems appeared to be the most effective. One randomized controlled trial 8 compared the measurement of EWS at eight or 12 hour intervals. The authors found no significant differences between groups in 30 day mortality, cardiac arrests, ICU admissions, length of stay, or elevated EWS at 48 hours. 8 Two SRs 2-3 examined the role of patients and their families in escalating patient deterioration to response teams in hospital. Both reviews found patient and family escalation was used appropriately and did not result in an overuse of hospital resources. 2-3 Feedback provided by participants was generally positive 3 but the process seemed to increase staff stress. 3 Response teams were sometimes called for non-urgent reasons. 2 One guideline from the National Guideline Centre was identified that recommends that hospitals consider using an early warning score to assess people with suspected sepsis in acute hospital settings. 9 SUMMARY OF ABSTRACTS Tools for the Early Identification of Adult Inpatients at Risk for Deterioration 4

References Summarized Health Technology Assessments 1. Health Information and Quality Authority. Health technology assessment of the use of information technology for early warning and clinical handover systems [Internet]. Dublin (Ireland): Health Information and Quality Authority; 2015 [cited 2017 Sep 29]. Available from: https://www.hiqa.ie/sites/default/files/2017-01/hta-of-use-ofinformation-technology-for-early-warning-and-clinical-handover-systems.pdf Systematic Reviews and Meta-analyses 2. Albutt AK, O'Hara JK, Conner MT, Fletcher SJ, Lawton RJ. Is there a role for patients and their relatives in escalating clinical deterioration in hospital? A systematic review. Health Expect. 2017 Oct;20(5):818-25. PubMed: PM27785868 3. Gill FJ, Leslie GD, Marshall AP. The Impact of implementation of family-initiated escalation of care for the deteriorating patient in hospital: a systematic review. Worldviews Evid Based Nurs. 2016 Aug;13(4):303-13. PubMed: PM27258792 4. Alam N, Hobbelink EL, van Tienhoven AJ, van de Ven PM, Jansma EP, Nannyakkara PW. The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review. Resuscitation. 2014 May;85(5):587-94. PubMed: PM24467882 5. Smith ME, Chiovaro JC, O'Neil M, Kansagara D, Quinones A, Freeman M, et al. Early warning system scores: a systematic review [Internet]. Washington, DC: Department of Veterans Affairs. Evidence-based Synthesis Program. 2014 Jan [cited 2017 Sep 29]. PubMed: PM25506953 6. Smith ME, Chiovaro JC, O'Neil M, Kansagara D, Quinones AR, Freeman M, et al. Early warning system scores for clinical deterioration in hospitalized patients: a systematic review. Annals Am Thorac Soc. 2014;11(9):1454-1465. PubMed: PM25296111 7. McNeill G, Bryden D. Do either early warning systems or emergency response teams improve hospital patient survival? A systematic review. Resuscitation. 2013 Dec;84(12):1652-67. PubMed: PM23962485 Randomized Controlled Trials 8. Petersen JA, Antonsen K, Rasmussen LS. Frequency of early warning score assessment and clinical deterioration in hospitalized patients: a randomized trial. Resuscitation. 2016 Apr;101:91-6. PubMed: PM26891861 SUMMARY OF ABSTRACTS Tools for the Early Identification of Adult Inpatients at Risk for Deterioration 5

Guidelines and Recommendations 9. National Guideline Clearinghouse. Guideline summary: sepsis: recognition, diagnosis, and management. In: National Guideline Clearinghouse [Internet]. Rockville (MD): Agency for Healthcare and Research Quality (AHRQ) 2016 [cited 2017 Sep 29]. Summary available rom: https://www.guideline.gov/summaries/summary/50412/sepsisrecognition-diagnosis-and-early-management?q=early+warning+ SUMMARY OF ABSTRACTS Tools for the Early Identification of Adult Inpatients at Risk for Deterioration 6

Appendix Further Information Previous CADTH Reports 10. Monitoring of vital signs in adult patients: clinical evidence and guidelines [Internet]. Ottawa (ON): CADTH; 2011 [cited 2017 Sep 29]. Available from: https://www.cadth.ca/sites/default/files/pdf/htis/jan- 2011/K0294_Monitoring_vital_signs.pdf 11. Tools for the early identification of adult inpatients at risk for deterioration: clinical evidence and guidelines [Internet]. Ottawa (ON): CADTH; 2011 [cited 2017 Sep 29]. Available from: https://www.cadth.ca/sites/default/files/pdf/htis/nov-2011/rb0442-000%20deterioration%20screening.pdf Non-Randomized Studies 12. Churpek MM, Snyder A, Sokol S, Pettit N, Edelson DP. Investigating the impact of different suspicion of infection criteria on the accuracy of quick sepsis-related organ failure assessment, systemic inflammatory response syndrome, and early warning scores. Crit Care Med; 2017 Jul 21. PubMed: PM28737573 13. Douw G, Huisman-de Waal G, van Zanten ARH, van der Hoeven JG, Schoonhoven L. Capturing early signs of deterioration: the dutch-early-nurse-worry-indicator-score and its value in the Rapid Response System. J Clin Nurs. 2017 Sep;26(17-18):2605-13. PubMed: PM27865003 14. Kim WY, Lee J, Lee JR, Jung YK, Kim HJ, Huh JW, et al. A risk scoring model based on vital signs and laboratory data predicting transfer to the intensive care unit of patients admitted to gastroenterology wards. J Crit Care. 2017 Aug;40:213-7. PubMed: PM28445859 15. Peek KN, Gillham M. Is the New Zealand Early Warning Score useful following cardiac surgery? N Z Med J. 2017 Sep 1;130(1461):9-14. PubMed: PM28859061 16. Romero-Brufau S, Morlan BW, Johnson M, Hickman J, Kirkland LL, Naessens JM, et al. Evaluating automated rules for rapid response system alarm triggers in medical and surgical patients. J Hosp Med. 2017 Apr;12(4):217-23. PubMed: PM28411289 17. Subbe CP, Duller B, Bellomo R. Effect of an automated notification system for deteriorating ward patients on clinical outcomes. Crit Care. 2017 Mar 14;21(1):52. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc5348741 PubMed: PM28288655 18. Douw G, Huisman-de Waal G, van Zanten AR, van der Hoeven JG, Schoonhoven L. Nurses' 'worry' as predictor of deteriorating surgical ward patients: a prospective cohort study of the Dutch-Early-Nurse-Worry-Indicator-Score. Int J Nurs Stud. 2016 Jul;59:134-40. PubMed: PM27222458 SUMMARY OF ABSTRACTS Tools for the Early Identification of Adult Inpatients at Risk for Deterioration 7

19. Hollis RH, Graham LA, Lazenby JP, Brown DM, Taylor BB, Heslin MJ, et al. A Role for the early warning score in early identification of critical postoperative complications. Ann Surg. 2016 May;263(5):918-23. PubMed: PM26692076 20. Kang MA, Churpek MM, Zadravecz FJ, Adhikari R, Twu NM, Edelson DP. Real-time risk prediction on the wards: a feasibility study. Crit Care Med. 2016 Aug;44(8):1468-73. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4949091 PubMed: PM27075140 21. Smith GB, Prytherch DR, Jarvis S, Kovacs C, Meredith P, Schmidt PE, et al. A Comparison of the ability of the physiologic components of medical emergency team criteria and the U.K. National Early Warning Score to discriminate patients at risk of a range of adverse clinical outcomes. Crit Care Med. 2016 Dec;44(12):2171-81. PubMed: PM27513547 22. Smith HJ, Pasko DN, Haygood CL, Boone JD, Harper LM, Straughn JM, Jr. Early Warning Score: an indicator of adverse outcomes in postoperative patients on a gynecologic oncology service. Gynecol Oncol. 2016 Oct;143(1):105-8. PubMed: PM27507186 23. Capan M, Ivy JS, Rohleder T, Hickman J, Huddleston JM. Individualizing and optimizing the use of Early Warning Scores in acute medical care for deteriorating hospitalized patients. Resuscitation. 2015 Aug;93:107-12. PubMed: PM25597507 24. Ludikhuize J, Brunsveld-Reinders AH, Dijkgraaf MG, Smorenburg SM, de Rooij SE, Adams R, et al. Outcomes associated with the nationwide introduction of rapid response systems in The Netherlands. Crit Care Med. 2015 Dec;43(12):2544-51. PubMed: PM26317569 25. Mathukia C, Fan W, Vadyak K, Biege C, Krishnamurthy M. Modified Early Warning System improves patient safety and clinical outcomes in an academic community hospital. J Community Hosp Intern Med Perspect. 2015;5(2):26716. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4387337 PubMed: PM25846353 26. Yoo JW, Lee JR, Jung YK, Choi SH, Son JS, Kang BJ, et al. A combination of Early Warning Score and lactate to predict intensive care unit transfer of inpatients with severe sepsis/septic shock. Korean J Intern Med. 2015 Jul;30(4):471-7. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4497334 PubMed: PM26161013 27. Churpek MM, Yuen TC, Winslow C, Robicsek AA, Meltzer DO, Gibbons RD, et al. Multicenter development and validation of a risk stratification tool for ward patients. Am J Respir Crit Care Med. 2014 Sep 15;190(6):649-55. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4214112 PubMed: PM25089847 SUMMARY OF ABSTRACTS Tools for the Early Identification of Adult Inpatients at Risk for Deterioration 8

28. Ludikhuize J, Borgert M, Binnekade J, Subbe C, Dongelmans D, Goossens A. Standardized measurement of the Modified Early Warning Score results in enhanced implementation of a Rapid Response System: a quasi-experimental study. Resuscitation. 2014 May;85(5):676-82. PubMed: PM24561029 29. Petersen JA, Mackel R, Antonsen K, Rasmussen LS. Serious adverse events in a hospital using Early Warning Score - what went wrong? Resuscitation. 2014 Dec;85(12):1699-703. PubMed: PM25238741 30. Churpek MM, Yuen TC, Edelson DP. Risk stratification of hospitalized patients on the wards. Chest. 2013 Jun;143(6):1758-65. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3673668 PubMed: PM23732586 31. Hands C, Reid E, Meredith P, Smith GB, Prytherch DR, Schmidt PE, et al. Patterns in the recording of vital signs and Early Warning Scores: compliance with a clinical escalation protocol. BMJ Qual Saf. 2013 Sep;22(9):719-26. PubMed: PM23603474 32. Churpek MM, Yuen TC, Huber MT, Park SY, Hall JB, Edelson DP. Predicting cardiac arrest on the wards: a nested case-control study. Chest. 2012 May;141(5):1170-6. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3342781 PubMed: PM22052772 33. Churpek MM, Yuen TC, Park SY, Meltzer DO, Hall JB, Edelson DP. Derivation of a cardiac arrest prediction model using ward vital signs*. Crit Care Med. 2012 Jul;40(7):2102-8. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3378796 PubMed: PM22584764 Economic Evaluations 34. Murphy A, Cronin J, Whelan R, Drummond FJ, Savage E, Hegarty J. Economics of Early Warning Scores for identifying clinical deterioration-a systematic review. Ir J Med Sci. 2017 Jun 3. PubMed: PM28580508 Clinical Practice Guidelines Methodology Not Specified 35. Royal College of Physicians. National early warning score (NEWS) [Internet]. London (UK): Royal College of Physicians; 2015 [cited 2017 Sep 29]. Available from: https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news 36. SIGN. Care of deteriorating patients [Internet]. Edinburgh, Scotland: Scottish Intercollegiate Guidelines Network (SIGN); 2014 May [cited 2017 Sep 29]. Available from: http://www.sign.ac.uk/sign-139-care-of-deteriorating-patients.html Full-text available: http://www.sign.ac.uk/assets/sign139.pdf See: 2.2 NATIONAL EARLY WARNING SCORE, page 2 SUMMARY OF ABSTRACTS Tools for the Early Identification of Adult Inpatients at Risk for Deterioration 9

Review Articles 37. Le Lagadec MD, Dwyer T. Scoping review: The use of early warning systems for the identification of in-hospital patients at risk of deterioration. Aus Crit Care; 2017 Jul;30(4):211-218.. PubMed: PM27863876 38. McGaughey J, O'Halloran P, Porter S, Blackwood B. Early Warning Systems and rapid response to the deteriorating patient in hospital: a systematic realist review. J Adv Nurs. 2017 Jul 20. PubMed: PM28727184 39. NICE. EarlySense for heart and respiratory monitoring and predicting patient deterioration [Internet]. London (UK): NICE; 2017 [cited 2017 Sep 29]. (Medtech innovation briefing [MIB49]). Available from: https://www.nice.org.uk/advice/mib49 40. NICE. VitalPac for assessing vital signs of patients in hospital [Internet]. London (UK): NICE; 2016 [cited 2017 Sep 29]. (Medtech innovation briefing [MIB79]). Available from: https://www.nice.org.uk/guidance/mib79/resources/vitalpac-for-assessing-vital-signs-ofpatients-in-hospital-pdf-63499355857861 41. Quinn AC, Meek T, Waldmann C. Obstetric Early Warning Systems to prevent bad outcome. Curr Opin Anaesthesiol. 2016 Jun;29(3):268-72. PubMed: PM27031791 42. Roney JK, Whitley BE, Maples JC, Futrell LS, Stunkard KA, Long JD. Modified early warning scoring (MEWS): evaluating the evidence for tool inclusion of sepsis screening criteria and impact on mortality and failure to rescue. J Clin Nurs. 2015 Dec;24(23-24):3343-54. PubMed: PM26780181 43. Mapp ID, Davis LL, Krowchuk H. Prevention of unplanned intensive care unit admissions and hospital mortality by early warning systems. Dimens Crit Care Nurs. 2013 Nov-Dec;32(6):300-9. PubMed: PM24100432 Additional References 44. Giuliano KK. Improving Patient Safety through the Use of Nursing Surveillance. Biomed Instrum Technol. 2017 Feb;51(s2):34-43. PubMed: PM28296456 45. Royal College of Physicians. National early warning score (NEWS): working party report [Internet]. London (UK): Royal College of Physicians; 2015 May [cited 2017 Sep 29]. Available from: https://www.rcplondon.ac.uk/projects/outputs/national-early-warningscore-news SUMMARY OF ABSTRACTS Tools for the Early Identification of Adult Inpatients at Risk for Deterioration 10