Mortality, Clinical Deterioration, Geriatric Patients, Frailty, Emergency Department Visits
Conditions
Keywords
Early warning systems, geriatric patients, 28-day mortality, frailty
Brief summary
This prospective observational cohort study evaluated the prognostic performance of commonly used early warning scores for predicting 28-day all-cause mortality among geriatric patients presenting to the emergency department with non-traumatic conditions. Patients aged 65 years and older were consecutively screened during the study period. Demographic characteristics, comorbidities, vital signs, level of consciousness, blood gas parameters, complete blood count parameters, frailty status, and early warning scores were recorded at emergency department presentation or within the first hour of admission. The evaluated scoring systems included National Early Warning Score (NEWS/NEWS2), Modified Early Warning Score (MEWS), quick Sequential Organ Failure Assessment (qSOFA), Rapid Emergency Medicine Score (REMS), Cardiac Arrest Risk Triage (CART), and Hamilton Early Warning Score (HEWS) score. The primary outcome was 28-day all-cause mortality. The study also examined whether age, comorbidity burden, frailty, laboratory markers, and hemodynamic parameters were independently associated with 28-day mortality in this population.
Detailed description
Emergency departments are high-acuity clinical settings in which early recognition of patients at risk of deterioration is essential. Early warning scores are widely used to support risk stratification by converting abnormalities in physiological parameters into structured clinical scores. However, the prognostic performance of these tools may be limited in older adults because of age-related physiological changes, reduced physiological reserve, atypical clinical presentation, polypharmacy, and high comorbidity burden. This prospective, single-center observational cohort study was conducted in the emergency department of Haseki Training and Research Hospital, Istanbul, Türkiye. Consecutive patients aged 65 years and older who presented with non-traumatic conditions were screened for eligibility. Data were recorded in real time using a standardized case report form. The evaluated early warning scores included the National Early Warning Score, National Early Warning Score 2, Modified Early Warning Score, quick Sequential Organ Failure Assessment, Systemic Inflammatory Response Syndrome criteria, Rapid Emergency Medicine Score, Hamilton Early Warning Score, Triage Early Warning Score, Rapid Acute Physiology Score, and Cardiac Arrest Risk Triage score. The Clinical Frailty Scale was also assessed. The primary objective was to evaluate the ability of these scores to predict 28-day all-cause mortality. Secondary analyses assessed comparative score performance and explored whether advanced age, comorbidity burden, frailty, laboratory parameters, and hemodynamic variables were independently associated with mortality.
Interventions
Baseline demographic characteristics were recorded at emergency department presentation. These included age and sex. Age was analyzed as a continuous variable and was also considered clinically relevant because the study population consisted of geriatric patients aged 65 years and older.
OTHERComorbidities
Pre-existing comorbid conditions were recorded for each participant based on medical history and available clinical records at emergency department presentation. The assessed comorbidities included hypertension, diabetes mellitus, coronary artery disease, chronic kidney disease, heart failure, ischemic stroke, chronic obstructive pulmonary disease, and malignancy. Comorbidity status was evaluated as part of baseline clinical risk assessment.
OTHERVital Signs
Vital signs were measured at emergency department presentation or within the first hour after admission. The recorded vital signs included systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate, body temperature, and peripheral oxygen saturation when available. These parameters were used both as individual clinical variables and as components of early warning score calculations.
Initial laboratory parameters obtained during emergency department evaluation were recorded. These included blood gas parameters and complete blood count results. Laboratory variables were assessed as potential predictors of 28-day all-cause mortality and were also evaluated in relation to acute physiological deterioration and metabolic stress. Parameters included, pH, partial pressure of carbon dioxide (PaCO₂, mmHg), bicarbonate (HCO₃-, mmol/L), base excess (BE, mmol/L), leukocyte count (10³/µL), and lactate level (mmol/L).
OTHERSeverity Scores
Severity-related clinical scores, including Glasgow Coma Scale, quick Sequential Organ Failure Assessment, and Systemic Inflammatory Response Syndrome criteria, were calculated using data obtained at emergency department presentation or within the first hour after admission. These scores were used to assess acute illness severity and early clinical deterioration risk in geriatric emergency department patients.
Frailty status was assessed using the Clinical Frailty Scale at emergency department presentation. The Clinical Frailty Scale was used to evaluate baseline vulnerability and physiological reserve in older adults. Its association with 28-day all-cause mortality was examined as part of geriatric risk stratification.
OTHEREarly Warning Scores
Early warning scores were calculated for each participant using clinical data obtained at emergency department presentation or within the first hour after admission. These scores were evaluated for their ability to predict 28-day all-cause mortality among geriatric patients presenting to the emergency department with non-traumatic conditions. The prognostic performance of each score was assessed using receiver operating characteristic curve analysis and diagnostic performance measures. Scores included National Early Warning Score, National Early Warning Score 2, Modified Early Warning Score, Rapid Emergency Medicine Score, Cardiac Arrest Risk Triage score, Hamilton Early Warning Score, Triage Early Warning Score, and Rapid Acute Physiology Score.
Sponsors
Haseki Training and Research Hospital
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Participants will be eligible for inclusion if they meet all of the following criteria: * Age 65 years or older * Presentation to the emergency department during the study period * Non-traumatic emergency department presentation * Availability of clinical data required for early warning score calculation * Availability of 28-day follow-up data * Written informed consent provided by the patient or, when applicable, by a legal representative
Exclusion criteria
Participants will be excluded if they meet any of the following criteria: * Trauma-related presentation * Insufficient clinical data for calculation of early warning scores * Incomplete 28-day follow-up data * Presentation in cardiac arrest * Death within the first hour after emergency department presentation * Known hematologic malignancy * Presentation for palliative support only * Inability to obtain informed consent from the patient or a legal representative
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Discriminatory Performance of Early Warning Scores for 28-Day Mortality | At emergency department presentation, with outcome assessment at 28 days | The prognostic performance of each early warning score for predicting 28-day all-cause mortality will be evaluated using receiver operating characteristic curve analysis. The area under the curve will be calculated for each score, including NEWS, NEWS2, MEWS, qSOFA, SIRS, REMS, HEWS, TREWS, RAPS, and CART. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Effect of Frailty on 28-Day Mortality Prediction | At emergency department presentation, with outcome assessment at 28 days | Frailty will be assessed using the Clinical Frailty Scale, and its association with 28-day all-cause mortality will be evaluated. The incremental clinical relevance of frailty in geriatric risk stratification will also be explored. |
| Diagnostic Performance Measures of Early Warning Score Cut-Off Values | At emergency department presentation, with outcome assessment at 28 days | Sensitivity, specificity, positive predictive value, and negative predictive value will be calculated for relevant cut-off values of the evaluated early warning scores for predicting 28-day all-cause mortality. |
| Independent Predictors of 28-Day Mortality in Geriatric Emergency Department Patients | At emergency department presentation, with outcome assessment at 28 days | The independent association of demographic variables, comorbidities, frailty, vital signs, laboratory parameters, and early warning scores with 28-day all-cause mortality will be assessed using multivariable logistic regression analysis. |
Countries
Turkey (Türkiye)
Contacts
PRINCIPAL_INVESTIGATORAdem Az
Sultangazi Haseki Eğitim ve Araştırma Hastanesi, Başhekimlik
Outcome results
None listed