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Combination of the National Early Warning Score (NEWS) and inflammatory biomarkers for early risk stratification in emergency department patients: results of a multinational, observational study
  1. Andreas Eckart1,
  2. Stephanie Isabelle Hauser1,
  3. Alexander Kutz1,
  4. Sebastian Haubitz1,2,
  5. Pierre Hausfater3,4,
  6. Devendra Amin5,
  7. Adina Amin5,
  8. Andreas Huber6,
  9. Beat Mueller1,7,
  10. Philipp Schuetz1,7
  1. 1 Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
  2. 2 Division of Infectious Diseases, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
  3. 3 Emergency Departement, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
  4. 4 Sorbonne Universités UPMC-Univ Paris 06, UMRS INSERM 1166, IHUC ICAN, Paris, France
  5. 5 Morton Plant Hospital, Clearwater, Florida, USA
  6. 6 Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
  7. 7 Medical Faculty, University of Basel, Basel, Switzerland
  1. Correspondence to Andreas Eckart; eckartan{at}


Objectives The National Early Warning Score (NEWS) helps to estimate mortality risk in emergency department (ED) patients. This study aimed to investigate whether the prognostic value of the NEWS at ED admission could be further improved by adding inflammatory blood markers (ie, white cell count (WCC), procalcitonin (PCT) and midregional-proadrenomedullin (MR-proADM).

Design Secondary analysis of a multinational, observational study (TRIAGE study, March 2013–October 2014).

Setting Three tertiary care centres in France, Switzerland and the USA.

Participants A total of 1303 adult medical patients with complete NEWS data seeking ED care were included in the final analysis. NEWS was calculated retrospectively based on admission data.

Main outcome measures The primary outcome was all-cause 30-day mortality. Secondary outcome was intensive care unit (ICU) admission. We used multivariate regression analyses to investigate associations of NEWS and blood markers with outcomes and area under the receiver operating curve (AUC) as a measure of discrimination.

Results Of the 1303 included patients, 54 (4.1%) died within 30 days. The NEWS alone showed fair prognostic accuracy for all-cause 30-day mortality (AUC 0.73), with a multivariate adjusted OR of 1.26 (95% CI 1.13 to 1.40, p<0.001). The AUCs for the prediction of mortality using the inflammatory markers WCC, PCT and MR-proADM were 0.64, 0.71 and 0.78, respectively. Combining NEWS with all three blood markers or only with MR-proADM clearly improved discrimination with an AUC of 0.82 (p=0.002). Combining the three inflammatory markers with NEWS improved prediction of ICU admission (AUC 0.70vs0.65 when using NEWS alone, p=0.006).

Conclusion NEWS is helpful in risk stratification of ED patients and can be further improved by the addition of inflammatory blood markers. Future studies should investigate whether risk stratification by NEWS in addition to biomarkers improve site-of-care decision in this patient population.

Trial registration number NCT01768494; Post-results.

  • risk management
  • internal medicine

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  • Patient consent for publication Not required.

  • AE and SIH contributed equally.

  • Contributors PS had complete access to all study data and takes full responsibility for the integrity of the data and the accuracy of the analyses. BM and PS were involved in the conceptualisation and design of the study. PH, DA, AA, AH and PS were responsible for the acquisition, analysis or interpretation of the data. AE, SIH and PS performed the statistical analyses and drafted the manuscript. AK and SH reviewed the draft and revised the manuscript for important intellectual content. All authors approved the final version of the manuscript and the decision to submit the manuscript for publication. AE and SIH contributed equally to this work.

  • Funding ThermoFisher provided an unrestricted research grant for the TRIAGE study. PS is supported by the Swiss National Science Foundation (SNSF Professorship, PP00P3_150531/1) and the Research Council of the Kantonsspital Aarau (1410.000.044).

  • Competing interests AK, BM, PH and PS have received research grants and support from BRAHMS AG (now ThermoFisher Scientific Biomarkers) and bioMérieux for attending meetings and fulfilling speaking engagements. BM has served as a consultant to both companies

  • Ethics approval Since it was an observational quality control study, the Institutional Review Boards (IRB) of the three hospitals approved the study and waived the need for individual informed consent (main Swiss IRB: Ethikkommission Kanton Aargau (EK 2012/059); French IRB: CCTIRS—Le Comité consultatif sur le traitement de l’information en matière de recherche (C.C.T.I.R.S.; CPP ID RCB: 2013-A00129-36); US IRB MPM-SAH Institutional Review Board, Clearwater Florida (IRB number 2013_005)).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Extra data can be accessed via the Dryad data repository at with the doi:10.5061/dryad.d22q6vh.