Modified Early Warning Score as a predictor of severe adverse events in adult trauma patients: a retrospective cohort study

Delazeri, Núbia Araújo; Dias da Costa, Juvenal Soares

doi:10.1590/1983-1447.2025.20250067.en

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Original Article • Rev. Gaúcha Enferm. 46 • 2025 • https://doi.org/10.1590/1983-1447.2025.20250067.en linkcopy

Modified Early Warning Score as a predictor of severe adverse events in adult trauma patients: a retrospective cohort study

Modified Early Warning Score como predictor de eventos adversos graves en adultos traumatizados: cohorte retrospective

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective: To evaluate the performance of the Modified Early Warning Score (MEWS) in predicting severe adverse events (SAEs) in adult trauma patients.

Method: A retrospective cohort study was conducted in a trauma hospital between July and October 2022. Adult trauma inpatients were included. Demographic and clinical data, along with MEWS scores, were collected every 6 hours for 30 days. Performance was assessed at 6, 12, 18, and 24 hours prior to the outcome using ROC curves, sensitivity, specificity, predictive values, and likelihood ratios. The outcome was defined as an SAE (cardiac arrest, ICU admission, or death). The optimal cutoff point for prediction was determined.

Results: Medical records of 670 patients (mean age 49.4±21.3 years) were reviewed, with 20 (3%) requiring intensive care unit admission and no deaths. The best performance was observed within 6 hours prior to the outcome (AUC-ROC 0.86) at a cutoff of ≥4, with sensitivity of 80%, and specificity of 73%. Subgroup analyses indicated distinct optimal cutoff points.

Conclusion: MEWS demonstrated good predictive ability, particularly within six hours prior to the outcome, with a cutoff of ≥4, favoring early detection of clinical deterioration.

Keywords:
Early Warning Score; Clinical Deterioration; Trauma Centers; Trauma; Cohort Studies

	3	2	1	0	1	2	3
Systolic blood pressure (mmHg)	< 70	71-80	81-100	101-199		≥ 200
Heart rate (bpm)		≤ 40	41-50	51-100	101-110	111-129	≥ 130
Respiratory rate (breaths/min)		< 9		9-14	15-20	21-29	≥ 30
Temperature (ºC)		< 35		35-38.4		≥ 38.5
AVPU Score^*				Alert	Responds to Verbal stimulus	Responds to Pain	Unresponsive

Variables	n (%)	SAE^* incidence n (%)	RR^†	^‡ 95%CI	p-value
Sex					0.003^§
Male	458 (68.4)	7 (1.5)	1.0
Female	212 (31.6)	13 (6.1)	4.0	1.60 ; 10.06
Race/Ethnicity					0.114^§
White	529 (79.0)	19 (3.6)	1.0
Non-white	141 (21.0)	1 (0.7)	0.2	0.03 ; 1.48
Age					0.001^§
18-59 years	458 (68.4)	6 (1.3)	1.0
≥ 60 years	212 (31.6)	14 (6.6)	5.0	1.96 ; 12.94
Comorbidities					0.002^§
0-1	386 (57.6)	4 (1.0)	1.0
≥ 2	284 (42.4)	16 (5.6)	5.4	1.84 ; 16.10
Length of hospital stay					<0.0001^§
1-4 days	398 (59.4)	2 (0.5)	1.0
5-9 days	149 (22.2)	5 (3.4)	1.79	-0.01 ; 0.06

Parameters	MEWS^* 6h^†	MEWS^* 12h^†	MEWS^* 18h^†	MEWS^* 24h^†
Sensitivity (%)	80.00	57.89	40.00	63.16
Specificity (%)	72.99	77.51	74.55	73.18
PPV^‡ (%) (95%CI)	0.86 (0.03 ; 1.68)	1.67 (0.53 ; 2.80)	2.41 (1.01 ; 3.81)	1.65 (0.45 ; 2.86)
NPV^§ (%) (95%CI)	100.00 (100.00 ; 100.00)	100.00 (100.00 ; 100.00)	85.71 (82.53 ; 88.90)	100.00 (100.00 ; 100.00)
LR+^**	14.01	2.57	1.57	2.36
LR-^††	0.21	0.54	0.80	0.5034
AUC-ROC^‡‡ (95%CI)	0.86 (0.84 ; 0.89)	0.72 (0.68 ; 0.75)	0.58 (0.54 ; 0.62)	0.70 (0.67 ; 0.74)
p-value^***	<0.0001	<0.0001	<0.0001	<0.0001
Cutoff point^††† (^§§ 95%CI)	MEWS^* ≥ 4 (1.93 ; 2.42)	MEWS^* ≥ 3 (1.57 ; 1.93)	MEWS^* ≥ 3 (1.39 ; 1.71)	MEWS^* ≥ 3 (1.39 ; 1.72)

Variable/ category	Parameter	MEWS^* 6h^†	MEWS^* 12h^†	MEWS^* 18h^†	MEWS^* 24h^†
Sex: male	Sensitivity (%)	57.14	33.33	28.57	57.14
	Specificity (%)	99.78	96.48	76.92	74.38
	AUC-ROC^‡ (^§ 95%CI)	0.73 (0.69 ; 0.77)	0.60 (0.55 ; 0.65)	0.49 (0.44 ; 0.54)	0.69 (0.64 ; 0.73)
	p-value	<0.0001	<0.0001	<0.0001	<0.0001
	Cutoff point (^§ 95%CI)	MEWS^* ≥ 6 (2.27 ; 3.67)	MEWS^* ≥ 4 (2.06 ; 2.87)	MEWS^* ≥3 (1.41 ; 1.80)	MEWS^* ≥ 3 (1.47 ; 1.89)
Sex: female	Sensitivity (%)	92.31	69.23	46.15	67.67
	Specificity (%)	92.96	71.35	69.31	70.45
	AUC-ROC^‡ (^§ 95%CI)	0.93 (0.89 ; 0.96)	0.76 (0.69 ; 0.81)	0.62 (0.54 ; 0.68)	0.70 (0.63 ; 0.77)
	p-value	<0.0001	<0.0001	<0.0001	<0.0001
	Cutoff point (^§ 95%CI)	MEWS^* ≥ 4 (1.83 ; 2.75)	MEWS^* ≥ 3 (1.35 ; 1.94)	MEWS^* ≥ 3 (1.19 ; 1.71)	MEWS^* ≥ 3 (1.09 ; 1.59)
Age: adult	Sensitivity (%)	66.67	20.00	33.33	66.67
	Specificity (%)	99.78	100.00	100.00	72.29
	AUC-ROC^‡ (^§ 95%CI)	0.79 (0.75 ; 0.83)	0.52 (0.47 ; 0.57)	0.53 (0.48 ; 0.58)	0.73 (0.68 ; 0.77)
	p-value	<0.0001	<0.0001	p=0.031	p<0.0001
	Cutoff point (^§ 95%CI)	MEWS^* ≥ 6 (2.38 ; 3.96)	MEWS^* ≥ 6 (---)	MEWS^* ≥ 6 (0.47 ; 10.29)	MEWS^* ≥ 3 (1.35 ; 1.73)
Age: elderly	Sensitivity (%)	85.71	71.43	42.86	61.54
	Specificity (%)	92.39	73.96	70.74	75.14
	AUC-ROC^‡ (^§ 95%CI)	0.89 (0.84 ; 0.93)	0.78 (0.71 ; 0.83)	0.59 (0.52 ; 0.66)	0.70 (0.63 ; 0.76)
	p-value	< 0.0001	< 0.0001	< 0.0001	< 0.0001
	Cutoff point (^§ 95%CI)	MEWS^* ≥ 4 (1.74 ; 2.57)	MEWS^* ≥ 3 (1.34 ; 1.93)	MEWS^* ≥ 2 (1.33 ; 1.92)	MEWS^* ≥ 3 (1.30 ; 1.88)
Hospital stay: 1-4 days	Sensitivity (%)	83.33	50.00	33.33	80.00
	Specificity (%)	94.32	77.27	75.21	74.27
	AUC-ROC^‡ (^§ 95%CI)	0.88 (0.84 ; 0.90)	0.67 (0.62 ; 0.71)	0.56 (0.51 ; 0.61)	0.78 (0.74 ; 0.82)
	p-value	< 0.0001	< 0.0001	< 0.0001	< 0.0001
	Cutoff point (^§ 95%CI)	MEWS^* ≥ 4 (1.92 ; 2.48)	MEWS^* ≥ 3 (0.52 ; 1.92)	MEWS^* ≥ 3 (1.35 ; 1.71)	MEWS^* ≥ 3 (1.47 ; 1.86)
Hospital stay: ≥ 5 days	Sensitivity (%)	78.57	61.54	42.86	57.14
	Specificity (%)	94.16	78.36	72.18	69.47
	AUC-ROC^‡ (^§ 95%CI)	0.86 (0.79 ; 0.91)	0.74 (0.66 ; 0.81)	0.59 (0.50 ; 0.67)	0.66 (0.57 ; 0.73)
	p-value	< 0.0001	< 0.0001	< 0.0001	< 0.0001
	Cutoff point (^§ 95%CI)	MEWS^* ≥ 4 (1.60 ; 2.58)	MEWS^* ≥ 3 (1.42 ; 2.22)	MEWS^* ≥ 3 (1.27 ; 1.96)	MEWS^* ≥ 2 (1.00 ; 1.57)

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[TFN1] Source: Adapted from Subbe et al. 2001¹³.

[TFN2] ^*AVPU: Alert, Verbal, Pain, Unresponsive.