Article Text

Download PDFPDF
Determination of the best early warning scores to predict clinical outcomes of patients in the emergency department
  1. William Spencer1,
  2. Jesse Smith2,
  3. Patrick Date3,
  4. Erik de Tonnerre4,
  5. David McDonald Taylor5,6
  1. 1 Alfred Health, Melbourne, Victoria, Australia
  2. 2 Central Gippsland Health, Sale, Sydney, Victoria, Australia
  3. 3 Austin Hospital, Heidelberg, Victoria, Australia
  4. 4 Northern Sydney Local Health District, NSW Health, NSW, Australia
  5. 5 Emergency Department, Austin Health, Heidelberg, Victoria, Australia
  6. 6 Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
  1. Correspondence to Professor David McDonald Taylor, Emergency Department, Austin Health, Heidelberg, VIC 3084, Australia; david.taylor{at}


Objective Early warning scores (EWS) are used to predict patient outcomes. We aimed to determine which of 13 EWS, based largely on emergency department (ED) vital sign data, best predict important clinical outcomes.

Method We undertook a prospective cohort study in a metropolitan, tertiary-referral ED in Melbourne, Australia (February–April 2018). Patient demographics, vital signs and management data were collected while the patients were in the ED and EWS were calculated using each EWS criteria. Outcome data were extracted from the medical record (2-day, 7-day and 28-day inhospital mortality, clinical deterioration within 2 days, intensive care unit (ICU) admission within 2 days, admission to hospital). Area under the receiver operator characteristic (AUROC; 95% CIs) curves were used to evaluate the predictive ability of each EWS for each outcome.

Results Of 1730 patients enrolled, 690 patients were admitted to the study hospital. Most EWS were good or excellent predictors of 2-day mortality. When considering the point estimates, the VitalPac EWS was the most strongly predictive (AUROC: 0.96; 95% CI: 0.92 to 0.99). However, when considering the 95% CIs, there was no significant difference between the highest performing EWS. The predictive ability for 7-day and 28-day mortality was generally less. No EWS was a good predictor for clinical deterioration (AUROC range: 0.54–0.70), ICU admission (range: 0.51–0.72) or admission to hospital (range: 0.51–0.68).

Conclusion Several EWS have excellent predictive ability for 2-day mortality and have the potential to risk stratify patients in ED. No EWS adequately predicted clinical deterioration, admission to either ICU or the hospital.

  • emergency department
  • assessment
  • clinical management

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors DT and WS designed the study and obtained ethics committee approval. WS, JS, PD and EdeT collected all the data. WS managed the data collection and entry into the study database. DT and WS undertook all data analysis and preparation of the manuscript. All authors contributed to revision of the manuscript and approved the final version. DT supervised the study overall.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Ethics approval The Austin Health Human Research Ethics Committee, Heidelberg, Victoria, Australia, approved the study. Approval number: LNR17Austin454.

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

  • Patient consent for publication Not required.