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Performance of early warning and risk stratification scores versus clinical judgement in the acute setting: a systematic review
  1. Lars Ingmar Veldhuis1,2,
  2. Milan L Ridderikhof1,
  3. Lyfke Bergsma3,
  4. Faridi Van Etten-Jamaludin4,
  5. Prabath WB Nanayakkara5,
  6. Markus Hollmann2
  1. 1Emergency Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
  2. 2Anaesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
  3. 3Internal Medicine, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
  4. 4Clinical Library, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
  5. 5Section Acute Medicine, Department of Internal Medicine, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
  1. Correspondence to Dr Milan L Ridderikhof, Emergency Medicine, Amsterdam UMC - Locatie AMC, Amsterdam, 1105 AZ, Netherlands; m.l.ridderikhof{at}


Objective Risk stratification is increasingly based on Early Warning Score (EWS)-based models, instead of clinical judgement. However, it is unknown how risk-stratification models and EWS perform as compared with the clinical judgement of treating acute healthcare providers. Therefore, we performed a systematic review of all available literature evaluating clinical judgement of healthcare providers to the use of risk-stratification models in predicting patients’ clinical outcome.

Methods Studies comparing clinical judgement and risk-stratification models in predicting outcomes in adult patients presenting at the ED were eligible for inclusion. Outcomes included the need for intensive care unit (ICU) admission; severe adverse events; clinical deterioration and mortality. Risk of bias among the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool.

Results Six studies (6419 participants) were included of which 4 studies were judged to be at high risk of bias. Only descriptive analysis was performed as a meta-analysis was not possible due to few included studies and high clinical heterogeneity. The performance of clinical judgement and risk-stratification models were both moderate in predicting mortality, deterioration and need for ICU admission with area under the curves between 0.70 and 0.89. The performance of clinical judgement did not significantly differ from risk-stratification models in predicting mortality (n=2 studies) or deterioration (n=1 study). However, clinical judgement of healthcare providers was significantly better in predicting the need for ICU admission (n=2) and severe adverse events (n=1 study) as compared with risk-stratification models.

Conclusion Based on limited existing data, clinical judgement has greater accuracy in predicting the need for ICU admission and the occurrence of severe adverse events compared with risk-stratification models in ED patients. However, performance is similar in predicting mortality and deterioration.

PROSPERO registration number CRD42020218893.

  • emergency department
  • clinical management
  • risk management
  • care systems
  • clinical assessment

Data availability statement

Data are available on reasonable request. No data are available.

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Data availability statement

Data are available on reasonable request. No data are available.

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  • Handling editor Kirsty Challen

  • Contributors LIV designed, analysed, interpreted the data and draft the article and is guarantor for overall content. FVE-J performed the literature search. LB assisted in study selection and data extraction. All other authors revised critically for important intellectual content and helped with final version to be submitted.

  • 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.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.