Medicina · 7 authors, 6 centres
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This retrospective study of 306 hospitalized COVID-19 patients in a Taiwanese tertiary hospital compared three early warning scores (MEWS, NEWS, REMS) for predicting in-hospital mortality. The Rapid Emergency Medicine Score (REMS) showed the highest discriminatory ability with an AUC of 0.773, outperforming NEWS (AUC 0.730) and MEWS (AUC 0.695). REMS may help emergency physicians rapidly identify high-risk COVID-19 patients using only bedside vital signs and age.
**Background:** During the COVID-19 pandemic, emergency departments were overloaded, and early warning scores (EWS) were used to identify high-risk patients for immediate intervention. The Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), and Rapid Emergency Medicine Score (REMS) are among the most studied EWS, but a direct comparison of their ability to predict in-hospital mortality in COVID-19 patients had not been reported. This study aimed to evaluate and compare the discriminatory ability of these three scores in COVID-19 patients admitted through the ED of a designated tertiary hospital in Taiwan.
**Methods:** This retrospective study was conducted at MacKay Memorial Hospital, a tertiary medical center in Taipei City, and conformed to TRIPOD guidelines. The study included adult (≥20 years) COVID-19 patients confirmed by PCR who were admitted to the ED and hospitalized between May 1 and July 31, 2021. Exclusion criteria included patients previously de-isolated from COVID-19, transferred from other hospitals, with out-of-hospital cardiac arrest (OHCA), or missing vital sign or demographic data. Data on age, sex, past medical history, and laboratory tests within 24 hours of admission were retrieved. MEWS, NEWS, and REMS were calculated from vital signs recorded at initial ED triage. The primary outcome was in-hospital mortality. Receiver operating characteristic (ROC) analysis was performed, and discriminatory performance was estimated using the area under the curve (AUC) calculated via the DeLong method. The optimal cut-off value was determined using the Youden Index. Statistical significance was defined as p < 0.05.
**Key Results:** Of 325 adult COVID-19 patients hospitalized during the study period, 306 were included after exclusions (OHCA n=1, previously de-isolated n=4, transferred n=5, missing data n=9). The mean age was 61.07 ± 15.12 years, 52.9% were male, and in-hospital mortality occurred in 35 patients (11.4%). Non-survivors were older (69.7 vs. 59.9 years, p < 0.05), more likely male (65.7% vs. 51.2%, p < 0.05), and had higher prevalence of hypertension (60% vs. 31%, p < 0.05), diabetes mellitus (43% vs. 23%, p < 0.05), coronary artery disease (26% vs. 9%, p < 0.05), heart failure (11% vs. 2%, p < 0.05), and chronic kidney disease (40% vs. 5%, p < 0.05). Non-survivors had lower GCS (13.8 vs. 14.7, p < 0.05), lower SpO2 (88.6% vs. 95.4%, p < 0.05), higher heart rate (103.2 vs. 92 bpm, p < 0.05), and higher respiratory rate (21.9 vs. 19.6 bpm, p < 0.05). All three EWS were significantly higher in non-survivors: REMS (8.46 vs. 4.87, p < 0.05), NEWS (6.06 vs. 3.25, p < 0.05), and MEWS (3.49 vs. 2.22, p < 0.05). REMS had the highest AUC (0.773, 95% CI: 0.692–0.854), followed by NEWS (0.730, 95% CI: 0.639–0.820) and MEWS (0.695, 95% CI: 0.597–0.792). The optimal cut-off for REMS was >6.5, yielding a sensitivity of 71.4%, specificity of 76.3%, PPV of 27.9%, and NPV of 95.4%. For NEWS, the optimal cut-off was >4.5 (sensitivity 60.0%, specificity 74.1%, PPV 23.0%, NPV 93.5%). For MEWS, the optimal cut-off was >3.5 (sensitivity 45.7%, specificity 83.8%, PPV 26.6%, NPV 92.3%).
**Clinical Implications:** This is the first study to directly compare MEWS, NEWS, and REMS for predicting in-hospital mortality in COVID-19 patients. REMS demonstrated superior discriminatory ability, likely because it incorporates both age and SpO2—two critical factors in COVID-19 prognosis. MEWS performed worst, possibly because it does not include SpO2, despite COVID-19 primarily affecting the respiratory system. NEWS performed intermediately; it includes SpO2 but not age. REMS can be calculated rapidly using only basic bedside vital signs and age, making it a practical tool for emergency physicians to identify high-risk COVID-19 patients for immediate intervention. Limitations include the retrospective single-center design, a relatively small cohort, and the fact that the study population had no complete vaccination (data collected in 2021 before widespread vaccination). Multi-center prospective studies are needed to validate these findings.