Are Early Warning Scores Useful Predictors for Mortality and Morbidity in Hospitalised Acutely Unwell Older Patients? A Systematic Review

Romesh Jayasundera, Mark Neilly, Toby Smith, Phyo Myint* (Corresponding Author)

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

26 Citations (Scopus)
8 Downloads (Pure)


Background: Early warning scores (EWSs) are used to identify deteriorating patients for appropriate interventions. We performed a systematic review to examine the usefulness of EWSs in predicting inpatient mortality and morbidity (transfer to higher-level care and length of hospital stay) in older people admitted to acute medical units with sepsis, acute cardiovascular events, or pneumonia. Methods: A systematic review of published and unpublished databases was conducted. Cochrane′s tool for assessing Risk of Bias in Non-Randomised Studies—of Interventions (ROBINS-I) was used to appraise the evidence. A narrative synthesis was performed due to substantial heterogeneity. RESULTS: Five studies (n = 12,057) were eligible from 1033 citations. There was an overall “moderate” risk of bias for all studies. The predictive ability of EWSs regarding mortality was reported in one study (n = 274), suggesting EWSs were better at predicting survival, (negative predictive value >90% for all scores). Three studies (n = 1819) demonstrated a significant association between increasing modified EWSs (MEWSs) and increased risk of mortality. Hazards ratios for a composite death/intensive care (ICU) admission with MEWSs ≥5 were significant in one study (p = 0.003). Two studies (n = 1421) demonstrated that a MEWS ≥6 was associated with 21 times higher probability of mortality (95% Confidence Interval (CI): 2.71–170.57) compared with a MEWS ≤1. A MEWS of ≥5 was associated with 22 times higher probability of mortality (95% CI: 10.45–49.16). Conclusion: Increasing EWSs are strongly associated with mortality and ICU admission in older acutely unwell patients. Future research should be targeted at better understanding the usefulness of high and increasing EWSs for specific acute illnesses in older adults.
Original languageEnglish
Article number309
Number of pages11
JournalJournal of Clinical Medicine
Issue number10
Early online date28 Sept 2018
Publication statusPublished - 1 Oct 2018

Bibliographical note

Funding: No funding was gained to directly support the conduct of this study. Toby Smith is supported by funding from the National Institute for Health Research (NIHR) Oxford Health Biomedical Research Centre. The views expressed are those of the author(s) and not necessarily those of the NIHR.
Acknowledgments: We thank Samuel Ronald Neal who proofread the manuscript.


  • EWS
  • vital signs
  • geriatrics
  • older people
  • mortality
  • morbidity
  • critical care


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