Investigation of the Relationship between Early Warning Scores and Clinical Course in Patients Presenting to the Emergency Department with Hematuria

Abstract

This study aimed to investigate the relationship between the the Modified Early Warning Score, the National Early Warning Score 2, the Rapid Emergency Medicine Score (REMS), and the Emergency Department Triage Early Warning Score, and shock index at presentation to the emergency department in patients with hematuria presenting to the emergency department, and mortality on days 28 and 90. Patients presenting with hematuria to a single-center, tertiary emergency department were retrospectively analyzed. Mortality on days 28 and 90 after the emergency department discharge was analyzed. A total of 179 patients were included in the study. The median age of the patients was 69 years [Inter Quartile Range (IQR), 25-75: 61-79)], and 137 (76.5%) were male. In the receiver operating characteristic analysis (ROC) performed for the 28- and 90-day mortality prediction values of the patients, only the REMS score was found to be statistically significant. The area under the curve (AUC) value of the REMS score for 28-day mortality prediction was 0.740 [95% Confidence interval (CI) (0.538-0.943)], (p<0.05), and the AUC value of the REMS score for 90-day mortality prediction was 0.685 [(95% CI 0.541-0.828), (p<0.05)]. When the REMS score was set at a cutoff value of 6.5 for 28-day mortality prediction, the sensitivity was 71.4% and the specificity was 73.3%. When the cutoff value was set at 5.5 for 90-day mortality prediction, the sensitivity was 90.9% and the specificity was 45.2%. We found that REMS is superior to other early warning scores in predicting short- and medium-term mortality. These findings support the routine use of REMS in emergency departments, contributing to timely and effective intervention for patients at high risk of mortality.

Keywords

• Early Warning Scores
• Hematuria
• Mortality

Acil Servise Hematüri ile Başvuran Hastalarda Erken Uyarı Skorları ile Klinik Seyir Arasındaki İlişkinin Araştırılması

Abstract

Bu çalışmanın amacı, acil servise başvuran hematürili hastalarda başvuru esnasında, Modified Early Warning Skor, National Early Warning Skor 2, Rapid Emergency Medicine Skor (REMS), Emergency Department Triage Early Warning Skorları ve şok indeksinin ile bu hastalarda 28. ve 90. günlerde meydana gelen mortalite durumu arasındaki ilişkiyi araştırmaktır. Tek merkezli, 3. basamak bir acil servise hematüri ile başvuran hastalar retrospektif olarak incelendi. Acil servis sonlanımından sonra 28. ve 90. Günlerdeki mortalite durumları incelendi. Çalışmaya toplam 179 hasta dahil edildi. Hastaların, ortanca yaşı 69 [Inter Quartile Range (IQR) ,25-75: 61-79] yıl ve 137’si (%76,5) erkek olarak saptandı. Hastaların, 28 ve 90 günlük mortalite tahmini değerleri için yapılan receiver operating characteristic (ROC) analizinde sadece REMS skorunun istatistiksel olarak anlamlı olduğu saptandı. 28 günlük mortalite tahmini için REMS skorunun eğri altındaki alan (AUC) değeri, 0,740 [%95 Güven Aralığı (GA) (0,538-0,943), (p<0,05)], 90 günlük mortalite tahmini için REMS skorunun AUC değeri, 0,685 [(%95 GA 0,541-0,828), (p<0,05)] olarak saptandı. REMS skorunun 28 günlük mortalite tahmininde kesim değeri 6,5 olduğunda sensitivitesi %71,4, spesifitesi %73,3, 90 günlük mortalite tahmininde ise kesim değeri 5,5 olduğunda sensitivitesi %90,9, spesifitesi %45,2 olarak saptandı. REMS’ in kısa ve orta vadeli mortaliteyi öngörmede diğer erken uyarı skorlarından üstün olduğunu saptadık. Bu bulgular, REMS’ in acil servislerde rutin kullanımını destekleyerek, yüksek mortalite riski taşıyan hastaların zamanında ve etkili müdahale almasına katkı sağlayabilir.

Keywords

• Erken Uyarı Skorları
• Hematüri
• Mortalite

References

1. 1. Choi H, Kim DW, Jung E, et al. Impact of intravesical administration of tranexamic acid on gross hematuria in the emergency department: A before-and-after study. Am J Emerg Med. 2023;68:68-72.
2. 2. Gross and Microscopic Hematuria [Internet]. [17 Haziran 2025]. Erişim adresi: https://www.ncbi.nlm.nih.gov/books/ NBK534213/
3. 3. Delanghe J, Speeckaert M, Delanghe S, Oyaert M. Pitfalls in the diagnosis of hematuria. Clin Chem Lab Med. 2023;61(8):1382-1387.
4. 4. Bolenz C, Schröppel B, Eisenhardt A, Schmitz-Dräger BJ, Grimm MO. The Investigation of Hematuria. Dtsch Arztebl Int. 2018;115(48):801-807.
5. 5. Yecies T, Bandari J, Macleod L, et al. Evaluation of the Risks and Benefits of Computed Tomography Urography for Assessment of Gross Hematuria. Urology. 2019;133:40-45.
6. 6. Ragonese M, Fettucciari D, Carbone L, et al. Predictive Factors for Major Complications and Urological Cancer Diagnosis in Older Adults (≥ 80 Years) Admitted to the Emergency Department for Hematuria. J Clin Med. 2024;13(10):2874.
7. 7. Nørgaard M, Farkas DK, Pedersen L, et al. Evaluation of Hospital-Based Hematuria Diagnosis and Subsequent Cancer Risk Among Adults in Denmark. JAMA Netw Open. 2018;1(7):e184909.
8. 8. Pavithran A, Bhatt NR, Banerjee G, Hawizy A. Management of Inpatient Macroscopic Haematuria: A Typical Urology Emergency With a High Mortality. Urology. 2022;166:22-28.

9. 9. Doğan N, Özturan İ U, Pekdemir M, Yaka E, Yılmaz S. Prognostic value of early warning scores in patients presenting to the emergency department with exacerbation of COPD. Med Klin Intensivmed Notfmed. 2024;119(2):129-135.
10. 10. Alhmoud B, Bonnici T, Patel R, et al. Performance of universal early warning scores in different patient subgroups and clinical settings: a systematic review. BMJ Open. 2021;11(4):e045849.
11. 11. Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified Early Warning Score in medical admissions. Qjm. 2001;94(10):521-526.
12. 12. Tapsiz H, Yolcu S, Yilmaz N, et al. Comparison of national early warning score-2 and qSOFA in predicting the prognosis of older adults with altered mental status. Ir J Med Sci. 2023;192(3):1355-1359.
13. 13. Imhoff BF, Thompson NJ, Hastings MA, et al. Rapid Emergency Medicine Score (REMS) in the trauma population: a retrospective study. BMJ Open. 2014;4(5):e004738.
14. 14. Lee SB, Kim DH, Kim T, et al. Emergency Department Triage Early Warning Score (TREWS) predicts in-hospital mortality in the emergency department. Am J Emerg Med. 2020;38(2):203-210.
15. 15. Allgöwer M, Burri C. ["Shock index"]. Dtsch Med Wochenschr. 1967;92(43):1947-1950.
16. 16. Rossaint R, Afshari A, Bouillon B, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care. 2023;27(1):80.
17. 17. Usman OA, Usman AA, Ward MA. Comparison of SIRS, qSOFA, and NEWS for the early identification of sepsis in the emergency department. Am J Emerg Med. 2019;37(8):1490-1497.
18. 18. Smith GB, Prytherch DR, Meredith P, Schmidt PE, Featherstone PI. The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death. Resuscitation. 2013;84(4):465-470.
19. 19. Churpek MM, Snyder A, Han X, et al. Quick Sepsis-related Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and Early Warning Scores for detecting clinical deterioration in infected patients outside the ICU. Am J Respir Crit Care Med. 2017;195(7):906-911.
20. 20. Brajkovic M, Vukcevic M, Nikolic S, et al. The Predictive Value of Risk Factors and Prognostic Scores in Hospitalized COVID-19 Patients. Diagnostics (Basel). 2023;13(16):2653.
21. 21. Bulut M, Cebicci H, Sigirli D, et al. The comparison of modified early warning score with rapid emergency medicine score: a prospective multicentre observational cohort study on medical and surgical patients presenting to emergency department. Emerg Med J. 2014;31(6):476-481.
22. 22. Ruangsomboon O, Boonmee P, Limsuwat C, Chakorn T, Monsomboon A. The utility of the rapid emergency medicine score (REMS) compared with SIRS, qSOFA and NEWS for Predicting in-hospital Mortality among Patients with suspicion of Sepsis in an emergency department. BMC Emerg Med. 2021;21(1):2.
23. 23. Keski C, Yüksel M, Şensoy B, et al. Investigation of the Efficacy of Risk Scoring Systems on Prognosis in Patients with STEMI Presenting to the Emergency Department. Eurasian J Emerg Med. 2024;23(4): 242-50.
24. 24.Aygun H, Eraybar S. The role of emergency department triage early warning score (TREWS) and modified early warning score (MEWS) to predict in-hospital mortality in COVID-19 patients. Ir J Med Sci. 2022;191(3):997-1003.
25. 25.Rady MY, Rivers EP, Nowak RM. Resuscitation of thecritically ill in the ED: responses of blood pressure, heart rate,shock index, central venous oxygen saturation, and lactate. AmJ Emerg Med. 1996;14(2):218-225.
26. 26.Xu F, Zhang L, Huang T, et al. Effects of growth trajectory ofshock index within 24 h on the prognosis of patients withsepsis. Front Med (Lausanne). 2022;9:898424.