Skip to main content

Main menu

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • COVID-19 submission information
    • Peer reviewer login
  • Alerts
  • Podcasts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • COVID-19 submission information
    • Peer reviewer login
  • Alerts
  • Podcasts
  • Subscriptions

A physiological–social score for triaging of pandemic influenza patients

K. Challen, J. Bright, A. Bentley, D. Walter
European Respiratory Journal 2006 28: 253-254; DOI: 10.1183/09031936.06.00025106
K. Challen
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
J. Bright
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
A. Bentley
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
D. Walter
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

To the Editors:

We read with interest the endorsement of “barefoot medicine” by Ewig et al. 1 in a recent issue of the European Respiratory Journal. As with Niederman et al. 2, we recognise the limitations of CURB-65 (confusion, urea >7 mmol·L−1, respiratory rate ≥30·min−1, low blood pressure, and aged ≥65 yrs) scoring but the importance of its simplicity and ease of use. As part of the planning for a potential H5N1 influenza pandemic, using Dept of Health and Health Protection Agency projections 3, we have been forced to acknowledge that our urban emergency department, which normally sees ∼250 patients·day−1, will see 450 excess attenders·day−1 with influenza symptoms at a pandemic peak. We aimed to develop a rapidly applicable, purely clinical scoring system for use in primary and secondary care, to identify those in need of hospital admission and to reassure those fit for discharge. We suggest that the ideal score should reflect acute physiological derangement, as well as accommodating age, comorbidities and social factors, and could be used to triage and track for admission, intensive care unit (ICU) treatment and mortality. We believe that our proposed system has gone some way towards addressing this.

We modified our hospital pandemic medical early warning score (PMEWS) 4 to include transcutaneous oxygen saturation. We also concur with Ewig et al. 1 and Niederman et al. 2 that comorbidities and social factors have to be taken into account when making admission and discharge decisions, and our score incorporates an extra point for being aged ≥65 yrs and another single point for any of the following: 1) social isolation (defined as living alone or having no fixed abode); 2) chronic disease (respiratory, cardiac, renal, diabetes mellitus or immunosuppression of any cause); or 3) performance status of limited activity or worse (modified Karnofsky >2 5).

The validation of 195 adult patients (101 aged <65 yrs) with a diagnosis of lower respiratory tract infection presenting to our emergency department (South Manchester University Hospitals Trust, Manchester, UK) between February and December 2005 showed good discrimination for the physiological section of the score, which was further improved by the addition of age and social factors. We retrospectively calculated PMEWS, CURB-65 and CRB-65 scores from emergency department medical and nursing notes, and constructed receiver-operating characteristics (ROC) curves for the prediction of admission (fig. 1⇓). PMEWS without the arterial oxygen saturation component is shown as we recognise that not all primary care providers will have access to a pulse oximeter.

Fig. 1—
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig. 1—

Receiver-operating characteristics curve for admission to hospital. Diagonal segments are produced by ties. ––––: pandemic medical early warning score (PMEWS) 0.953 (0.927–0.978); -----: PMEWS without arterial oxygen saturation 0.937 (0.906–0.967); – – –: CURB-65 (confusion, urea >7 mmol·L−1, respiratory rate ≥30·min−1, low blood pressure, and aged ·65 yrs) 0.858 (0.806–0.909); – - –: CRB-65 (confusion, respiratory rate ≥30·min−1, low blood pressure, and aged ≥65 yrs) 0.818 (0.760–0.877).

We extended this to assess the value of the PMEWS score in predicting requirements for higher levels of care. Figure 2⇓ shows the ROC curves for discrimination of need for high dependency or ICU care amongst 91 patients admitted with community-acquired pneumonia to our 855-bed secondary and tertiary care hospital from February to December 2005. A further number of patients (n = 19) were omitted from this analysis as invasive care and cardiopulmonary resuscitation were deemed inappropriate.

Fig. 2—
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig. 2—

Receiver-operating characteristics curve for admission to level 2/3 care. Diagonal segments are produced by ties. ––––: pandemic medical early warning score 0.856 (0.768–0.943); – – –: CURB-65 (confusion, urea >7 mmol·L−1, respiratory rate ≥30·min−1, low blood pressure, and aged ≥65 yrs) 0.667 (0.549–0.785); -----: CRB-65 (confusion, respiratory rate ≥30·min−1, low blood pressure, and aged ≥65 yrs) 0.631 (0.497–0.765).

We suggest that as the pandemic medical early warning score is not disease specific, it can provide a more accurate assessment of need for hospital admission, clinical deterioration and improvement, and will be a valuable track and triage tool in the event of an influenza pandemic. Further validation is ongoing.

    • © ERS Journals Ltd

    References

    1. ↵
      Ewig S, Torres A, Woodhead M. Assessment of pneumonia severity: a European perspective. Eur Respir J 2006;27:6–8.
      OpenUrlFREE Full Text
    2. ↵
      Niederman M, Feldman C, Richards G. Combining information from prognostic scoring tools for CAP: an American view on how to get the best of all worlds. Eur Respir J 2006;27:9–11.
      OpenUrlFREE Full Text
    3. ↵
      UK Health Departments. UK Influenza Pandemic Contingency Plan. London, Department of Health, 2005
    4. ↵
      Subbe C, Kruger M, Rutherford P, Gemmell L. Validation of a modified early warning score in medical admissions. Quarterly Journal of Medicine 2001;94:521–6.
      OpenUrlAbstract/FREE Full Text
    5. ↵
      British Thoracic Society Standards of Care Committee. Non-invasive ventilation in acute respiratory failure. Thorax 2002;57:192–211.
      OpenUrlFREE Full Text
    View Abstract
    PreviousNext
    Back to top
    View this article with LENS
    Vol 28 Issue 1 Table of Contents
    European Respiratory Journal: 28 (1)
    • Table of Contents
    • Index by author
    Email

    Thank you for your interest in spreading the word on European Respiratory Society .

    NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

    Enter multiple addresses on separate lines or separate them with commas.
    A physiological–social score for triaging of pandemic influenza patients
    (Your Name) has sent you a message from European Respiratory Society
    (Your Name) thought you would like to see the European Respiratory Society web site.
    CAPTCHA
    This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
    Print
    Citation Tools
    A physiological–social score for triaging of pandemic influenza patients
    K. Challen, J. Bright, A. Bentley, D. Walter
    European Respiratory Journal Jul 2006, 28 (1) 253-254; DOI: 10.1183/09031936.06.00025106

    Citation Manager Formats

    • BibTeX
    • Bookends
    • EasyBib
    • EndNote (tagged)
    • EndNote 8 (xml)
    • Medlars
    • Mendeley
    • Papers
    • RefWorks Tagged
    • Ref Manager
    • RIS
    • Zotero

    Share
    A physiological–social score for triaging of pandemic influenza patients
    K. Challen, J. Bright, A. Bentley, D. Walter
    European Respiratory Journal Jul 2006, 28 (1) 253-254; DOI: 10.1183/09031936.06.00025106
    del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
    Full Text (PDF)

    Jump To

    • Article
      • References
    • Figures & Data
    • Info & Metrics
    • PDF
    • Tweet Widget
    • Facebook Like
    • Google Plus One

    More in this TOC Section

    • Risk factors for disease progression in fibrotic hypersensitivity pneumonitis
    • Optimised surveillance of bronchial dysplasia in risky population
    • Reply: Risk factors for disease progression in fibrotic hypersensitivity pneumonitis
    Show more Correspondence

    Related Articles

    Navigate

    • Home
    • Current issue
    • Archive

    About the ERJ

    • Journal information
    • Editorial board
    • Reviewers
    • Press
    • Permissions and reprints
    • Advertising

    The European Respiratory Society

    • Society home
    • myERS
    • Privacy policy
    • Accessibility

    ERS publications

    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS books online
    • ERS Bookshop

    Help

    • Feedback

    For authors

    • Instructions for authors
    • Publication ethics and malpractice
    • Submit a manuscript

    For readers

    • Alerts
    • Subjects
    • Podcasts
    • RSS

    Subscriptions

    • Accessing the ERS publications

    Contact us

    European Respiratory Society
    442 Glossop Road
    Sheffield S10 2PX
    United Kingdom
    Tel: +44 114 2672860
    Email: journals@ersnet.org

    ISSN

    Print ISSN:  0903-1936
    Online ISSN: 1399-3003

    Copyright © 2023 by the European Respiratory Society