EWSs and 28-Day Mortality in Geriatric ED Patients (EWSsGer)

Performance of Different Early Warning Systems in Predicting 28-day Mortality Among Geriatric Emergency Department Patients

This prospective observational cohort study evaluated the prognostic performance of commonly used early warning scores for predicting 28-day all-cause mortality among geriatric patients presenting to the emergency department with non-traumatic conditions. Patients aged 65 years and older were consecutively screened during the study period. Demographic characteristics, comorbidities, vital signs, level of consciousness, blood gas parameters, complete blood count parameters, frailty status, and early warning scores were recorded at emergency department presentation or within the first hour of admission. The evaluated scoring systems included National Early Warning Score (NEWS/NEWS2), Modified Early Warning Score (MEWS), quick Sequential Organ Failure Assessment (qSOFA), Rapid Emergency Medicine Score (REMS), Cardiac Arrest Risk Triage (CART), and Hamilton Early Warning Score (HEWS) score. The primary outcome was 28-day all-cause mortality. The study also examined whether age, comorbidity burden, frailty, laboratory markers, and hemodynamic parameters were independently associated with 28-day mortality in this population.

Study Overview

• Status: Completed
• Conditions: Mortality; Frailty; Geriatric Patients; Clinical Deterioration; Emergency Department Visits
• Intervention / Treatment: Other: Demographic Characteristics; Other: Comorbidities; Other: Vital Signs; Other: Laboratory Parameters; Other: Severity Scores; Other: Clinical Frailty Scale; Other: Early Warning Scores

Detailed Description

Emergency departments are high-acuity clinical settings in which early recognition of patients at risk of deterioration is essential. Early warning scores are widely used to support risk stratification by converting abnormalities in physiological parameters into structured clinical scores. However, the prognostic performance of these tools may be limited in older adults because of age-related physiological changes, reduced physiological reserve, atypical clinical presentation, polypharmacy, and high comorbidity burden.

This prospective, single-center observational cohort study was conducted in the emergency department of Haseki Training and Research Hospital, Istanbul, Türkiye. Consecutive patients aged 65 years and older who presented with non-traumatic conditions were screened for eligibility. Data were recorded in real time using a standardized case report form. The evaluated early warning scores included the National Early Warning Score, National Early Warning Score 2, Modified Early Warning Score, quick Sequential Organ Failure Assessment, Systemic Inflammatory Response Syndrome criteria, Rapid Emergency Medicine Score, Hamilton Early Warning Score, Triage Early Warning Score, Rapid Acute Physiology Score, and Cardiac Arrest Risk Triage score. The Clinical Frailty Scale was also assessed.

The primary objective was to evaluate the ability of these scores to predict 28-day all-cause mortality. Secondary analyses assessed comparative score performance and explored whether advanced age, comorbidity burden, frailty, laboratory parameters, and hemodynamic variables were independently associated with mortality.

• Study Type: Observational
• Enrollment (Actual): 2744

Contacts and Locations

Study Locations

• Turkey (Türkiye)
  • Istanbul
    • Istanbul, Istanbul, Turkey (Türkiye), 34265
      • Haseki Training and Research Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Older Adult
• Accepts Healthy Volunteers: No

• Sampling Method: Probability Sample

Study Population

Patients aged 65 years and older presenting to the emergency department with non-traumatic conditions who met the eligibility criteria and had complete data for early warning score calculation and 28-day follow-up.

Description

Inclusion Criteria:

Participants will be eligible for inclusion if they meet all of the following criteria:

• Age 65 years or older
• Presentation to the emergency department during the study period
• Non-traumatic emergency department presentation
• Availability of clinical data required for early warning score calculation
• Availability of 28-day follow-up data
• Written informed consent provided by the patient or, when applicable, by a legal representative

Exclusion Criteria:

Participants will be excluded if they meet any of the following criteria:

• Trauma-related presentation
• Insufficient clinical data for calculation of early warning scores
• Incomplete 28-day follow-up data
• Presentation in cardiac arrest
• Death within the first hour after emergency department presentation
• Known hematologic malignancy
• Presentation for palliative support only
• Inability to obtain informed consent from the patient or a legal representative

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Survivors; Survivors were defined as eligible geriatric emergency department patients who remained alive within 28 days after the index emergency department presentation.	Other: Demographic Characteristics; Baseline demographic characteristics were recorded at emergency department presentation. These included age and sex. Age was analyzed as a continuous variable and was also considered clinically relevant because the study population consisted of geriatric patients aged 65 years and older.; Other: Comorbidities; Pre-existing comorbid conditions were recorded for each participant based on medical history and available clinical records at emergency department presentation. The assessed comorbidities included hypertension, diabetes mellitus, coronary artery disease, chronic kidney disease, heart failure, ischemic stroke, chronic obstructive pulmonary disease, and malignancy. Comorbidity status was evaluated as part of baseline clinical risk assessment.; Other: Vital Signs; Vital signs were measured at emergency department presentation or within the first hour after admission. The recorded vital signs included systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate, body temperature, and peripheral oxygen saturation when available. These parameters were used both as individual clinical variables and as components of early warning score calculations.; Other: Laboratory Parameters; Initial laboratory parameters obtained during emergency department evaluation were recorded. These included blood gas parameters and complete blood count results. Laboratory variables were assessed as potential predictors of 28-day all-cause mortality and were also evaluated in relation to acute physiological deterioration and metabolic stress. Parameters included, pH, partial pressure of carbon dioxide (PaCO₂, mmHg), bicarbonate (HCO₃-, mmol/L), base excess (BE, mmol/L), leukocyte count (10³/µL), and lactate level (mmol/L).; Other: Severity Scores; Severity-related clinical scores, including Glasgow Coma Scale, quick Sequential Organ Failure Assessment, and Systemic Inflammatory Response Syndrome criteria, were calculated using data obtained at emergency department presentation or within the first hour after admission. These scores were used to assess acute illness severity and early clinical deterioration risk in geriatric emergency department patients.; Other: Clinical Frailty Scale; Frailty status was assessed using the Clinical Frailty Scale at emergency department presentation. The Clinical Frailty Scale was used to evaluate baseline vulnerability and physiological reserve in older adults. Its association with 28-day all-cause mortality was examined as part of geriatric risk stratification.; Other: Early Warning Scores; Early warning scores were calculated for each participant using clinical data obtained at emergency department presentation or within the first hour after admission. These scores were evaluated for their ability to predict 28-day all-cause mortality among geriatric patients presenting to the emergency department with non-traumatic conditions. The prognostic performance of each score was assessed using receiver operating characteristic curve analysis and diagnostic performance measures. Scores included National Early Warning Score, National Early Warning Score 2, Modified Early Warning Score, Rapid Emergency Medicine Score, Cardiac Arrest Risk Triage score, Hamilton Early Warning Score, Triage Early Warning Score, and Rapid Acute Physiology Score.
Non-survivors; Non-survivors were defined as eligible geriatric emergency department patients who experienced all-cause mortality within 28 days after the index emergency department presentation.	Other: Demographic Characteristics; Baseline demographic characteristics were recorded at emergency department presentation. These included age and sex. Age was analyzed as a continuous variable and was also considered clinically relevant because the study population consisted of geriatric patients aged 65 years and older.; Other: Comorbidities; Pre-existing comorbid conditions were recorded for each participant based on medical history and available clinical records at emergency department presentation. The assessed comorbidities included hypertension, diabetes mellitus, coronary artery disease, chronic kidney disease, heart failure, ischemic stroke, chronic obstructive pulmonary disease, and malignancy. Comorbidity status was evaluated as part of baseline clinical risk assessment.; Other: Vital Signs; Vital signs were measured at emergency department presentation or within the first hour after admission. The recorded vital signs included systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate, body temperature, and peripheral oxygen saturation when available. These parameters were used both as individual clinical variables and as components of early warning score calculations.; Other: Laboratory Parameters; Initial laboratory parameters obtained during emergency department evaluation were recorded. These included blood gas parameters and complete blood count results. Laboratory variables were assessed as potential predictors of 28-day all-cause mortality and were also evaluated in relation to acute physiological deterioration and metabolic stress. Parameters included, pH, partial pressure of carbon dioxide (PaCO₂, mmHg), bicarbonate (HCO₃-, mmol/L), base excess (BE, mmol/L), leukocyte count (10³/µL), and lactate level (mmol/L).; Other: Severity Scores; Severity-related clinical scores, including Glasgow Coma Scale, quick Sequential Organ Failure Assessment, and Systemic Inflammatory Response Syndrome criteria, were calculated using data obtained at emergency department presentation or within the first hour after admission. These scores were used to assess acute illness severity and early clinical deterioration risk in geriatric emergency department patients.; Other: Clinical Frailty Scale; Frailty status was assessed using the Clinical Frailty Scale at emergency department presentation. The Clinical Frailty Scale was used to evaluate baseline vulnerability and physiological reserve in older adults. Its association with 28-day all-cause mortality was examined as part of geriatric risk stratification.; Other: Early Warning Scores; Early warning scores were calculated for each participant using clinical data obtained at emergency department presentation or within the first hour after admission. These scores were evaluated for their ability to predict 28-day all-cause mortality among geriatric patients presenting to the emergency department with non-traumatic conditions. The prognostic performance of each score was assessed using receiver operating characteristic curve analysis and diagnostic performance measures. Scores included National Early Warning Score, National Early Warning Score 2, Modified Early Warning Score, Rapid Emergency Medicine Score, Cardiac Arrest Risk Triage score, Hamilton Early Warning Score, Triage Early Warning Score, and Rapid Acute Physiology Score.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Discriminatory Performance of Early Warning Scores for 28-Day Mortality	The prognostic performance of each early warning score for predicting 28-day all-cause mortality will be evaluated using receiver operating characteristic curve analysis. The area under the curve will be calculated for each score, including NEWS, NEWS2, MEWS, qSOFA, SIRS, REMS, HEWS, TREWS, RAPS, and CART.	At emergency department presentation, with outcome assessment at 28 days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Diagnostic Performance Measures of Early Warning Score Cut-Off Values	Sensitivity, specificity, positive predictive value, and negative predictive value will be calculated for relevant cut-off values of the evaluated early warning scores for predicting 28-day all-cause mortality.	At emergency department presentation, with outcome assessment at 28 days
Independent Predictors of 28-Day Mortality in Geriatric Emergency Department Patients	The independent association of demographic variables, comorbidities, frailty, vital signs, laboratory parameters, and early warning scores with 28-day all-cause mortality will be assessed using multivariable logistic regression analysis.	At emergency department presentation, with outcome assessment at 28 days
Effect of Frailty on 28-Day Mortality Prediction	Frailty will be assessed using the Clinical Frailty Scale, and its association with 28-day all-cause mortality will be evaluated. The incremental clinical relevance of frailty in geriatric risk stratification will also be explored.	At emergency department presentation, with outcome assessment at 28 days

Collaborators and Investigators

• Sponsor: Haseki Training and Research Hospital
• Investigators: Principal Investigator: Adem Az, Sultangazi Haseki Eğitim ve Araştırma Hastanesi, Başhekimlik

Publications and helpful links

General Publications

• Covino M, Sandroni C, Della Polla D, De Matteis G, Piccioni A, De Vita A, Russo A, Salini S, Carbone L, Petrucci M, Pennisi M, Gasbarrini A, Franceschi F. Predicting ICU admission and death in the Emergency Department: A comparison of six early warning scores. Resuscitation. 2023 Sep;190:109876. doi: 10.1016/j.resuscitation.2023.109876. Epub 2023 Jun 17.
• Baeyens H, Haegdorens F, Martens S, Abeele MEV, Wallaert S, Van Den Noortgate N, Brys ADH. Validation and performance of a geriatric early warning score (GEWS) versus the national early warning score (NEWS) in predicting clinical deterioration in frail older patients. Eur Geriatr Med. 2026 Apr;17(2):615-627. doi: 10.1007/s41999-025-01316-7. Epub 2025 Oct 6.
• Kim I, Song H, Kim HJ, Park KN, Kim SH, Oh SH, Youn CS. Use of the National Early Warning Score for predicting in-hospital mortality in older adults admitted to the emergency department. Clin Exp Emerg Med. 2020 Mar;7(1):61-66. doi: 10.15441/ceem.19.036. Epub 2020 Mar 31.
• Gerry S, Bonnici T, Birks J, Kirtley S, Virdee PS, Watkinson PJ, Collins GS. Early warning scores for detecting deterioration in adult hospital patients: systematic review and critical appraisal of methodology. BMJ. 2020 May 20;369:m1501. doi: 10.1136/bmj.m1501.
• Guan G, Lee CMY, Begg S, Crombie A, Mnatzaganian G. The use of early warning system scores in prehospital and emergency department settings to predict clinical deterioration: A systematic review and meta-analysis. PLoS One. 2022 Mar 17;17(3):e0265559. doi: 10.1371/journal.pone.0265559. eCollection 2022.

Study record dates

Study Major Dates

• Study Start (Actual): July 1, 2025
• Primary Completion (Actual): January 29, 2026
• Study Completion (Actual): January 29, 2026

Study Registration Dates

• First Submitted: May 3, 2026
• First Submitted That Met QC Criteria: May 3, 2026
• First Posted (Actual): May 11, 2026

Study Record Updates

• Last Update Posted (Actual): May 11, 2026
• Last Update Submitted That Met QC Criteria: May 3, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Keywords: frailty; geriatric patients; 28-day mortality; Early warning systems
• Additional Relevant MeSH Terms: Pathologic Processes; Disease Attributes; Disease Progression; Pathological Conditions, Signs and Symptoms; Frailty; Clinical Deterioration; Organization and Administration; Health Services Administration; Health Care Quality, Access, and Evaluation; Investigative Techniques; Epidemiologic Methods; Data Collection; Health Care Evaluation Mechanisms; Quality of Health Care; Public Health; Environment and Public Health; Health Surveys; Surveys and Questionnaires; Records; Epidemiologic Factors; Severity of Illness Index; Patient Acuity; Health Status Indicators; Medical Records; Trauma Severity Indices; Comorbidity; Injury Severity Score; Early Warning Score
• Other Study ID Numbers: 01/2025

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Stored in non-publicly avaliableAvaliable on request

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No