OBJECTIVE To provide an overview and critical appraisal of early warning scores for adult hospital patients. DESIGN Systematic review. DATA SOURCES Medline, CINAHL, PsycInfo, and Embase until June 2019. ELIGIBILITY CRITERIA FOR STUDY SELECTION Studies describing the development or external validation of an early warning score for adult hospital inpatients. RESULTS 13 171 references were screened and 95 articles were included in the review. 11 studies were development only, 23 were development and external validation, and 61 were external validation only. Most early warning scores were developed for use in the United States (n=13/34, 38%) and the United Kingdom (n=10/34, 29%). Death was the most frequent prediction outcome for development studies (n=10/23, 44%) and validation studies (n=66/84, 79%), with different time horizons (the most frequent was 24 hours). The most common predictors were respiratory rate (n=30/34, 88%), heart rate (n=28/34, 83%), oxygen saturation, temperature, and systolic blood pressure (all n=24/34, 71%). Age (n=13/34, 38%) and sex (n=3/34, 9%) were less frequently included. Key details of the analysis populations were often not reported in development studies (n=12/29, 41%) or validation studies (n=33/84, 39%). Small sample sizes and insufficient numbers of event patients were common in model development and external validation studies. Missing data were often discarded, with just one study using multiple imputation. Only nine of the early warning scores that were developed were presented in sufficient detail to allow individualised risk prediction. Internal validation was carried out in 19 studies, but recommended approaches such as bootstrapping or cross validation were rarely used (n=4/19, 22%). Model performance was frequently assessed using discrimination (development n=18/22, 82%; validation n=69/84, 82%), while calibration was seldom assessed (validation n=13/84, 15%). All included studies were rated at high risk of bias. CONCLUSIONS Early warning scores are widely used prediction models that are often mandated in daily clinical practice to identify early clinical deterioration in hospital patients. However, many early warning scores in clinical use were found to have methodological weaknesses. Early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care. Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017053324.

中文翻译：

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检测成人医院患者病情恶化的早期预警评分：方法的系统回顾和批判性评估。


目的 提供成人医院患者早期预警评分的概述和严格评估。设计 系统审查。数据来源 Medline、CINAHL、PsycInfo 和 Embase 截至 2019 年 6 月。 研究选择的资格标准 研究描述成人医院住院患者早期预警评分的制定或外部验证。结果 筛选了 13 171 篇参考文献，95 篇文章纳入综述。 11 项研究仅用于开发，23 项研究用于开发和外部验证，61 项研究仅用于外部验证。大多数早期预警评分是为美国（n=13/34，38%）和英国（n=10/34，29%）开发的。死亡是发展研究（n=10/23，44%）和验证研究（n=66/84，79%）最常见的预测结果，具有不同的时间范围（最常见的是 24 小时）。最常见的预测因素是呼吸频率 (n=30/34, 88%)、心率 (n=28/34, 83%)、氧饱和度、体温和收缩压（全部 n=24/34, 71%） ）。年龄 (n=13/34, 38%) 和性别 (n=3/34, 9%) 较少被纳入。开发研究 (n=12/29, 41%) 或验证研究 (n=33/84, 39%) 中通常没有报告分析人群的关键细节。在模型开发和外部验证研究中，样本量小和事件患者数量不足是常见的情况。缺失的数据经常被丢弃，只有一项研究使用了多重插补。所制定的早期预警评分中，只有九个评分足够详细，可以进行个性化风险预测。 19 项研究进行了内部验证，但很少使用推荐的方法，例如自举或交叉验证（n=4/19，22%）。 经常使用歧视来评估模型性能（开发 n=18/22，82%；验证 n=69/84，82%），而很少评估校准（验证 n=13/84，15%）。所有纳入的研究均被评为具有高偏倚风险。结论 早期预警评分是广泛使用的预测模型，通常在日常临床实践中强制要求，以识别医院患者的早期临床恶化。然而，许多临床使用的早期预警评分被发现存在方法学上的弱点。早期预警评分可能不会达到预期效果，因此可能会对患者护理产生不利影响。未来的工作应侧重于遵循推荐的方法来制定和评估早期预警评分，并调查在临床实践中使用这些评分的影响和安全性。系统审查注册 PROSPERO CRD42017053324。