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：

---

用于检测成人医院患者病情恶化的预警评分：系统评价和方法学的严格评估。

目的对成年住院患者的预警评分进行概述和严格评估。设计系统评价。数据来源Medline，CINAHL，PsycInfo和Embase直至2019年6月。研究选择的资格标准研究描述了成人医院住院患者早期预警评分的发展或外部验证。结果筛选了13 171篇参考文献，其中95篇文章纳入评价。11项研究仅是开发，23项是开发和外部验证，61项仅是外部验证。大多数预警评分是针对美国（n = 13 / 34，38％）和英国（n = 10 / 34，29％）开发的。在发展研究（n = 10 / 23，44％）和验证研究（n = 66 / 84，79％）中，死亡是最常见的预测结果，具有不同的时间范围（最频繁的时间是24小时）。最常见的预测指标是呼吸频率（n = 30/34，88％），心率（n = 28/34，83％），血氧饱和度，体温和收缩压（所有n = 24/34，71％） ）。年龄（n = 13/34，38％）和性别（n = 3/34，9％）的频率较低。在开发研究（n = 12 / 29，41％）或验证研究（n = 33 / 84，39％）中，经常没有报告分析人群的关键细节。小样本量和事件患者人数不足在模型开发和外部验证研究中很常见。丢失的数据经常被丢弃，只有一项研究使用多重插补。所开发的早期预警评分中只有9种得到了足够详细的介绍，可以进行个性化的风险预测。内部验证在19个研究中进行，但是很少使用推荐的方法，例如自举或交叉验证（n = 4 / 19，22％）。经常使用辨别力评估模型性能（发展n = 18 / 22，82％；验证n = 69 / 84，82％），而很少评估校准（验证n = 13 / 84，15％）。所有纳入研究均被评定为偏倚风险高。结论预警评分是广泛使用的预测模型，通常在日常临床实践中必须使用该模型来识别住院患者的早期临床恶化。但是，发现许多临床使用的预警评分方法均存在不足。预警评分可能无法达到预期的效果，因此可能会对患者的护理产生不利影响。未来的工作应集中于遵循推荐的方法来开发和评估预警分数，并研究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。