1 Beane A, et al. BMJ Open 2018;8:e019387. doi:10.1136/bmjopen-2017-019387 Open Access Evaluation of the feasibility and performance of early warning scores to identify patients at risk of adverse outcomes in a low-middle income country setting Abi Beane, 1,2,3 Ambepitiyawaduge Pubudu De Silva, 1,4,5 Nirodha De Silva, 6 Jayasingha A Sujeewa, 6 R M Dhanapala Rathnayake, 6 P Chathurani Sigera, 1,4 Priyantha Lakmini Athapattu, 4,7 Palitha G Mahipala, 8 Aasiyah Rashan, 1 Sithum Bandara Munasinghe, 1 Kosala Saroj Amarasiri Jayasinghe, 9 Arjen M Dondorp, 2 Rashan Haniffa 1,2,4 To cite: Beane A, De Silva AP, De Silva N, et al. Evaluation of the feasibility and performance of early warning scores to identify patients at risk of adverse outcomes in a low-middle income country setting. BMJ Open 2018;8:e019387. doi:10.1136/ bmjopen-2017-019387 ► Prepublication history and additional material for this paper are available online. To view these fles, please visit the journal online (http://dx.doi. org/10.1136/bmjopen-2017- 019387). Received 15 September 2017 Revised 10 January 2018 Accepted 22 January 2018 For numbered affliations see end of article. Correspondence to Dr Rashan Haniffa; rashan@nicslk.com Research ABSTRACT Objective This study describes the availability of core parameters for Early Warning Scores (EWS), evaluates the ability of selected EWS to identify patients at risk of death or other adverse outcome and describes the burden of triggering that front-line staff would experience if implemented. Design Longitudinal observational cohort study. Setting District General Hospital Monaragala. Participants All adult (age >17 years) admitted patients. Main outcome measures Existing physiological parameters, adverse outcomes and survival status at hospital discharge were extracted daily from existing paper records for all patients over an 8-month period. Statistical analysis Discrimination for selected aggregate weighted track and trigger systems (AWTTS) was assessed by the area under the receiver operating characteristic (AUROC) curve. Performance of EWS are further evaluated at time points during admission and across diagnostic groups. The burden of trigger to correctly identify patients who died was evaluated using positive predictive value (PPV). Results Of the 16 386 patients included, 502 (3.06%) had one or more adverse outcomes (cardiac arrests, unplanned intensive care unit admissions and transfers). Availability of physiological parameters on admission ranged from 90.97% (95% CI 90.52% to 91.40%) for heart rate to 23.94% (95% CI 23.29% to 24.60%) for oxygen saturation. Ability to discriminate death on admission was less than 0.81 (AUROC) for all selected EWS. Performance of the best performing of the EWS varied depending on admission diagnosis, and was diminished at 24 hours prior to event. PPV was low (10.44%). Conclusion There is limited observation reporting in this setting. Indiscriminate application of EWS to all patients admitted to wards in this setting may result in an unnecessary burden of monitoring and may detract from clinician care of sicker patients. Physiological parameters in combination with diagnosis may have a place when applied on admission to help identify patients for whom increased vital sign monitoring may not be benefcial. Further research is required to understand the priorities and cues that infuence monitoring of ward patients. Trial registration number NCT02523456. INTRODUCTION   Patients who suffer adverse events in hospital wards, such as cardiac arrest and death, often show changes in basic physiological parame- ters during the hours before the event. Based on this, Early Warning Scores (EWS) have been developed and widely implemented in high-income countries (HICs) with the aim of early identification of clinical deterioration. 1 Both aggregate weighted track and trigger systems (AWTTS) and single-parameter track and trigger systems (SPTTS) use physiological measures and other clinically significant vari- ables (eg, age) categorised and scored based on their degree of abnormality. 2 AWTTS use a range of parameters which are weighted and calculated to form a composite and often complex score. SPTTS, while often including more than one parameter, allow for a single parameter to act as an independent trigger. Although less well evaluated, SPTTS tend Strengths and limitations of this study ► Considers score feasibility in the context of re- al-world application. ► Large, diverse dataset for a low-income and mid- dle-income country setting. ► Single centre. ► No validation of the accuracy of the vital signs measured.