Resuscitation 84 (2013) 471–476 Contents lists available at ScienceDirect Resuscitation journal homepage: www.elsevier.com/locate/resuscitation Clinical paper Changes and their prognostic implications in the abbreviated VitalPAC TM Early Warning Score (ViEWS) after admission to hospital of 18,827 surgical patients  John Kellett a,∗ , Fei Wang c , Simon Woodworth b , Wendy Huang c a Thunder Bay Regional Health Sciences Center, Thunder Bay, Ontario, Canada b Health Information Systems Research Center, University College Cork, Ireland c Department of Mathematical Sciences, Lakehead University, Thunder Bay, Ontario, Canada article info Article history: Received 15 October 2012 Received in revised form 22 November 2012 Accepted 1 December 2012 Keywords: Early warning scores Surgery Rapid response systems abstract Background: It is not known how often, to what extent and over what time frame any early warning scores change in surgical patients, and what the implications of these changes are. Setting: Thunder Bay Regional Health Sciences Centre, Ontario, Canada. Methods: The changes in the first three recordings of the abbreviated version of the VitalPAC TM Early Warning Score (ViEWS) after admission to hospital of 18,827 surgical patients, and their relationship to subsequent in-hospital mortality were examined. Results: In the 2.0 SD 2.4 h between admission and the second recording the score changed in 12.6% of patients. If the initial abbreviated ViEWS was ≤2 points (78% of all patients) the in-hospital mortality was 0.5%, and not significantly different in the 3.7% of patients that either increased or decreased their score. Patients who had an initial score ≥3 had a significantly higher overall in-hospital mortality (odds ratio 5.48, Chi-square 120.72, p < 0.0001). Of these patients, those with a lower second score (42.3% of patients) had a significantly lower in-hospital mortality than those with an unchanged second score (i.e. 1.5% versus 3.3%, odds ratio 0.43, Chi-square 11.08, p < 0.001). Conclusion: The abbreviated ViEWS score measured on admission identifies the majority of surgical patients who are at low risk of in-hospital death. Patients with an initial abbreviated ViEWS ≥3 who do not reduce their score within 2–3 h of admission have a further significantly increased mortality. © 2012 Elsevier Ireland Ltd. All rights reserved. 1. Introduction In 1997 Morgan and colleagues described the first early warn- ing score system (EWS), designed to alert clinicians to deteriorating patients using aggregate weighted scoring of vital signs. 1 Stenhouse et al. evaluated a modified form of this score in 206 surgical patients over 9 months. 2 At the present time the EWS that predicts mor- tality within 24 h best is the internally and externally validated VitalPAC TM Early Warning Score (ViEWS) 3–5 on which the National Early Warning Score of the United Kingdom and the Republic of Ireland is based. 6  A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.12.002. ∗ Corresponding author at: Hospitalist Service, Thunder Bay Regional Health Sci- ences Center, 980 Oliver Road, Thunder Bay, Ontario, P78 7A5 Canada. Tel.: +1 807 684 6030; fax: +1 807 684 5894. E-mail address: jgkellett@eircom.net (J. Kellett). Despite evidence that physiological instability proceeds criti- cal clinical deterioration 7–10 early warning score systems alone cannot be expected to improve patient outcomes as there is no consensus on how to respond to elevation and/or changes in any of these scores. At present it is not known how often, to what extent and over what time frame early warning scores change, and what the implications of these changes are. Without this information it is impossible to develop rational treatment protocols on how to respond to them. An abbreviated version of ViEWS that does not include changes in mental function has a similar discrimination and performance to ViEWS. 5 We recently reported that there were no changes in the abbreviated ViEWS in the vast majority of acutely ill medical patients during the first few hours after their admission to hos- pital and that if changes did occur these changes carried little or no prognostic information. 11 It was not until the third abbreviated ViEWS recording that a change in score was clearly associated with a corresponding change in in-hospital mortality. In this study we have examined a large cohort of surgical patients to determine if changes in their abbreviated ViEWS after admission are similar to 0300-9572/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.resuscitation.2012.12.002