title: Modified Early Warning Score (MEWS) Identifies Critical Illness among Ward Patients in a Resource Restricted Setting in Kampala, Uganda: A Prospective Observational Study.
abstract: BACKGROUND
  Providing optimal critical care in developing countries is limited by lack of recognition of critical illness and lack of essential resources. The Modified Early Warning Score (MEWS), based on physiological parameters, is validated in adult medical and surgical patients as a predictor of mortality. The objective of this study performed in Uganda was to determine the prevalence of critical illness on the wards as defined by the MEWS, to evaluate the MEWS as a predictor of death, and to describe additional risk factors for mortality.
  
  
  METHODS
  We conducted a prospective observational study at Mulago National Referral Teaching Hospital in Uganda. We included medical and surgical ward patients over 18 years old, excluding patients discharged the day of enrolment, obstetrical patients, and patients who self-discharged prior to study completion. Over a 72-hour study period, we collected demographic and vital signs, and calculated MEWS; at 7-days we measured outcomes. Patients discharged prior to 7 days were assumed to be alive at study completion. Descriptive and inferential statistical analyses were performed.
  
  
  RESULTS
  Of 452 patients, the median age was 40.5 (IQR 29-54) years, 53.3% were male, 24.3% were HIV positive, and 45.1% had medical diagnoses. MEWS ranged from 0 to 9, with higher scores representing hemodynamic instability. The median MEWS was 2 [IQR 1-3] and the median length of hospital stay was 9 days [IQR 4-24]. In-hospital mortality at 7-days was 5.5%; 41.4% of patients were discharged and 53.1% remained on the ward. Mortality was independently associated with medical admission (OR: 7.17; 95% CI: 2.064-24.930; p = 0.002) and the MEWS ≥ 5 (OR: 5.82; 95% CI: 2.420-13.987; p<0.0001) in the multivariable analysis.
  
  
  CONCLUSIONS
  There is a significant burden of critical illness at Mulago Hospital, Uganda. Implementation of the MEWS could provide a useful triage tool to identify patients at greatest risk of death. Future research should include refinement of MEWS for low-resource settings, and development of appropriate interventions for patients identified to be at high risk of death based on early warning scores.
authors.affiliation: Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Kruisselbrink
authors.affiliation: Department of Anesthesia and Critical Care, Makerere University, Kampala, Uganda.
authors.forename: Arthur
authors.initials: A
authors.lastname: Kwizera
authors.affiliation: Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Mark
authors.initials: M
authors.lastname: Crowther
authors.affiliation: Department of Critical Care, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Alison
authors.initials: A
authors.lastname: Fox-Robichaud
authors.affiliation: Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Timothy
authors.initials: T
authors.lastname: O'Shea
authors.affiliation: Department of Medicine, Mulago Hospital, Kampala, Uganda.
authors.forename: Jane
authors.initials: J
authors.lastname: Nakibuuka
authors.affiliation: Department of Medicine, Makerere University, Kampala, Uganda.
authors.forename: Isaac
authors.initials: I
authors.lastname: Ssinabulya
authors.affiliation: Department of Medicine, Makerere University, Kampala, Uganda.
authors.forename: Joan
authors.initials: J
authors.lastname: Nalyazi
authors.affiliation: Department of Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Ashley
authors.initials: A
authors.lastname: Bonner
authors.affiliation: Department of Health Research Methodology, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Tahira
authors.initials: T
authors.lastname: Devji
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Wong
authors.affiliation: Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Deborah
authors.initials: D
authors.lastname: Cook
mesh_terms: D000328:Adult; D016638:Critical Illness / Q000401:mortality*; D042241:Early Diagnosis; D005260:Female; D006305:Health Status Indicators; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011446:Prospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D014454:Uganda; D055986:Vital Signs; D055815:Young Adult