Title: Integration of the cumulative fluid balance (CBF) into the NEWS score for predicting the risk of clinical destabilization in septic patients: a prospective observational study in a IMCU Background: Sepsis remains one of the leading causes of in-hospital morbidity and mortality, requiring early recognition and timely treatment to improve clinical outcomes. The prompt identification of clinical deterioration is essential to prevent progression to septic shock and organ failure. The National Early Warning Score (NEWS) has become a validated nursing tool for monitoring vital signs and detecting early hemodynamic or respiratory instability. At the same time, fluid management plays a key role in sepsis therapy, as restoring adequate tissue perfusion is crucial for survival. However, individual responses to fluid therapy may vary considerably, highlighting the need for a dynamic and personalized approach to volume resuscitation. Objective: To evaluate whether integrating Cumulative Fluid Balance (CFB) into the NEWS score improves the predictive accuracy for clinical deterioration in septic patients admitted to a IMCU, compared with the use of NEWS alone. ● P (Population): Adult patients admitted to the HDU with confirmed or suspected sepsis and SOFA score ≥ 2. ● I (Intervention): Integration of CFB with NEWS for clinical monitoring. ● C (Comparison): Use of NEWS alone without CFB. ● O (Outcome): Improved predictive ability for clinical deterioration. Materials and Methods: A prospective observational study was conducted at the Medical High-Dependency Unit of Alto Vicentino Hospital (ULSS 7 Pedemontana, Santorso, Italy) from January 1, 2023, to June 30, 2025. A total of 388 adult patients with confirmed or suspected sepsis (SOFA ≥ 2) were enrolled. Demographic, clinical, and nursing data were collected, including vital signs for NEWS calculation and daily CFB values. Statistical analyses evaluated the association between NEWS, CFB, and clinical outcomes. Longitudinal effects were assessed using Generalized Estimating Equations (GEE). Results: During the observation period, the number of eligible patients decreased from 388 on day 1 to 371 on day 4. Mean NEWS and CFB showed a progressive decline over time (3.3 ± 2.5 and +2.1 ± 2.1% on day 1; 2.1 ± 2.4 and +1.4 ± 4.8% on day 4). At each reassessment, 30-day non-survivors showed significantly higher NEWS and CFB values than survivors (all p < 0.001). Integration of CFB into NEWS, assessed through Net Reclassification Improvement (NRI), demonstrated progressive enhancement in predictive performance for 30-day mortality: 28.7% on day 1 (p = 0.002), 38.5% on day 2 (p < 0.001), 35.9% on day 3 (p < 0.001), and 42.4% on day 4 (p < 0.001). In the GEE model, both NEWS and CFB were independent predictors of 30-day mortality: each additional NEWS point increased death risk by 19% (OR = 1.195; 95% CI 1.117–1.277; p < 0.001), and each 1% increase in CFB raised mortality risk by 15% (OR = 1.151; 95% CI 1.089–1.217; p < 0.001). Model fit improved with the addition of CFB (QIC = 1476.352 vs 1621.081). Discussion and Conclusion: Integrating CFB into the NEWS assessment enhances early identification of clinical deterioration in septic patients. This approach, simple and based on objective data, strengthens nursing practice by promoting more proactive and individualized management. The combined NEWS–CFB model represents a valuable tool for optimizing sepsis care and improving patient outcomes. Keywords: Cumulative fluid balance, NEWS score, Sepsis, Fluid therapy, Nursing assessment, Risk prediction
Titolo: Integrazione del bilancio cumulativo dei fluidi (CBF) nel punteggio NEWS per la predizione del rischio evolutivo del paziente settico: studio prospettico osservazionale presso una TSI Problema: La sepsi è una delle principali cause di mortalità ospedaliera e richiede un riconoscimento precoce per prevenire shock settico e danno d’organo. La National Early Warning Score (NEWS) consente di monitorare in modo standardizzato i parametri vitali e individuare precocemente instabilità cliniche. Parallelamente, la gestione dei fluidi è cruciale per mantenere una corretta perfusione tissutale. Il bilancio cumulativo dei fluidi (CFB) rappresenta un indicatore aggiuntivo utile a personalizzare la valutazione e la gestione del paziente settico. Obiettivo: Valutare se l’integrazione del CFB al punteggio NEWS incrementi la capacità predittiva del rischio evolutivo nei pazienti settici ricoverati in Terapia Semi-Intensiva (TSI), rispetto all’utilizzo del solo NEWS. ● P (Population): Pazienti adulti ricoverati in TSI con sepsi confermata o sospetta e punteggio SOFA ≥ 2. ● I (Intervention): Integrazione del CFB al punteggio NEWS per il monitoraggio clinico. ● C (Comparison): Utilizzo del solo punteggio NEWS. ● O (Outcome): Miglioramento della capacità predittiva del rischio evolutivo. Materiali e metodi : Studio prospettico osservazionale condotto presso la U.O.S. di Terapia Semi-Intensiva Medica dell’Ospedale Alto Vicentino di Santorso (ULSS 7 Pedemontana) tra il 1° gennaio 2023 e il 30 giugno 2025. Sono stati inclusi 388 pazienti adulti con sepsi confermata o sospetta (SOFA ≥ 2) al ricovero. Sono stati raccolti dati demografici, clinici e infermieristici, comprendenti i parametri vitali per il calcolo della NEWS e il bilancio cumulativo dei fluidi (CFB). L’associazione tra NEWS, CFB e outcome clinici è stata analizzata mediante test statistici e modelli longitudinali. Risultati: Durante il periodo di osservazione, i pazienti eleggibili sono passati da 388 al giorno 1 a 371 al giorno 4. Il punteggio medio di NEWS e il CFB hanno mostrato un andamento decrescente (da 3,3 ± 2,5 e +2,1 ± 2,1% al giorno 1 a 2,1 ± 2,4 e +1,4 ± 4,8% al giorno 4). A ogni rivalutazione, i pazienti deceduti a 30 giorni presentavano valori di NEWS e CFB significativamente più elevati rispetto ai sopravvissuti (p < 0,001). L’integrazione del CFB alla NEWS, valutata mediante Net Reclassification Improvement (NRI), ha evidenziato un miglioramento progressivo della capacità predittiva della mortalità a 30 giorni: 28,7% (p = 0,002) al primo giorno, 38,5% (p < 0,001) al secondo, 35,9% (p < 0,001) al terzo e 42,4% (p < 0,001) al quarto giorno. Nel modello GEE, sia il punteggio NEWS sia il CFB giornaliero sono risultati predittori indipendenti di mortalità a 30 giorni: ogni punto aggiuntivo di NEWS aumentava il rischio del 19% (OR = 1,195; IC95% 1,117–1,277; p < 0,001), mentre ogni incremento dell’1% di CFB incrementava il rischio del 15% (OR = 1,151; IC95% 1,089–1,217; p < 0,001). L’aggiunta del CFB migliorava significativamente il modello predittivo (QIC = 1476,352 vs 1621,081) Discussione e conclusione : L’integrazione del CFB nel punteggio NEWS migliora l’identificazione precoce del deterioramento clinico nei pazienti settici. Questo approccio, semplice e basato su dati oggettivi, rafforza la pratica infermieristica, favorendo una gestione più proattiva e personalizzata e contribuendo al miglioramento complessivo degli esiti clinici. Parole chiave: Bilancio cumulativo dei fluidi; NEWS; Sepsi; Terapia volemica; Monitoraggio infermieristico; Predizione del rischio
Integrazione del bilancio cumulativo dei fluidi (CFB) nel punteggio NEWS nella predizione del rischio evolutivo del paziente settico: studio prospettico osservazionale presso una TSI
MORO, ELEONORA
2024/2025
Abstract
Title: Integration of the cumulative fluid balance (CBF) into the NEWS score for predicting the risk of clinical destabilization in septic patients: a prospective observational study in a IMCU Background: Sepsis remains one of the leading causes of in-hospital morbidity and mortality, requiring early recognition and timely treatment to improve clinical outcomes. The prompt identification of clinical deterioration is essential to prevent progression to septic shock and organ failure. The National Early Warning Score (NEWS) has become a validated nursing tool for monitoring vital signs and detecting early hemodynamic or respiratory instability. At the same time, fluid management plays a key role in sepsis therapy, as restoring adequate tissue perfusion is crucial for survival. However, individual responses to fluid therapy may vary considerably, highlighting the need for a dynamic and personalized approach to volume resuscitation. Objective: To evaluate whether integrating Cumulative Fluid Balance (CFB) into the NEWS score improves the predictive accuracy for clinical deterioration in septic patients admitted to a IMCU, compared with the use of NEWS alone. ● P (Population): Adult patients admitted to the HDU with confirmed or suspected sepsis and SOFA score ≥ 2. ● I (Intervention): Integration of CFB with NEWS for clinical monitoring. ● C (Comparison): Use of NEWS alone without CFB. ● O (Outcome): Improved predictive ability for clinical deterioration. Materials and Methods: A prospective observational study was conducted at the Medical High-Dependency Unit of Alto Vicentino Hospital (ULSS 7 Pedemontana, Santorso, Italy) from January 1, 2023, to June 30, 2025. A total of 388 adult patients with confirmed or suspected sepsis (SOFA ≥ 2) were enrolled. Demographic, clinical, and nursing data were collected, including vital signs for NEWS calculation and daily CFB values. Statistical analyses evaluated the association between NEWS, CFB, and clinical outcomes. Longitudinal effects were assessed using Generalized Estimating Equations (GEE). Results: During the observation period, the number of eligible patients decreased from 388 on day 1 to 371 on day 4. Mean NEWS and CFB showed a progressive decline over time (3.3 ± 2.5 and +2.1 ± 2.1% on day 1; 2.1 ± 2.4 and +1.4 ± 4.8% on day 4). At each reassessment, 30-day non-survivors showed significantly higher NEWS and CFB values than survivors (all p < 0.001). Integration of CFB into NEWS, assessed through Net Reclassification Improvement (NRI), demonstrated progressive enhancement in predictive performance for 30-day mortality: 28.7% on day 1 (p = 0.002), 38.5% on day 2 (p < 0.001), 35.9% on day 3 (p < 0.001), and 42.4% on day 4 (p < 0.001). In the GEE model, both NEWS and CFB were independent predictors of 30-day mortality: each additional NEWS point increased death risk by 19% (OR = 1.195; 95% CI 1.117–1.277; p < 0.001), and each 1% increase in CFB raised mortality risk by 15% (OR = 1.151; 95% CI 1.089–1.217; p < 0.001). Model fit improved with the addition of CFB (QIC = 1476.352 vs 1621.081). Discussion and Conclusion: Integrating CFB into the NEWS assessment enhances early identification of clinical deterioration in septic patients. This approach, simple and based on objective data, strengthens nursing practice by promoting more proactive and individualized management. The combined NEWS–CFB model represents a valuable tool for optimizing sepsis care and improving patient outcomes. Keywords: Cumulative fluid balance, NEWS score, Sepsis, Fluid therapy, Nursing assessment, Risk prediction| File | Dimensione | Formato | |
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https://hdl.handle.net/20.500.12608/98243