Comparison of early warning scores for predicting outcomes in adult and older patients in emergency department: Multicenter study

Abstract

Background: Early Warning Scores (EWS), such as the quick Sequential Organ Failure Assessment (qSOFA), National Early Warning Score 2 (NEWS2), and Rapid Emergency Medicine Score (REMS), are widely used for risk stratification in emergency departments (EDs). However, their predictive performance in older patients remains unclear. This study aimed to evaluate and compare the predictive performance of qSOFA, NEWS2, and REMS for ICU admission and in-hospital mortality in adult (18–64 years) and older (≥65 years) ED patients. Methods: This retrospective study analyzed the data of ED patients from three tertiary hospitals in South Korea from August to October 2023. We calculated their qSOFA, NEWS2, and REMS scores and compared their predictive performance using AUROC analysis. Optimal cut-off values were determined using Youden's index, and DeLong's method was applied for statistical comparisons between the age groups. Results: 6931 patients (3757 adults, 3174 older adult) were included. qSOFA maintained similar discriminative ability across both groups (AUROC 0.710 vs. 0.711 for ICU admission; 0.771 vs. 0.753 for in-hospital mortality). REMS showed significantly lower AUROC values in older patients than adults for ICU admission (0.770 vs. 0.687, p < 0.001). For in-hospital mortality, REMS and NEWS2 showed significantly lower AUROC values in older patients (REMS: 0.801 vs. 0.734, p < 0.001; NEWS2: 0.842 vs. 0.778, p < 0.001). Conclusion: Traditional EWS exhibited reduced predictive performance in older patients, with REMS and NEWS2 showing significant declines in accuracy. These results highlight the need for age-adjusted modifications or novel geriatric-specific risk stratification tools to improve emergency care outcomes for older adults. © 2025 Elsevier Inc.