Construction of a dynamic early warning protocol for pre-tracheostomy condition assessment in patients with cervical spinal cord injury

English Keywords:Cervical spinal cord injury  Tracheotomy  Influencing factors  National Early Warning Score  Condition assessment

English Abstract:

  【Abstract】 Objectives: To develop a dynamic early warning protocol for pre-tracheostomy condition assessment in patients with cervical spinal cord injur(CSCI), providing a reference for clinical monitoring before tracheostomy. Methods: A systematic search were conducted in databases including China National Knowledge Infrastructure(CNKI), Wanfang, VIP, China Biology Medicine(CBM), PubMed, Embase, Web of Science, Cochrane Library and Scopus(from inception to June 2022) to identify published literature on tracheostomy in CSCI patients. Meta-analysis was used to identify influencing factors for tracheostomy, based on which a risk assessment scale was constructed. CSCI patients admitted to Guizhou Provincial People′s Hospital between January 1, 2014 and September 30, 2022 were selected. Propensity Score Matching(PSM) was applied in a 1∶2 ratio to match tracheostomy patients(case group) with non-tracheostomy patients(control group). The receiver operating characteristics(ROC) curve was plotted with the tracheotomy risk score and the National Early Warning Score(NEWS) at different times before tracheotomy as test variables. The area under the curve(AUC) and the 95% confidence interval(CI) were used to evaluate the discriminatory ability. The optimal cutoff values of the pre-tracheotomy risk assessment table and the NEWS score were determined based on the maximum Youden index. A preliminary draft of the dynamic early warning protocol was developed through research group discussions. Further, 14 medical experts from two 3A hospitals were invited to revise the draft via expert panel discussions, finalizing the formal protocol. Results: There were 110 cases in the case group, while 220 in the control group. The risk assessment scores between the two groups showed statistically significant differences(P<0.05), with the maximum AUC being 0.946(95%CI: 0.923-0.968) and an optimal cutoff value of 34.5 points. Significant differences in NEWS scores were observed at 0.5h, 4h, and 8h before tracheostomy(P<0.05), but not at 12h(P>0.05). In the case group, the NEWS score at 0.5h before tracheostomy yielded the largest AUC with an optimal cutoff value of 7.5 points. The final protocol consists of two parts: assessment indicators and clinical response measures. The assessment indicators include 18 items from the CSCI tracheostomy risk assessment scale and NEWS. Clinical responses were stratified into five levels based on the total score. Conclusions: The dynamic warning protocol developed in this study sets up different warning levels and corresponding clinical response measures based on tracheostomy risk scores and NEWS results, it can be applied for dynamic assessment of CSCI patients before tracheostomy and offer practical recommendations for clinical nursing care.