Emergency department evaluation of early warning scores in predicting mortality in febrile neutropenia patients.

Background: To compare the ability of five risk-stratification tools-the Multinational Association for Supportive Care in Cancer (MASCC) index, Clinical Index of Stable Febrile Neutropenia (CISNE), National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), and Quick Sequential Organ Failure Assessment (qSOFA)-to predict in-hospital mortality among adults presenting to the emergency department (ED) with febrile neutropenia (FN).

Methods: A single-center retrospective cross-sectional review included all FN visits to a tertiary ED (1 January 2018-31 December 2021). FN was defined as fever ≥38°C with an absolute neutrophil count <1000 cells/μL. After exclusions, 90 encounters were analyzed. Demographics, vital signs, laboratory data, and calculated scores were compared between survivors and non-survivors. Receiver-operating-characteristic curves and areas under the curve (AUC) determined prognostic performance.

Results: Median age was 59 years (interquartile range 40-68); 68.9% were male. Fifteen patients died (16.6%). All five scores discriminated mortality (P < 0.001). NEWS showed the highest AUC (0.851; 73.3% sensitivity, 78.7% specificity at cut-off 5.5), followed by MEWS (0.839), qSOFA (0.829), MASCC (0.816), and CISNE (0.798).

Conclusion: Physiology-based early warning scores, particularly NEWS and MEWS, outperformed oncology-specific indices for early mortality prediction in FN patients in the ED. Incorporating these rapid scores alongside MASCC or CISNE could enhance triage accuracy, inform disposition and ultimately improve outcomes. Key messages What is already known on this topic?  Febrile neutropenia (FN) is a life-threatening oncologic emergency requiring rapid risk stratification in the emergency department. Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) are commonly used oncology-specific tools for risk assessment, but their performance in acute emergency department (ED) settings is variable. General early warning scores like National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), and Quick Sequential Organ Failure Assessment (qSOFA) have been validated for sepsis but less frequently applied to febrile neutropenic patients. What this study adds?  This study is among the few to directly compare MASCC, CISNE, NEWS, MEWS, and qSOFA in predicting in-hospital mortality in FN patients in the ED. NEWS and MEWS demonstrated the highest area under the curve values and more balanced sensitivity-specificity ratios, outperforming oncology-specific scores. Vital sign-based scores, calculated rapidly at presentation, offer strong prognostic value for early identification of high-risk FN patients. How this study might affect research, practice, or policy?  Supports the integration of physiologic early warning scores (NEWS and MEWS) into FN triage protocols in emergency departments. Suggests a multidimensional risk assessment model combining both oncologic and general scoring systems for more accurate and efficient patient management. May influence policy and guideline development to enhance outpatient vs. inpatient decision-making and resource allocation in FN care.