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Abstract
Objectives & Background Early recognition and treatment of sepsis in the emergency department (ED) has been shown to reduce mortality. At present, we are able to identify patients who satisfy the septic shock criteria. However, many patients admitted to the intensive care unit (ICU) do not satisfy the shock criteria whilst in the ED yet have a mortality rate of approximately 30% (unpublished internal data). The Mortality In Severe Sepsis in the Emergency Department (MISSED) score was derived and validated in ED patients admitted to the ICU. This score enables identification of patients at high risk of death. The score has now been simplified. The simplified MISSED score is made up of three independent variables which predict mortality in sepsis. They are, age >65 years, a serum albumin <27 g/l and an INR of >1.3. The score ranges from 0 to 3 depending on the number of variables present at presentation in the ED. The simplified MISSED score has been internally validated in 674 ED patients admitted in 2012. The aim of this study is to identify the mortality rate associated with the simplified MISSED score at one year from the index admission.
Methods Of the 674 patients studied in the internal ED validation study, those with active malignancy and those whose final diagnosis was not one of infection were identified from the hospital IT system and excluded. The date a patients was last known to be alive before loss to follow up and dates of death were obtained from the hospital IT system. The in-hospital mortality rates and the one year mortality rates from the date of admission, were calculated for each of the simplified MISSED scores.
Results Of the 674 patients 100 had active malignancy and a further 44 did not have a final diagnosis of an infection. Thus 144 patients were excluded. The study population consisted of 530 patients. Of the 102 deaths which occurred within a year of the index admission 42 occurred on the index admission. The mortality rates associated with the simplified MISSED scores of 0, 1, 2 and 3 on the index admission were 0.5%, 7.5%, 26.8% and 25% and at one-year were 2.1%, 22.2%, 43.7% and 66.7%, respectively. The hazard ratio for mortality at 1 year for a score of 2 or 3 compared to a score of 0 or 1 was 3.9 [95% confidence interval 2.2–6.9], p<0.0001.
Conclusion In patients admitted with an infection, increasing simplified MISSED scores in the ED were associated with significantly increased mortality rates at one year⇓.
Kaplan Meier plot illustrating the one-year survival associated with the simplified MISSED score
- emergency care systems