Original ContributionPerformance of the Mortality in emergency department Sepsis score for predicting hospital mortality among patients with severe sepsis and septic shock☆
Introduction
Seven hundred fifty thousand persons per year in the United States develop severe sepsis with a mortality rate of 30%, equating to approximately 215 000 deaths annually [1]. Recent estimates indicate that the rate of severe sepsis hospitalizations doubled during the last decade and age-adjusted population based mortality is increasing [2]. Inasmuch as nearly half of sepsis hospitalizations originate in the emergency department (ED), it is important to develop accurate and reliable methods to assess severity of illness and risk-stratify patients to ensure proper allocation of limited hospital resources [3], [4].
Logistic regression–derived scoring systems are commonly used to determine the severity of illness and assess prognosis among critically ill patients. The Mortality in Emergency Department Sepsis (MEDS) score was specifically developed to predict 28-day mortality among ED patients with suspected infection [5]. The MEDS score assigns various points to 9 components (age >65 years, nursing home resident, rapid terminal comorbid illness, lower respiratory tract infection, bands >5%, tachypnea or hypoxemia, septic shock, platelet count <150 000, altered mental status) that are readily available at the time of ED evaluation. A recent report indicates it is also efficient at predicting mortality at 1-year after the index hospitalization for infection [6]. Its performance in specific populations with infection, such as those with severe sepsis and septic shock and those undergoing aggressive resuscitation and therapeutic intervention, has not been studied. The aims of this study were to (1) determine if the MEDS score, when applied to a cohort of ED patients with severe sepsis and septic shock, will perform with high accuracy for predicting hospital mortality, defined as an area under the receiver operating characteristic (ROC) curve of more than 0.80 [7] and (2) determine if the high accuracy of the score will be maintained in both patients receiving and not receiving early goal-directed therapy (EGDT) [8].
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Materials and methods
This study was a preplanned secondary analysis of patients enrolled in a prospective before and after interventional trial investigating the clinical effectiveness of implementing EGDT as a standard-of-care resuscitation protocol in ED patients with severe sepsis and septic shock [9]. This study protocol was reviewed and approved by the institutional review board for the execution of human research before enrollment of patients.
Subjects were enrolled from August 2004 through November 2006 in
Results
A total of 143 patients, 79 pre-EGDT and 64 post-EGDT, were analyzed. Table 1 summarizes the demographics and initial clinical characteristics of the entire study population and the subpopulations that either received or did not received EGDT. The average MEDS score was 10 ± 3 points in the entire population, 10 ± 3 points in pre-EGDT patients, and 11 ± 3 points in post-EGDT patients. The in-hospital mortality rate of the entire population was 23% (33/143).
Fig. 1 compares predictive ability for
Discussion
The results of this study suggest that the MEDS scoring system functions with poor accuracy for predicting in-hospital mortality when applied to ED patients with severe sepsis and septic shock. Furthermore, the score consistently underestimated mortality risk in patients resuscitated with EGDT. Thus, the routine use of the MEDS score in the risk stratification of ED patients with severe sepsis and septic shock cannot be recommended without further investigation.
The MEDS score was derived and
Conclusions
The MEDS score demonstrated poor accuracy for predicting in-hospital mortality among ED patients with severe sepsis and septic shock. The score consistently underestimated mortality in the moderate-risk groups. These results suggest the need for further validation of the MEDS score before widespread clinical use.
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This study was supported by grant K23GM076652-01A1 from the National Institute of General Medical Sciences/National Institutes of Health, Bethesda, MD, to Dr Jones.