The Rapid Emergency Medicine Score?
I read with interest the Commentary by Roland and Coats with regard to early warning scores(1). The evidence base for the use of track and trigger systems (TTS)in the Emergency Department is not particularly strong and I agree that using a system that is designed for hospital inpatients will not be appropriate for our specific patient group.
The rapid emergency medicine score(REMS) is a physiological scoring system that was derived in a non-surgical ED in Sweden (2) and subsequently validated in a study of almost 12,000 patients (3). Area under ROC curve for in-hospital mortality was 0.852 (Standard Error of the Mean 0.014). It has also been evaluated in a UK-based study by Goodacre et al (4).
Clearly, TTS are here to stay and we need one which is appropriate to our patient population and helps to identify critically ill patients when they arrive in the ED. REMS was derived on ED patients, includes age as part of its scoring (itself an independent predictor of mortality) and studies involving it have much greater sample sizes than work on MEWS. It has its limitations, in that it has only (so far) been used on medical patients and it is a more complicated tool than MEWS. Also a recent survey of UK EDs (conducted by the author) revealed that whilst MEWS is in widespread use, REMS is not being used at all.
However, if we are looking for a TTS to use in ED, should we not start with REMS, rather than modify a ward-based system?
A postal survey of 254 UK EDs was undertaken. Responses were received from 145 departments giving a response rate of 57%. 87% of respondents are currently using early warning scores. Of those, 80% are using MEWS, 10% are using the Patient at Risk Score (PARS) and none are using REMS. 93% of respondents are in support of early warning scores in the ED.
1. Roland D, Coats TJ. An early warning? Universal risk scoring in emergency medicine. Emerg Med J 2010;1.doi10.1136/emj.2010.106104
2. Olsson T, Lind L. Comparison of the Rapid Emergency Medicine Score and APACHE II in nonsurgical emergency department patients. Acad Emerg Med 2003;10:1040-1048
3. Olsson T, Terent A, Lind L. Rapid emergency medicine score: a new prognostic tool for in-hospital mortality in nonsurgical emergency department patients. Journal of Internal Medicine 2004;255:579-587
4. Goodacre S, Turner J, Nicholl J. Prediction of mortality among emergency medical admissions. Emerg Med J 2006;23:372-375
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