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Performance of severity of illness scoring systems in emergency department patients with infection
Michael D Howell1, Michael W Donnino, Daniel Talmor
1Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA. mhowell@bidmc.harvard.edu
Objectives:
To validate the Mortality in Emergency Department Sepsis (MEDS) score, the Confusion, Urea nitrogen, Respiratory rate, Blood pressure, 65 years of age and older (CURB-65) score, and a modified Rapid Emergency Medicine Score (mREMS) in patients with suspected infection.
Methods:
This was a prospective cohort study. Adult patients with clinically suspected infection admitted from December 10, 2003, to September 30, 2004, in an urban emergency department with approximately 50,000 annual visits were eligible. The MEDS and CURB-65 scores were calculated as originally described, but REMS was modified in neurologic scoring because a full Glasgow Coma Scale score was not uniformly available. Discrimination of each score was assessed with the area under the receiver operating characteristics curve (AUC).
Results:
Of 2,132 patients, 3.9% (95% confidence interval [CI] = 3.1% to 4.7%) died. Mortality stratified by the MEDS score was as follows: 0-4 points, 0.4% (95% CI = 0.0 to 0.7%); 5-7 points, 3.3% (95% CI = 1.7% to 4.9%); 8-12 points, 6.6% (95% CI = 4.4% to 8.8%); and > or = 13 points, 31.6% (95% CI = 22.4% to 40.8%). Mortality stratified by CURB-65 was as follows: 0 points, 0% (0 of 457 patients); 1 point, 1.6% (95% CI = 0.6% to 2.6%); 2 points, 4.1% (95% CI = 2.3% to 6.0%); 3 points, 4.9% (95% CI = 2.8% to 6.9%); 4 points, 18.1% (95% CI = 11.9% to 24.3%); and 5 points, 28.0% (95% CI = 10.4% to 45.6%). Mortality stratified by the mREMS was as follows: 0-2 points, 0.6% (95% CI = 0 to 1.2%); 3-5 points, 2.0% (95% CI = 0.8% to 3.1%); 6-8 points, 2.3% (95% CI = 1.1% to 3.5%); 9-11 points, 7.1% (95% CI = 4.2% to 10.1%); 12-14 points, 20.0% (95% CI = 12.5% to 27.5%); and > or = 15 points, 40.0% (95% CI = 22.5% to 57.5%). The AUCs were 0.85, 0.80, and 0.79 for MEDS, mREMS, and CURB-65, respectively.
Conclusions:
In this large cohort of patients with clinically suspected infection, MEDS, mREMS, and CURB-65 all correlated well with 28-day in-hospital mortality.
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