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Internal emergency department validation of the simplified MISSED score
Narani Sivayoham1, Paul Holmes, Maurizio Cecconi
1Departments of aEmergency Medicine bIntensive Care Medicine, St George's Healthcare NHS Trust and St George's University of London, London, UK.
Background:
The MISSED score was derived and validated in emergency department (ED) patients with sepsis who were admitted to the ICU. This score has now been refined and simplified. The independent variables associated with mortality are age at least 65 years, serum albumin 27 g/l or less, and an international normalized ratio at least 1.3. The simplified MISSED score ranges from 0 to 3 depending on the number of variables present.
Objective:
The primary objective is to validate the simplified MISSED score for predicting all-cause mortality in the ED population admitted with sepsis. The secondary end-point is to validate the risk stratification for ICU admission.
Methods:
This is a pragmatic retrospective study of prospectively collected data. ED patients admitted with a diagnosis of sepsis in the year 2012 were studied. Those on warfarin were excluded. The simplified MISSED score was calculated for each patient. The test characteristics for mortality of the simplified MISSED score and the odds ratios of the high-risk groups for the secondary end-point were calculated.
Results:
In total, 674 patients, including 65 deaths, were studied. The area under the curve for the simplified MISSED score was 0.74 [95% confidence interval (CI) 0.70-0.77; P<0.0001]. The test characteristics for mortality were as follows: sensitivity 93.9% (95% CI 85-98.3), specificity 37.9% (95% CI 34.1-41.9), positive predictive value 13.9% (95% CI 10.8-17.5), and negative predictive value 98.3% (95% CI 95.7-99.5). The odds ratio for mortality for a score 2 or more was 5.01 (95% CI 2.93-8.57; P<0.0001), and that for ICU admission was 3.00 (95% CI 1.70-5.28; P=0.0001).
Conclusion:
The simplified MISSED score could be used to risk stratify septic patients in the ED.
Insights
The simplified MISSED score effectively predicts mortality in emergency department sepsis patients. This validated tool aids in risk stratification for intensive care unit admission, improving patient management.
Area of Science:
- Emergency Medicine
- Critical Care Medicine
- Clinical Risk Stratification
Background:
- The original MISSED score was developed for emergency department (ED) sepsis patients requiring ICU admission.
- A refined, simplified MISSED score incorporates age (≥65 years), low serum albumin (≤27 g/L), and elevated INR (≥1.3).
- The simplified score ranges from 0 to 3, reflecting the number of risk factors present.
Purpose of the Study:
- To validate the simplified MISSED score's ability to predict all-cause mortality in ED sepsis patients.
- To assess the simplified MISSED score's utility in risk stratifying patients for ICU admission.
Main Methods:
- A pragmatic retrospective analysis of prospectively collected data from 2012.
- Inclusion of ED patients diagnosed with sepsis, excluding those on warfarin.
- Calculation of the simplified MISSED score and analysis of its predictive characteristics for mortality and ICU admission.
Main Results:
- The study included 674 sepsis patients, with 65 deaths. The simplified MISSED score demonstrated an AUC of 0.74 for mortality prediction.
- Key performance metrics for mortality included sensitivity of 93.9% and negative predictive value of 98.3%.
- A simplified MISSED score of 2 or higher was associated with a 5-fold increased odds of mortality and 3-fold increased odds of ICU admission.
Conclusions:
- The simplified MISSED score is a validated tool for risk stratification of sepsis patients in the emergency department.
- This score can aid clinicians in identifying high-risk patients who may benefit from closer monitoring or earlier ICU transfer.
