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Is the Mortality in the Emergency Department Sepsis score a reliable predictive tool for the ED physician?
American Journal of Emergency Medicine (2008) 26, 693–694
www.elsevier.com/locate/ajem
Editorial
Is the Mortality in the Emergency Department Sepsis score a reliable predictive tool for the ED physician? Joseph Varon MD a,⁎, Pilar Acosta MD b a
The University of Texas Health Science Center at Houston, St. Luke's Episcopal Hospital and Clinical Professor of Medicine, The University of Texas Medical Branch at Galveston and Houston, TX, USA b Dorrington Medical Associates, Houston, TX, USA Received 1 February 2008; accepted 2 February 2008
In the United States, approximately 700 000 patients a year will present to the emergency department (ED) with sepsis, severe sepsis, or septic shock [1]. This spectrum of illnesses ranks among the leading reasons for admission to intensive care units throughout the world. Indeed, sepsis and the multiorgan dysfunction syndrome, which commonly follows sepsis, use enormous intensive care unit resources and have a mortality rate that ranges from 30% to 50% [2]. The ability to promptly and accurately evaluate a patient's source of sepsis, as well as the severity of illness (including mortality risk), upon presentation to the ED is important to health care providers to implement prompt and appropriate therapy [3]. Those patients in the ED who suffer from severe sepsis are critically ill and require immediate attention to avoid deterioration. Some treatment algorithms have evolved over the past few decades in an attempt to rapidly resuscitate these patients and improve outcome [4]. It is clear that a prompt diagnosis, risk stratification, and management of patients with sepsis are major determinants to a successful treatment [2]. A variety of scoring systems have been developed in an attempt to determine severity of illness in critically ill patients, such as Acute Physiology and Chronic Health Evaluation (APACHE), APACHE II, APACHE III, the Therapeutic Intervention Scoring System, the Mortality Predictor Model, and the Simplified Acute ⁎ Corresponding author. 2219 Dorington Houston, TX 77030, USA. Tel.: +1 713 669 1670. E-mail address: [email protected] (J. Varon). 0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2008.02.001
Physiology Score [5-7]. Nonetheless, risk stratification for patients with sepsis in the ED has received little attention. The Mortality in the Emergency Department Sepsis (MEDS) score was initially described and validated by Shapiro et al in 2003 [8]. One of the primary purposes of MEDS was to select those patients that would benefit the most from a more aggressive management (ie, administration of activated protein C), as well as a better utilization of resources [8]. The popularity of the MEDS score is based on its simplicity to calculate outcome prediction scores with information that is readily available at the ED. Early studies of this scoring system have correlated with 28-day inhospital mortality [9]. Some investigators have even found that the prognostic features of the MEDS score reach to 1 year after presentation [10]. In this issue of The American Journal of Emergency Medicine, Jones et al [11] attempt to validate the MEDS score with mortality outcomes among patients with severe sepsis and septic shock in a single center study of 143 patients. Their results are in direct opposition to previously published data [5,8,10]. In this study, the MEDS score underestimated mortality in this patient population. The contrast of the outcome reported in this article, as opposed to those of other published reports, gives pause to the reliability of the results, which may have been hindered by the single center design. Although several studies have been published in favor using MEDS score in the ED, the design limitations of this study underscore the need for additional multicenter trials using the instrument as an outcome predictor. We believe that
694 further investigation is warranted before the widespread use of this outcome predictor can be recommended in the ED. Multicenter, randomized trials with comparative mortality rates in an extended subject population are needed to accept this score as a reliable indicator.
References [1] Martin GS, Mannino DM, Eaton S, et al. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003;348: 1546-54. [2] Marik PE, Varon J. Sepsis state of the art. Dis Month 2001;47(10): 465-532. [3] Butler J. The surviving sepsis campaign and the emergency department. Emerg Med J 2008;25(1):2-3. [4] Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368-77.
Editorial [5] Chen CC, Chong CF, Liu YL, et al. Risk stratification of severe sepsis patients in the emergency department. Emerg Med J 2006;23: 281-5. [6] Knaus WA, Zimmerman JE, Wagner DP, et al. APACHE—Acute Physiology and Chronic Health Evaluation: a physiologically based classification system. Crit Care Med 1981;9:591-7. [7] Knaus WA, Draper EA, Wagner DP, et al. APACHE II: a severity of disease classification system. Crit Care Med 1985;13:818-29. [8] Shapiro NI, Wolfe RE, Moore RB, et al. Mortality in the Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule. Crit Care Med 2003;31(3):670-5. [9] Howell MD, Donnino MW, Talmor D, et al. Performance of severity illness scoring systems in emergency department patients with infection. Acad Emerg Med 2007;14(8):709-14. [10] Shapiro NI, Howell MD, Talmor D, et al. Mortality in the Emergency Department Sepsis (MEDS) score predicts 1-year mortality. Crit Care Med 2007;35(1):192-8. [11] Jones AE, Saak K, Kline JA. Performance of the Mortality in emergency department Sepsis score for predicting hospital mortality among patients with severe sepsis and septic shock. Am J Emerg Med 2008;26:689-92.
www.elsevier.com/locate/ajem
Editorial
Is the Mortality in the Emergency Department Sepsis score a reliable predictive tool for the ED physician? Joseph Varon MD a,⁎, Pilar Acosta MD b a
The University of Texas Health Science Center at Houston, St. Luke's Episcopal Hospital and Clinical Professor of Medicine, The University of Texas Medical Branch at Galveston and Houston, TX, USA b Dorrington Medical Associates, Houston, TX, USA Received 1 February 2008; accepted 2 February 2008
In the United States, approximately 700 000 patients a year will present to the emergency department (ED) with sepsis, severe sepsis, or septic shock [1]. This spectrum of illnesses ranks among the leading reasons for admission to intensive care units throughout the world. Indeed, sepsis and the multiorgan dysfunction syndrome, which commonly follows sepsis, use enormous intensive care unit resources and have a mortality rate that ranges from 30% to 50% [2]. The ability to promptly and accurately evaluate a patient's source of sepsis, as well as the severity of illness (including mortality risk), upon presentation to the ED is important to health care providers to implement prompt and appropriate therapy [3]. Those patients in the ED who suffer from severe sepsis are critically ill and require immediate attention to avoid deterioration. Some treatment algorithms have evolved over the past few decades in an attempt to rapidly resuscitate these patients and improve outcome [4]. It is clear that a prompt diagnosis, risk stratification, and management of patients with sepsis are major determinants to a successful treatment [2]. A variety of scoring systems have been developed in an attempt to determine severity of illness in critically ill patients, such as Acute Physiology and Chronic Health Evaluation (APACHE), APACHE II, APACHE III, the Therapeutic Intervention Scoring System, the Mortality Predictor Model, and the Simplified Acute ⁎ Corresponding author. 2219 Dorington Houston, TX 77030, USA. Tel.: +1 713 669 1670. E-mail address: [email protected] (J. Varon). 0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2008.02.001
Physiology Score [5-7]. Nonetheless, risk stratification for patients with sepsis in the ED has received little attention. The Mortality in the Emergency Department Sepsis (MEDS) score was initially described and validated by Shapiro et al in 2003 [8]. One of the primary purposes of MEDS was to select those patients that would benefit the most from a more aggressive management (ie, administration of activated protein C), as well as a better utilization of resources [8]. The popularity of the MEDS score is based on its simplicity to calculate outcome prediction scores with information that is readily available at the ED. Early studies of this scoring system have correlated with 28-day inhospital mortality [9]. Some investigators have even found that the prognostic features of the MEDS score reach to 1 year after presentation [10]. In this issue of The American Journal of Emergency Medicine, Jones et al [11] attempt to validate the MEDS score with mortality outcomes among patients with severe sepsis and septic shock in a single center study of 143 patients. Their results are in direct opposition to previously published data [5,8,10]. In this study, the MEDS score underestimated mortality in this patient population. The contrast of the outcome reported in this article, as opposed to those of other published reports, gives pause to the reliability of the results, which may have been hindered by the single center design. Although several studies have been published in favor using MEDS score in the ED, the design limitations of this study underscore the need for additional multicenter trials using the instrument as an outcome predictor. We believe that
694 further investigation is warranted before the widespread use of this outcome predictor can be recommended in the ED. Multicenter, randomized trials with comparative mortality rates in an extended subject population are needed to accept this score as a reliable indicator.
References [1] Martin GS, Mannino DM, Eaton S, et al. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003;348: 1546-54. [2] Marik PE, Varon J. Sepsis state of the art. Dis Month 2001;47(10): 465-532. [3] Butler J. The surviving sepsis campaign and the emergency department. Emerg Med J 2008;25(1):2-3. [4] Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368-77.
Editorial [5] Chen CC, Chong CF, Liu YL, et al. Risk stratification of severe sepsis patients in the emergency department. Emerg Med J 2006;23: 281-5. [6] Knaus WA, Zimmerman JE, Wagner DP, et al. APACHE—Acute Physiology and Chronic Health Evaluation: a physiologically based classification system. Crit Care Med 1981;9:591-7. [7] Knaus WA, Draper EA, Wagner DP, et al. APACHE II: a severity of disease classification system. Crit Care Med 1985;13:818-29. [8] Shapiro NI, Wolfe RE, Moore RB, et al. Mortality in the Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule. Crit Care Med 2003;31(3):670-5. [9] Howell MD, Donnino MW, Talmor D, et al. Performance of severity illness scoring systems in emergency department patients with infection. Acad Emerg Med 2007;14(8):709-14. [10] Shapiro NI, Howell MD, Talmor D, et al. Mortality in the Emergency Department Sepsis (MEDS) score predicts 1-year mortality. Crit Care Med 2007;35(1):192-8. [11] Jones AE, Saak K, Kline JA. Performance of the Mortality in emergency department Sepsis score for predicting hospital mortality among patients with severe sepsis and septic shock. Am J Emerg Med 2008;26:689-92.