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Intensive care unit scoring systems outperform emergency department scoring systems for mortality prediction in critically ill patients: a prospective cohort study.

ABSTRACT:

Background

Multiple scoring systems have been developed for both the intensive care unit (ICU) and the emergency department (ED) to risk stratify patients and predict mortality. However, it remains unclear whether the additional data needed to compute ICU scores improves mortality prediction for critically ill patients compared to the simpler ED scores.

Methods

We studied a prospective observational cohort of 227 critically ill patients admitted to the ICU directly from the ED at an academic, tertiary care medical center. We compared Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, Simplified Acute Physiology Score (SAPS) II, Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), Prince of Wales Emergency Department Score (PEDS), and a pre-hospital critical illness prediction score developed by Seymour et al. (JAMA 2010, 304(7):747-754). The primary endpoint was 60-day mortality. We compared the receiver operating characteristic (ROC) curves of the different scores and their calibration using the Hosmer-Lemeshow goodness-of-fit test and visual assessment.

Results

The ICU scores outperformed the ED scores with higher area under the curve (AUC) values (p?=?0.01). There were no differences in discrimination among the ED-based scoring systems (AUC 0.698 to 0.742; p?=?0.45) or among the ICU-based scoring systems (AUC 0.779 to 0.799; p?=?0.60). With the exception of the Seymour score, the ED-based scoring systems did not discriminate as well as the best-performing ICU-based scoring system, APACHE III (p?=?0.005 to 0.01 for comparison of ED scores to APACHE III). The Seymour score had a superior AUC to other ED scores and, despite a lower AUC than all the ICU scores, was not significantly different than APACHE III (p?=?0.09). When data from the first 24 h in the ICU was used to calculate the ED scores, the AUC for the ED scores improved numerically, but this improvement was not statistically significant. All scores had acceptable calibration.

Conclusions

In contrast to prior studies of patients based in the emergency department, ICU scores outperformed ED scores in critically ill patients admitted from the emergency department. This difference in performance seemed to be primarily due to the complexity of the scores rather than the time window from which the data was derived.

SUBMITTER: Moseson EM

PROVIDER: S-EPMC4424730 | biostudies-literature | 2014

REPOSITORIES: biostudies-literature

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Publications

Intensive care unit scoring systems outperform emergency department scoring systems for mortality prediction in critically ill patients: a prospective cohort study.

Moseson Erika M EM Zhuo Hanjing H Chu Jeff J Stein John C JC Matthay Michael A MA Kangelaris Kirsten N KN Liu Kathleen D KD Calfee Carolyn S CS

Journal of intensive care 20140701

<h4>Background</h4>Multiple scoring systems have been developed for both the intensive care unit (ICU) and the emergency department (ED) to risk stratify patients and predict mortality. However, it remains unclear whether the additional data needed to compute ICU scores improves mortality prediction for critically ill patients compared to the simpler ED scores.<h4>Methods</h4>We studied a prospective observational cohort of 227 critically ill patients admitted to the ICU directly from the ED at ...[more]

PMID: 25960880

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Project description:ObjectivesRapid and early severity-of-illness assessment appears to be important for critically ill patients with novel coronavirus disease (COVID-19). This study aimed to evaluate the performance of the rapid scoring system on admission of these patients.MethodsA total of 138 medical records of critically ill patients with COVID-19 were included in the study. Demographic and clinical characteristics on admission used for calculating Modified Early Warning Score (MEWS) and Rapid Emergency Medicine Score (REMS) and outcomes (survival or death) were collected for each case and extracted for analysis. All patients were divided into two age subgroups (<65 years and ≥65 years). The receiver operating characteristic (ROC) curve analyses were performed for overall patients and both subgroups.ResultsThe median [25th quartile, 75th quartile] of MEWS of survivors versus nonsurvivors were 1 [1, 2] and 2 [1, 3] and those of REMS were 5 [2, 6] and 7 [6, 10], respectively. In overall analysis, the area under the ROC curve for the REMS in predicting mortality was 0.833 (95% confidence interval [CI] = 0.737 to 0.928), higher than that of MEWS (0.677, 95% CI = 0.541 to 0.813). An optimal cutoff of REMS (≥6) had a sensitivity of 89.5%, a specificity of 69.8%, a positive predictive value of 39.5%, and a negative predictive value of 96.8%. In the analysis of subgroup of patients aged <65 years, the area under the ROC curve for the REMS in predicting mortality was 0.863 (95% CI = 0.743 to 0.941), higher than that of MEWS (0.603, 95% CI = 0.462 to 0.732).ConclusionTo our knowledge, this study was the first exploration on rapid scoring systems for critically ill patients with COVID-19. The REMS could provide emergency clinicians with an effective adjunct risk stratification tool for critically ill patients with COVID-19, especially for the patients aged <65 years. The effectiveness of REMS for screening these patients is attributed to its high negative predictive value.

Project description:ObjectivesEmergency department boarding is the practice of caring for admitted patients in the emergency department after hospital admission, and boarding has been a growing problem in the United States. Boarding of the critically ill has achieved specific attention because of its association with poor clinical outcomes. Accordingly, the Society of Critical Care Medicine and the American College of Emergency Physicians convened a Task Force to understand the implications of emergency department boarding of the critically ill. The objective of this article is to review the U.S. literature on (1) the frequency of emergency department boarding among the critically ill, (2) the outcomes associated with critical care patient boarding, and (3) local strategies developed to mitigate the impact of emergency department critical care boarding on patient outcomes.Data sources and study selectionReview article.Data extraction and data synthesisEmergency department-based boarding of the critically ill patient is common, but no nationally representative frequency estimates has been reported. Boarding literature is limited by variation in the definitions used for boarding and variation in the facilities studied (boarding ranges from 2% to 88% of ICU admissions). Prolonged boarding in the emergency department has been associated with longer duration of mechanical ventilation, longer ICU and hospital length of stay, and higher mortality. Health systems have developed multiple mitigation strategies to address emergency department boarding of critically ill patients, including emergency department-based interventions, hospital-based interventions, and emergency department-based resuscitation care units.ConclusionsEmergency department boarding of critically ill patients was common and was associated with worse clinical outcomes. Health systems have generated a number of strategies to mitigate these effects. A definition for emergency department boarding is proposed. Future work should establish formal criteria for analysis and benchmarking of emergency department-based boarding overall, with subsequent efforts focused on developing and reporting innovative strategies that improve clinical outcomes of critically ill patients boarded in the emergency department.

Project description:ImportanceIncreased patient acuity, decreased intensive care unit (ICU) bed availability, and a shortage of intensivist physicians have led to strained ICU capacity. The resulting increase in emergency department (ED) boarding time for patients requiring ICU-level care has been associated with worse outcomes.ObjectiveTo determine the association of a novel ED-based ICU, the Emergency Critical Care Center (EC3), with 30-day mortality and inpatient ICU admission.Design, setting, and participantsThis retrospective cohort study used electronic health records of all ED visits between September 1, 2012, and July 31, 2017, with a documented clinician encounter at a large academic medical center in the United States with approximately 75 000 adult ED visits per year. The pre-EC3 cohort included ED patients from September 2, 2012, to February 15, 2015, when the EC3 opened, and the post-EC3 cohort included ED patients from February 16, 2015, to July 31, 2017. Data analyses were conducted from March 2, 2018, to May 28, 2019.ExposuresImplementation of EC3, an ED-based ICU designed to provide rapid initiation of ICU-level care in the ED setting and seamless transition to inpatient ICUs.Main outcomes and measuresThe main outcomes were 30-day mortality among ED patients and rate of ED to ICU admission.ResultsA total of 349 310 visits from a consecutive sample of ED patients (mean [SD] age, 48.5 [19.7] years; 189 709 [54.3%] women) were examined; the pre-EC3 cohort included 168 877 visits and the post-EC3 cohort included 180 433 visits. Implementation of EC3 was associated with a statistically significant reduction in risk-adjusted 30-day mortality among all ED patients (pre-EC3, 2.13%; post-EC3, 1.83%; adjusted odds ratio, 0.85; 95% CI, 0.80-0.90; number needed to treat, 333 patient encounters; 95% CI, 256-476). The risk-adjusted rate of ED admission to ICU decreased with implementation of EC3 (pre-EC3, 3.2%; post-EC3, 2.7%; adjusted odds ratio, 0.80; 95% CI, 0.76-0.83; number needed to treat, 179 patient encounters; 95% CI, 149-217).Conclusions and relevanceImplementation of a novel ED-based ICU was associated with improved 30-day survival and reduced inpatient ICU admission. Additional research is warranted to further explore the value of this novel care delivery model in various health care systems.

Dataset Information

Intensive care unit scoring systems outperform emergency department scoring systems for mortality prediction in critically ill patients: a prospective cohort study.

Background

Methods

Results

Conclusions

Publications

Intensive care unit scoring systems outperform emergency department scoring systems for mortality prediction in critically ill patients: a prospective cohort study.

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