Evidence-based medicineRisk Stratification of the Potentially Septic Patient in the Emergency Department: The Mortality in the Emergency Department Sepsis (MEDS) Score
Section snippets
Case
A 67-year-old-woman presents to the Emergency Department (ED) with complaints of fever, cough, and weakness for the last 2 days. She reports no past medical history and lives at home. She denies any recent travel, hospitalization, or exposures to possible health care-acquired pneumonia. Physical examination reveals temperature 38.3°C, heart rate 110 beats/min, blood pressure 125/50 mm Hg, respiratory rate 22 breaths/min, and a normal mental status examination. Her chest radiograph reveals a
Clinical Question
Can a risk-stratification tool predict 1-month mortality in ED patients with suspected infection?
Context
In the United States, over 700,000 patients present to the ED each year with sepsis, severe sepsis, or septic shock (1). Approximately 40% of sepsis patients initially present to the ED, and intensive care unit (ICU) admission is frequently delayed (1, 2). Although early goal-directed therapy significantly reduces sepsis-related mortality, non-specific presentations in overcrowded EDs may result in poor disease recognition and suboptimal care (3, 4, 5). Multiple scoring systems have been
Evidence Search
Using the TRIP (Translating Research into Practice) database (http://www.tripdatabase.com), the search term “emergency department sepsis score” was entered on December 12, 2008 and identified a secondary review of the validation of the Mortality in the Emergency Department Sepsis (MEDS) score on PUBMED. On PUBMED, the “related articles” tab was selected, yielding 114 citations. Among these results, six were chosen for this critical appraisal.
MEDS Derivation
Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule. Critical Care Medicine, 2003 (18).
Conclusion
After validation across prospective samples from multiple institutions, the MEDS score is an accurate and reliable risk-stratification tool for 28-day mortality in ED patients with SIRS. The MEDS score is a Level II clinical decision rule and can therefore be used in various settings with confidence. Some elements of the MEDS score may prove problematic due to interpretation bias (terminal illness) or lack of routine availability (band counts in an era of automated white blood cell counts).
Commentary by H. Bryant Nguyen, MD, MS
At the turn of this century, we have now witnessed significant progress in our understanding of the pathogenesis, recognition, and management of sepsis (33, 34). As emergency physicians, we have moved beyond simply considering a patient with infection on vasopressors and mechanical ventilation as merely septic. It is crucial that emergency physicians understand the definitions of severe sepsis and septic shock, as early intervention in the ED for this subgroup has been shown to significantly
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Cited by (37)
Automatic learning of mortality in a CPN model of the systemic inflammatory response syndrome
2017, Mathematical BiosciencesCitation Excerpt :Due to the lack of data in our database available to make a comparison to MEDS, we can make a comparison to performance reported in the literature. The MEDS score is probably the best known scoring system for patients with suspected sepsis, and has good discriminatory performance in ED patients with suspected sepsis or SIRS (AUC 0.75–0.88) [29] although it performed poorly in a cohort of patients with severe sepsis and septic shock with AUC = 0.61 [30]. The LA Sepsis CPN performs similarly with an AUC of 0.79, and is well calibrated.
Usefulness of the Mortality in Severe Sepsis in the Emergency Department score in an urban tertiary care hospital
2016, American Journal of Emergency MedicineCitation Excerpt :Although multiple scoring systems exist, there are few that were specifically designed for use in ED patients. The Mortality in Emergency Department Sepsis (MEDS) score is one of these systems [5–9]; however, there have been several studies that have challenge its generalizability [10–15]. In a recent study done in the United Kingdom, Sivayoham et al [16,17] proposed the Mortality in Severe Sepsis in the Emergency Department (MISSED) score to predict mortality risk in sepsis.
Risk factors for mortality despite early protocolized resuscitation for severe sepsis and septic shock in the emergency department
2016, Journal of Critical CareCitation Excerpt :In particular, no prior studies have assessed a comprehensive set of variables within a population of critically ill ED patients with severe sepsis or septic shock treated with early protocolized resuscitation [12,13]. Furthermore, existing ED-based sepsis prognostic scores that incorporate a large number of variables such as the Mortality in Emergency Department Sepsis [14] and Predisposition, Infection, Response, and Organ failure [15] were derived from primarily low-acuity populations and are significantly less accurate in patients with severe sepsis or septic shock [16,17]. Identifying which factors are associated with poor outcome can help guide future early interventions targeted to further reduce mortality in this at-risk population.
Clinical outcomes of ED patients with bandemia
2015, American Journal of Emergency MedicineCitation Excerpt :One must consider these values in conjunction with contextual evidence and clinician judgment to guide patient care [21,22]. Perhaps, these measures could be of added use if applied using modified, risk-stratified, weighted screening tools [23,24]. However, the relative lack of negative outcomes may also be an indicator of successful efforts to raise awareness and educate physicians on the mortality of SIRS/sepsis.