Evidence-based medicine
Risk Stratification of the Potentially Septic Patient in the Emergency Department: The Mortality in the Emergency Department Sepsis (MEDS) Score

https://doi.org/10.1016/j.jemermed.2009.03.016Get rights and content

Abstract

Background: The prompt recognition and management of septic patients remains a challenge within the busy Emergency Department (ED). Prognostic screening aids have traditionally required time-delayed laboratory measurements not validated upon the emergency medicine population. Recently, a brief prognostic tool has been derived and subsequently validated in heterogeneous ED populations. Clinical Question: Can a risk-stratification tool predict 1-month mortality in ED patients with suspected infection? Evidence Review: Six studies evaluating the Mortality in the Emergency Department Sepsis (MEDS) score were identified and evaluated. Results: Higher MEDS scores are associated with increasing mortality. MEDS score's short- and long-term prognostic accuracy is superior to other sepsis scales as well as isolated biomarkers C-reactive protein and procalcitonin. MEDS' prognostic accuracy in severe sepsis is inferior to undifferentiated systemic inflammatory response syndrome (SIRS) patients. Conclusion: The MEDS score is an accurate and reliable prognostic tool for 28-day mortality in ED SIRS patients, but may not be optimal for those with severe sepsis.

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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