The most commonly used disease severity scores are inappropriate for risk stratification of older emergency department sepsis patients: an observational multi-centre study

Abstract

BackgroundSepsis recognition in older emergency department (ED) patients is difficult due to atypical symptom presentation. We therefore investigated whether the prognostic and discriminative performance of the five most commonly used disease severity scores were appropriate for risk stratification of older ED sepsis patients (≥70 years) compared to a younger control group (<70 years).MethodsThis was an observational multi-centre study using an existing database in which ED patients who were hospitalized with a suspected infection were prospectively included. Patients were stratified by age < 70 and ≥70 years. We assessed the association with in-hospital mortality (primary outcome) and the area under the curve (AUC) with receiver operator characteristics of the Predisposition, Infection, Response, Organ dysfunction (PIRO), quick Sequential Organ Failure Assessment (qSOFA), Mortality in ED Sepsis (MEDS), and the Modified and National Early Warning (MEWS and NEWS) scores.ResultsIn-hospital mortality was 9.5% ((95%-CI); 7.4–11.5) in the 783 included older patients, and 4.6% (3.6–5.7) in the 1497 included younger patients. In contrast to younger patients, disease severity scores in older patients associated poorly with mortality. The AUCs of all disease severity scores were poor and ranged from 0.56 to 0.64 in older patients, significantly lower than the good AUC range from 0.72 to 0.86 in younger patients. The MEDS had the best AUC (0.64 (0.57–0.71)) in older patients. In older and younger patients, the newly proposed qSOFA score (Sepsis 3.0) had a lower AUC than the PIRO score (sepsis 2.0).ConclusionThe prognostic and discriminative performance of the five most commonly used disease severity scores was poor and less useful for risk stratification of older ED sepsis patients.Electronic supplementary materialThe online version of this article (10.1186/s13049-017-0436-3) contains supplementary material, which is available to authorized users.

The association between systolic blood pressure and in-hospital mortality in older emergency department patients who are hospitalised with a suspected infection

“…Our findings are in line with recent observations in surgical sepsis patients suggesting that SBP thresholds should be higher than 90 mmHg,3 and could explain the poor predictive performance of various screenings and risk stratification tools in older ED patients who are hospitalised with a suspected infection 4…”

National early warning score (NEWS) in a Finnish multidisciplinary emergency department and direct vs. late admission to intensive care

“…In December 2017, NEWS received formal endorsement from NHS England to become the early warning system for identifying acutely ill patients in hospitals in England [5]. In ED environments, however, the NEWS has been studied among rather small patient cohorts or pre-selected sub cohorts of patients [6][7][8][9][10][11][12][13]. Further, fixed patient outcomes, such as 30-day mortality, with the adjustment for important confounding factors, has not been studied in a heterogenous ED population [6][7][8][9][10][11][12][13].…”

Development and Internal Validation of a Model Predicting Safe, Early Discharge Among Patients Presenting to the Emergency Department with an Infection.

“…This method of data imputation provides similar outcomes for the qSOFA, PIRO and MEDS score compared to imputation with the multiple imputations function of SPSS. [48] The percentage of missing data points per variable will be shown in parentheses.…”