Validity of a Modified Sequential Organ Failure Assessment Score Using the Richmond Agitation-Sedation Scale

Abstract

Objective The Sequential Organ Failure Assessment (SOFA) and other severity of illness scales rely on the Glasgow Coma Scale (GCS) to measure acute neurologic dysfunction, but the GCS is unavailable or inconsistently applied in some institutions. The objective of this study was to assess the validity of a modified SOFA that uses the Richmond Agitation-Sedation Scale (RASS) instead of GCS. Design Prospective cohort study Setting Medical and surgical intensive care units within a large, tertiary care hospital. Patients Critically ill medical/surgical ICU patients. Interventions and measurements We calculated daily SOFA scores using electronic medical record-derived data. Using bedside nurse-recorded GCS and RASS measures, we calculated neurologic SOFA scores using the original GCS-based approach (SOFAGCS) and a novel RASS-based approach (SOFARASS), converting the 10-point RASS to a four-point neurologic SOFA score. We assessed construct validity of SOFARASS by analyzing correlations with established severity of illness constructs (APACHE II and SOFAGCS) and predictive validity by using logistic regression to determine whether SOFARASS predicts ICU, hospital, and 1-year mortality. We assessed discriminative performance with C-statistics. Main Results Among 513 patients (5,199 patient-days), SOFARASS was strongly correlated with APACHE II acute physiology score at enrollment (r = 0.583, 95% CI 0.518, 0.642) and daily SOFAGCS scores (r = 0.963, 95% CI 0.956 to 0.968). Mean SOFARASS scores predicted ICU mortality (AUC = 0.814)—as did mean SOFAGCS (0.799)—as well as hospital and 1-year mortality. Admission SOFA scores, whether using RASS or GCS were less accurate predictors of mortality; AUCs for ICU mortality for SOFARASS and SOFAGCS, for example, were 0.622 and 0.608, respectively. Conclusions A modified SOFA score that uses bedside RASS when GCS data are not available is a valid means of assessing daily severity of illness in the ICU and may be valuable for risk adjustment and benchmarking purposes.

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