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

      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.

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      References

        • Martin G.S.
        • Mannino D.M.
        • Eaton S.
        • Moss M.
        The epidemiology of sepsis in the United States from 1979 through 2000.
        N Engl J Med. 2003; 348: 1546-1554
        • Strehlow M.C.
        • Emond S.D.
        • Shapiro N.I.
        • Pelletier A.J.
        • Camargo Jr, C.A.
        National study of emergency department visits for sepsis, 1992 to 2001.
        Ann Emerg Med. 2006; 48: 326-331
        • De Miguel-Yanes J.M.
        • Andueza-Lillo J.A.
        • González-Ramallo V.J.
        • Pastor L.
        • Muñoz J.
        Failure to implement evidence-based clinical guidelines for sepsis at the ED.
        Am J Emerg Med. 2006; 24: 553-559
        • Nguyen H.B.
        • Rivers E.P.
        • Abrahamian F.M.
        • et al.
        Severe sepsis and septic shock: review of the literature and emergency department management guidelines.
        Ann Emerg Med. 2006; 48: 28-54
        • Rivers E.
        • Nguyen B.
        • Havstad S.
        • et al.
        Early goal-directed therapy in the treatment of severe sepsis and septic shock.
        N Engl J Med. 2001; 345: 1368-1377
        • Knaus W.A.
        • Draper E.A.
        • Wagner D.P.
        • et al.
        APACHE II: a severity of disease classification system.
        Crit Care Med. 1985; 13: 818-829
        • Knaus W.A.
        • Zimmerman J.E.
        • Wagner D.P.
        • et al.
        APACHE—acute physiology and chronic health evaluation: a physiologically based classification system.
        Crit Care Med. 1981; 9: 591-597
        • Le Gall J.R.
        • Loirat P.
        • Alperovitch A.
        • et al.
        A simplified acute physiology score for ICU patients.
        Crit Care Med. 1984; 12: 975-977
        • Lemeshow S.
        • Teres D.
        • Klar J.
        • et al.
        Mortality Probability Models (MPM II) based on an international cohort of intensive care unit patients.
        JAMA. 1993; 270: 2478-2486
        • Vincent J.L.
        • Moreno R.
        • Takala J.
        • et al.
        The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure.
        Intensive Care Med. 1996; 22: 707-710
        • Higgins T.L.
        • Teres D.
        • Copes W.S.
        • et al.
        Assessing contemporary intensive care unit outcome: an updated Mortality Probability Admission Model (MPM0-III).
        Crit Care Med. 2007; 35: 827-835
        • Metnitz P.G.H.
        • Moreno R.P.
        • Almeida E.
        • et al.
        SAPS 3—from evaluation of the patient to evaluation of the intensive care unit.
        Intensive Care Med. 2005; 31: 1336-1344
        • Zimmerman J.E.
        • Kramer A.A.
        • McNair D.S.
        • Malila F.M.
        Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today's critically ill patients.
        Crit Care Med. 2006; 34: 1297-1310
        • Sinuff T.
        • Adhikari N.K.J.
        • Cook D.J.
        • et al.
        Mortality predictions in the intensive care unit: comparing physicians with scoring systems.
        Crit Care Med. 2006; 34: 878-885
        • Abraham E.
        • Laterre P.F.
        • Garg R.
        • et al.
        Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death.
        N Engl J Med. 2005; 353: 1332-1341
        • Vincent J.L.
        • Bernard G.R.
        • Beale R.
        • et al.
        Drotrecogin alfa (activated) treatment in severe sepsis from the global open-label trial ENHANCE: further evidence for survival and safety and implications for early treatment.
        Crit Care Med. 2005; 33: 2266-2277
        • Laterre P.F.
        • Abraham E.
        • Janes J.M.
        • et al.
        ADDRESS (ADministration of DRotrecogin alfa [activated] in Early stage Severe Sepsis) long-term follow-up: one-year safety and efficacy evaluation.
        Crit Care Med. 2007; 35: 1457-1463
        • Shapiro N.I.
        • Wolfe R.E.
        • Moore R.B.
        • et al.
        Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule.
        Crit Care Med. 2003; 31: 670-675
        • Gilbert E.H.
        • Lowenstein S.R.
        • Koziol-McLain J.
        • et al.
        Chart reviews in emergency medicine research: where are the methods?.
        Ann Emerg Med. 1996; 27: 305-308
        • Worster A.
        • Bledsoe R.D.
        • Cleve P.
        • et al.
        Reassessing the methods of medical record review studies in emergency medicine research.
        Ann Emerg Med. 2005; 45: 448-451
        • McCabe W.R.
        • Jackson G.G.
        Gram-negative bacteremia.
        Arch Intern Med. 1962; 110: 856-864
        • Bone R.C.
        • Balk R.A.
        • Cerra F.B.
        • et al.
        Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.
        Chest. 1992; 101: 1644-1655
        • Chen C.C.
        • Chong C.F.
        • Liu Y.L.
        • et al.
        Risk stratification of severe sepsis patients in the emergency department.
        Emerg Med J. 2006; 23: 281-285
        • Howell M.D.
        • Donnino M.W.
        • Talmor D.
        • et al.
        Performance of severity of illness scoring systems in emergency department patients with infection.
        Acad Emerg Med. 2007; 14: 709-714
        • Lim W.S.
        • van der Eerden M.M.
        • Laing R.
        • et al.
        Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study.
        Thorax. 2003; 58: 377-382
        • Olsson T.
        • Lind L.
        Comparison of the rapid emergency medicine score and APACHE II in nonsurgical emergency department patients.
        Acad Emerg Med. 2003; 10: 1040-1048
        • Jones A.E.
        • Saak K.
        • Kline J.A.
        Performance of the Mortality in Emergency Department Sepsis score for predicting hospital mortality among patients with severe sepsis and septic shock.
        Am J Emerg Med. 2008; 26: 689-692
        • Lee C.C.
        • Chen S.Y.
        • Tsai C.L.
        • et al.
        Prognostic value of mortality in emergency department sepsis score, procalcitonin, and C-reactive protein in patients with sepsis at the emergency department.
        Shock. 2008; 29: 322-327
        • Sankoff J.D.
        • Goyal M.
        • Gaieski D.F.
        • et al.
        Validation of the Mortality in Emergency Department Sepsis (MEDS) score in patients with the systemic inflammatory response syndrome (SIRS).
        Crit Care Med. 2008; 36: 421-426
        • Le Gall J.R.
        • Lemeshow S.
        • Saulnier F.
        A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study.
        JAMA. 1993; 270: 2957-2963
        • Nguyen H.B.
        • Banta J.E.
        • Cho T.W.
        • et al.
        Mortality predictions using current physiological scoring systems in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle.
        Shock. 2008; 30: 23-28
        • Shapiro N.I.
        • Howell M.D.
        • Talmor D.
        • et al.
        Mortality in Emergency Department Sepsis (MEDS) score predicts 1-year mortality.
        Crit Care Med. 2007; 35: 192-198
        • Levy M.M.
        • Fink M.P.
        • Marshall J.C.
        • et al.
        2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference.
        Crit Care Med. 2003; 31: 1250-1256
        • Russell J.A.
        Management of sepsis.
        N Engl J Med. 2006; 355: 1699-1713
        • Antonelli M.
        • Levy M.
        • Andrews P.J.D.
        • et al.
        Hemodynamic monitoring in shock and implications for management.
        Intensive Care Med. 2007; 33: 575-590
        • Shapiro N.I.
        • Howell M.D.
        • Talmor D.
        • et al.
        Serum lactate as a predictor of mortality in emergency department patients with infection.
        Ann Emerg Med. 2005; 45: 524-528
        • Nguyen H.B.
        • Rivers E.P.
        • Knoblich B.P.
        • et al.
        Early lactate clearance is associated with improved outcome in severe sepsis and septic shock.
        Crit Care Med. 2004; 32: 1637-1642
        • Arnold R.C.
        • Shapiro N.I.
        • Jones A.E.
        • et al.
        Multi-center study of early lactate clearance as a determinant of survival in patients with presumed sepsis.
        Shock. 2008; (Dec 22 [Epub ahead of print])
        • Carlbom D.J.
        • Rubenfeld G.D.
        Barriers to implementing protocol-based sepsis resuscitation in the emergency department—results of a national survey.
        Crit Care Med. 2007; 35: 2525-2532