Rapid Emergency Medicine Score: A novel prognostic tool for predicting the outcomes of adult patients with hepatic portal venous gas in the emergency department

Aspirin-Induced Small-Bowel Injury Presenting Portal Venous Gas

Aspirin is well known to damage small intestinal mucosa; however, little is known about the extra-intestinal manifestations of this aspirin-induced small-bowel injury. Herein, we report a case of aspirin-induced small-bowel injury in an 84-year-old Japanese man who presented with portal venous gas. Six weeks after the aspirin was stopped, his abdominal pain gradually resolved. Various intestinal disorders can manifest portal venous gas, and understanding the pathophysiology in such situations can help physicians to avoid anchoring bias in diagnosis.

Predicting the 28-Day Mortality of Non-Trauma Patients using REMS and RAPS; a Prognostic Accuracy Study

Introduction

Various scoring systems have been designed for calculating the mortality risk of patients. This study evaluated the accuracy of Rapid Emergency Medicine Score (REMS) and Rapid Acute Physiology Score (RAPS) in predicting the 28-day mortality of non-trauma patients.

Methods

This prospective cross-sectional study was conducted on 1003 adult non-trauma patients, who referred to the emergency department of Imam Khomeini Hospital, Urmia, Iran, in the second half of 2018, using the census sampling. We determined the screening performance characteristics of REMS and RAPS in predicting the 28-day mortality of patients.

Results

This study examined 1003 non-trauma patients with a mean age of 61.5±18.05 years (60.6% male). The mean REMS (8.7 ± 3.2 vs. 6.0 ± 3.6; p < 0.001) and RAPS (3.7 ± 2.8 vs. 2.7 ± 2.0; p < 0.001) scores were significantly higher in deceased cases. Sensitivity and specificity of REMS in predicting the risk of non-trauma patients' mortality were 85.19% (95%CI: 78.05% - 90.71%) and 78.34% (95%CI: 75.45% - 81.04%), respectively. While, the Sensitivity and specificity of RAPS in this regard were 61.39% (95%CI: 53.33% - 69.02%) and 71.12% (95%CI: 67.94% - 74.16%), respectively. The area under the receiver operating characteristic (ROC) curve of REMS and RAPS were 0.72 (95% CI: 0.68 -0.75) and 0.62 (95% CI: 0.56 - 0.65) in predicting the patients' 28-day mortality, respectively (p = 0.001).

Conclusion

The total accuracies of REMS and RAPS in predicting the 28-day mortality of non-trauma patients were in good and poor range, respectively. The screening performance characteristics of REMS were a little better in this regard.

Shock Index Is a Validated Prediction Tool for the Short-Term Survival of Advanced Cancer Patients Presenting to the Emergency Department

Advanced cancer patients who are not expected to survive past the short term can benefit from early initiation of palliative care in the emergency department (ED). This discussion, however, requires accurate prognostication of their short-term survival. We previously found in our retrospective study that shock index (SI) is an ideal risk stratification tool in predicting the 60-day mortality risk of advanced cancer patients presenting to the ED. This study is a follow-up prospective validation study conducted from January 2019 to April 2021. A total of 410 advanced cancer patients who presented to the ED of a medical centre and could be followed-up feasibly were recruited. Univariate and multivariable logistic regression analyses were performed with receiver operator calibrating (ROC) curve analysis. Non-survivors had significantly lower body temperatures, higher pulse rates, higher respiratory rates, lower blood pressures, and higher SI. Each 0.1 increment of SI increased the odds of 60-day mortality by 1.591. Area under ROC curve was 0.7819. At optimal cut-off of 0.94, SI had 66.10% accuracy. These results were similar to our previous study, thus validating the use of SI in predicting the 60-day mortality of advanced cancer patients presenting to the ED. Identified patients may be offered palliative care.

The Accuracy of Rapid Emergency Medicine Score in Predicting Mortality in Non-Surgical Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Emergency department (ED) physicians often need to quickly assess patients and determine vital signs to prioritize them by the severity of their condition and make optimal treatment decisions. Effective triage requires optimal scoring systems to accelerate and positively influence the treatment of trauma cases. To this end, a variety of scoring systems have been developed to enable rapid assessment of ED patients. The present systematic review and meta-analysis aimed to investigate the accuracy of the rapid emergency medicine score (REMS) system in predicting the mortality rate in non-surgical ED patients.

METHODS

A systematic search of articles published between 1990 and 2020 was conducted using various scientific databases (Medline, Embase, Scopus, Web of Science, ProQuest, Cochrane Library, IranDOC, Magiran, and Scientific Information Database). Both cross-sectional and cohort studies assessing the REMS system to predict mortality in ED settings were considered. Two reviewers appraised the selected articles independently using the National Institutes of Health (NIH) quality assessment tool. The random-effects model was used for meta-analysis. I² index and Q statistic were used to examine heterogeneity between the articles.

RESULTS

The search resulted in 1,310 hits from which, 29 articles were eventually selected. Out of these, for 25 articles, the area under the curve value of REMS ranged from 0.52 to 0.986. The predictive power of REMS for the in-hospital mortality rate was high in 19 articles (67.85%) and low in nine articles (32.15%).

CONCLUSION

The results showed that the REMS system is an effective tool to predict mortality in non-surgical patients presented to the ED. However, further evidence using high-quality design studies is required to substantiate our findings.

Comparison of the National Early Warning Scores and Rapid Emergency Medicine Scores with the APACHE II Scores as a Prediction of Mortality in Patients with Medical Emergency Team Activation: a Single-centre Retrospective Cohort Study

Introduction

The medical emergency team enables the limitation of patients’ progression to critical illness in the general ward. The early warning scoring system (EWS) is one of the criteria for medical emergency team activation; however, it is not a valid criterion to predict the prognosis of patients with MET activation.

Aim

In this study, the National Early Warning Score (NEWS) and Rapid Emergency Medicine Score (REMS) was compared with that of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score in predicting the prognosis of patients who had been treated a medical emergency team.

Material and Methods

In this single-centre retrospective cohort study, patients treated by a medical emergency team between April 2013 and March 2019 and the 28-day prognosis of MET-activated patients were assessed using APACHE II, NEWS, and REMS.

Results

Of the 196 patients enrolled, 152 (77.5%) were men, and 44 (22.5%) were women. Their median age was 68 years (interquartile range: 57-76 years). The most common cause of medical emergency team activation was respiratory failure (43.4%). Univariate analysis showed that APACHE II score, NEWS, and REMS were associated with 28-day prognostic mortality. There was no significant difference in the area under the receiver operating characteristic curve of APACHE II (0.76), NEWS (0.67), and REMS (0.70); however, the sensitivity of NEWS (0.70) was superior to that of REMS (0.47).

Conclusion

NEWS is a more sensitive screening tool like APACHE II than REMS for predicting the prognosis of patients with medical emergency team activation. However, because the accuracy of NEWS was not sufficient compared with that of APACHE II score, it is necessary to develop a screening tool with higher sensitivity and accuracy that can be easily calculated at the bedside in the general ward.

The Value of Physiological Scoring Criteria in Predicting the In-Hospital Mortality of Acute Patients; a Systematic Review and Meta-Analysis

INTRODUCTION

There is no comprehensive meta-analysis on the value of physiological scoring systems in predicting the mortality of critically ill patients. Therefore, the present study intended to conduct a systematic review and meta-analysis to collect the available clinical evidence on the value of physiological scoring systems in predicting the in-hospital mortality of acute patients.

METHOD

An extensive search was performed on Medline, Embase, Scopus, and Web of Science databases until the end of year 2020. Physiological models included Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), modified REMS (mREMS), and Worthing Physiological Score (WPS). Finally, the data were summarized and the findings were presented as summary receiver operating characteristics (SROC), sensitivity, specificity and diagnostic odds ratio (DOR).

RESULTS

Data from 25 articles were included. The overall analysis showed that the area under the SROC curve of REMS, RAPS, mREMS, and WPS criteria were 0.83 (95% CI: 0.79-0.86), 0.89 (95% CI: 0.86-0.92), 0.64 (95% CI: 0.60-0.68) and 0.86 (95% CI: 0.83-0.89), respectively. DOR for REMS, RAPS, mREMS and WPS models were 11 (95% CI: 8-16), 13 (95% CI: 4-41), 2 (95% CI: 2-4) and 17 (95% CI: 5-59) respectively. When analyses were limited to trauma patients, the DOR of the REMS and RAPS models were 112 and 431, respectively. Due to the lack of sufficient studies, it was not possible to limit the analyses for mREMS and WPS.

CONCLUSION

The findings of the present study showed that three models of RAPS, REMS and WPS have a high predictive value for in-hospital mortality. In addition, the value of these models in trauma patients is much higher than other patient settings.

Internal validation and comparison of the prognostic performance of models based on six emergency scoring systems to predict in-hospital mortality in the emergency department

Background

Medical scoring systems are potentially useful to make optimal use of available resources. A variety of models have been developed for illness measurement and stratification of patients in Emergency Departments (EDs). This study was aimed to compare the predictive performance of the following six scoring systems: Simple Clinical Score (SCS), Worthing physiological Score (WPS), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), Modified Early Warning Score (MEWS), and Routine Laboratory Data (RLD) to predict in-hospital mortality.

Methods

A prospective single-center observational study was conducted from March 2016 to March 2017 in Edalatian ED in Emam Reza Hospital, located in the northeast of Iran. All variables needed to calculate the models were recorded at the time of admission and logistic regression was used to develop the models’ prediction probabilities. The Area Under the Curve for Receiver Operating Characteristic (AUC-ROC) and Precision-Recall curves (AUC-PR), Brier Score (BS), and calibration plots were used to assess the models’ performance. Internal validation was obtained by 1000 bootstrap samples. Pairwise comparison of AUC-ROC was based on the DeLong test.

Results

A total of 2205 patients participated in this study with a mean age of 61.8 ± 18.5 years. About 19% of the patients died in the hospital. Approximately 53% of the participants were male. The discrimination ability of SCS, WPS, RAPS, REMS, MEWS, and RLD methods were 0.714, 0.727, 0.661, 0.678, 0.698, and 0.656, respectively. Additionally, the AUC-PR of SCS, WPS, RAPS, REMS, EWS, and RLD were 0.39, 0.42, 0.35, 0.34, 0.36, and 0.33 respectively. Moreover, BS was 0.1459 for SCS, 0.1713 for WPS, 0.0908 for RAPS, 0.1044 for REMS, 0.1158 for MEWS, and 0.073 for RLD. Results of pairwise comparison which was performed for all models revealed that there was no significant difference between the SCS and WPS. The calibration plots demonstrated a relatively good concordance between the actual and predicted probability of non-survival for the SCS and WPS models.

Conclusion

Both SCS and WPS demonstrated fair discrimination and good calibration, which were superior to the other models. Further recalibration is however still required to improve the predictive performance of all available models and their use in clinical practice is still unwarranted.

Rapid Emergency Medicine Score as a Predictive Value for 30-day Outcome of Nonsurgical Patients Referred to the Emergency Department

Background and aims

Multiple scoring systems are designed and prepared nowadays that can be used to determine and predict the severity, morbidity, and mortality rate of patients. Among them, the rapid emergency medicine score (REMS) system has been designed to predict the motility of nonsurgical patients admitted to the emergency department (ED). This study was performed with the aim of evaluating the predictive value of REMS in the mortality rate of nonsurgical patients.

Materials and methods

This study was carried out in 2017 among 300 nonsurgical patients referred to the ED. Data were collected using a checklist containing two parts of demographic information and REMS scale.

Results

Based on the results, we found a significant correlation between the duration of hospitalization and other parameters of the study. The results of this study indicated that the REMS of patients increased by 11%, 3%, and 5%, per each unit rise in patient’s age, heart rate, and respiratory rate, respectively. On the contrary, 12% and 22% decrements for every unit increase in SPO₂ and GCS levels were observed, respectively. All the reported findings were statistically significant.

Conclusion

In sum, the outcomes of the present study corroborate the REMS system as a successful scale in predicting mortality and the duration of hospitalization in nonsurgical ED patients.

How to cite this article

Ala A, Vahdati SS, Jalali M, Parsay S. Rapid Emergency Medicine Score as a Predictive Value for 30-day Outcome of Nonsurgical Patients Referred to the Emergency Department. Indian J Crit Care Med 2020;24(6):418–422.

Rapid Emergency Medicine Score-Reinventing Prognostication in Emergency Care

Bajan K. Rapid Emergency Medicine Score-Reinventing Prognostication in Emergency Care. Indian J Crit Care Med 2020;24(6):378-379.

Risk of Mortality on Patients with Traffic Accidents of Emergency Department at dr. Soebandi Hospital, Jember Regency

Introduction: The number of deaths due to traffic accidents has become a global burden. In addition SDGs 2030 has set a target to decrease the number of fatalities and global injuries due to traffic accidents. The purpose of this study was to analyse the risk of mortality due to traffic accidents in the Emergency Department (ED) of dr.Soebandi Hospital Regional, Jember Regency.Methods: A retrospective observational study was carried out in the ED by studying medical records of the traffic accident patients aged ≥16 years. The sampling technique was simple random sampling with sample size 250. The study collected data with Modified Rapid Emergency Medicine Score. This study result was analyzed with frequency distribution and Chi-square test.Results: The result showed respondents who experienced traffic accidents were mostly 20-29 years old (19.6%). The majority of the patients were men (68.4%). The riders of two/three-wheeled vehicles who suffered traffic accidents reached 73.2%. Most of the accidents   occurred between 06.00-11.59am, 37.6%. Generally, traffic accidents occur to drivers as much as 68.4% and the number of types of head trauma as much as 57.2%. This study showed that 94.8% patients were at low risk of mortality. There was significant relationship between risk of mortality and the role in vehicle use (p-value = 0.043).Conclusion: Almost all patients have a low risk of mortality in the ED of dr. Soebandi Hospital Jember Regency.

Optimal treatment strategies for hepatic portal venous gas: A retrospective assessment

BACKGROUND

Hepatic portal venous gas (HPVG) generally indicates poor prognoses in patients with serious intestinal damage. Although surgical removal of the damaged portion is effective, some patients can recover with conservative treatments.

AIM

To establish an optimal treatment strategy for HPVG, we attempted to generate computed tomography (CT)-based criteria for determining surgical indication, and explored reliable prognostic factors in non-surgical cases.

METHODS

Thirty-four cases of HPVG (patients aged 34-99 years) were included. Necessity for surgery had been determined mainly by CT findings (i.e. free-air, embolism, lack of contrast enhancement of the intestinal wall, and intestinal pneumatosis). The clinical data, including treatment outcomes, were analyzed separately for the surgical cases and non-surgical cases.

RESULTS

Laparotomy was performed in eight cases (surgical cases). Seven patients (87.5%) survived but one (12.5%) died. In each case, severe intestinal damage was confirmed during surgery, and the necrotic portion, if present, was removed. Non-occlusive mesenteric ischemia was the most common cause (n = 4). Twenty-six cases were treated conservatively (non-surgical cases). Surgical treatments had been required for twelve but were abandoned because of the patients' poor general conditions. Surprisingly, however, three (25%) of the twelve inoperable patients survived. The remaining 14 of the 26 cases were diagnosed originally as being sufficiently cured by conservative treatments, and only one patient (7%) died. Comparative analyses of the fatal (n = 10) and recovery (n = 16) cases revealed that ascites, peritoneal irritation signs, and shock were significantly more frequent in the fatal cases. The mortality was 90% if two or all of these three clinical findings were detected.

CONCLUSION

HPVG related to intestinal necrosis requires surgery, and our CT-based criteria are probably useful to determine the surgical indication. In non-surgical cases, ascites, peritoneal irritation signs and shock were closely associated with poor prognoses, and are applicable as predictors of patients' prognoses.

Portal Venous Gas in Adults: Clinical Significance, Management, and Outcomes of 25 Consecutive Patients

BACKGROUND

Portal venous gas (PVG) is a rare finding and has a grave prognosis. The most common and critical underlying pathology of PVG is bowel necrosis. However, bowel necrosis is sometimes difficult to accurately diagnose. We retrospectively analyzed data from patients that contributed to the decision to perform emergency surgery and bowel resection.

METHODS

Between 2009 and 2019, 25 consecutive adult patients with PVG were identified retrospectively and divided into the Operation and Non-operation groups. The Operation group was further subdivided into the Bowel resection and Non-resection groups. Clinical, laboratory, and radiographic variables were analyzed.

RESULTS

Conservative management was successful for 32% (8/25) of patients (Non-operation group: mortality 0%); 68% (17/25) were treated surgically (Operation group: mortality 35.3%). In the Operation group, 52.9% (9/17) underwent bowel resection (Bowel resection group: mortality 55.6%); however, bowel resection was unnecessary in 47.1% (8/17) of cases (Non-resection group: mortality 12.5%). Univariate analysis revealed significant differences between the Operation and Non-operation groups in GCS, APACHE II, abdominal distention, CRP, lactate, and CT findings of bowel dilatation, pneumatosis intestinalis, and attenuation of contrast effects of the bowel wall. However, with the exception of GCS, there was no significant difference between the Bowel resection and Non-resection groups.

CONCLUSIONS

Analysis of clinical, laboratory, and radiographic variables can inform decisions on conservative management. However, 47.1% of the present patients who underwent surgery for suspected bowel necrosis did not require bowel resection, suggesting that this approach alone may not be sufficient to avoid non-therapeutic laparotomy. A new approach should be developed to improve this situation.

Vital Signs Data and Probability of Hospitalization, Transfer to Another Facility, or Emergency Department Death Among Adults Presenting for Medical Illnesses to the Emergency Department at a Large Urban Hospital in the United States

BACKGROUND

Vital signs are routinely measured from patients presenting to the emergency department (ED), but how they predict clinical outcomes like hospitalization is unclear.

OBJECTIVES

To evaluate how pulse, respiratory rate, temperature, and mean arterial pressure (MAP) at ED presentation predicted probability of hospitalization, transfer to another center, or death in the ED (as a composite outcome) vs. other ED dispositions (discharged, eloped, and sent to observation or labor and delivery), and to assess the performance of different modeling strategies, specifically, models including flexible forms of vital signs (as restricted cubic splines) vs. linear forms (untransformed numeric variables) vs. binary transformations (vital signs values categorized simply as normal or abnormal).

METHODS

We analyzed the data of 12,660 adults presenting for medical illnesses to the ED at the University of California, San Francisco Medical Center, San Francisco, California, throughout 2014. We used flexible forms of vital signs data at presentation (pulse, temperature, respiratory rate, and MAP) to predict ED disposition (admitted, transferred, or died, vs. other ED dispositions) and to guide binary transformation of vital signs. We compared performance of models including vital signs as flexible terms, binary transformations, or linear terms.

RESULTS

A model including flexible forms of vital signs and age to predict the outcome had good calibration and moderate discrimination (C-statistic = 71.2, 95% confidence interval [CI] 70.0-72.4). Binary transformation of vital signs had minimal impact on performance (C-statistic = 71.3, 95% CI 70.2-72.5). A model with linear forms was less calibrated and had slightly reduced discrimination (C-statistic = 70.3, 95% CI 69.1-71.5).

CONCLUSIONS

Findings suggest that flexible modeling of vital signs may better reflect their association with clinical outcomes. Future studies to evaluate how vital signs could assist clinical decision-making in acute care settings are suggested.

Predicting need for intensive care unit admission in adult emphysematous pyelonephritis patients at emergency departments: comparison of five scoring systems

This study assesses the performance of National Early Warning Score (NEWS), Quick Sepsis-related Organ Failure Assessment (qSOFA), Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), and Rapid Acute Physiology Score (RAPS) in predicting emphysematous pyelonephritis (EPN) patients' need for intensive care unit (ICU) admission. A retrospective analysis was conducted at four training and research hospitals' emergency departments (EDs) on all EPN adult patients from January 2007 to August 2017. Data extracted were used to calculate raw scores for five physiologic scoring systems. Mann-Whitney U tests and χ² tests were done for numerical and categorical variables respectively to examine differences between characteristics of ICU and non-ICU patient populations. Predictability of ICU admission was evaluated with AUROC analysis. ICU patients had lower GCS scores, SpO2, platelet counts, and estimated glomerular filtration rate; and higher bands, blood urea nitrogen, creatinine, and incidences of septic shock and nephrectomy. NEWS performed best, with 73.85% accuracy at optimal cut-off of 3. In this multicentre ED EPN series, we recommend using NEWS in early identification of critical EPN patients and advance planning for ICU admission. This would reduce delays in ICU transfer and ultimately improve patient outcomes.

Risk Factors for Non-optimal Resource Utilization for Emergent Interfacility Transfers by Air Ambulance in Ontario

Background: The use of air ambulance to facilitate interfacility transfer has been associated with improved mortality; however, air ambulance is a limited resource and sometimes the optimal resource to transport a patient is unavailable. When a non-optimal resource is used there is an inherent delay and critically unwell patients may deteriorate as a result. This study aimed to identify risk factors associated with non-optimal resource utilization for adult patients undergoing emergent interfacility transport by air ambulance in Ontario, Canada. A secondary objective was to determine if non-optimal resource utilization was associated with deterioration in clinical status by measuring a delta rapid emergency medicine score (REMS). Methods: This was a retrospective cohort study of all emergent, adult interfacility transfers transported by air ambulance over a 5-year period in Ontario, Canada. Determination of optimal resource use was based on distances and historic time data for all sending-receiving facility pairs. A logistic regression model was used to explore patient, provider and institutional risk factors for non-optimal resource use. To explore the secondary objective a linear regression model was used to explore impact of non-optimal resource use on deltaREMS. Results: There were a total of 9,687 patients included in the study cohort, with 4,984 having an optimal resource use and 4,703 having non-optimal resource. The median delay in interfacility transfer caused by a non-optimal transfer strategy was 35.7 minutes. Patients who required mechanical ventilation (OR 1.13, p = 0.031) and or were transferred out of nursing stations had higher odds of non-optimal resource use (OR 2.84, p = 0.019). Paramedic level of care of advanced (OR 0.37, p = < 0.001) and critical care (OR 0.28, p = < 0.001) as well as spring season (OR 0.75, p = < 0.001) had lower odds of non-optimal resource utilization. Optimal resource utilization did not significantly affect delta REMS (beta coefficient 0.002, p = 0.64). Conclusions: Patients who required mechanical ventilation and were transferred out from a nursing station had higher odds of non-optimal resource utilization while patients that required advanced or critical care level of care and spring season had lower odds of non-optimal resource use. Additionally, non-optimal resource use for air ambulance interfacility transfers did not result in patient deterioration as measured by a delta REMS score.

The Rapid Emergency Medicine Score: A Critical Appraisal of Its Measurement Properties and Applicability to the Air Retrieval Environment

OBJECTIVE

The Rapid Emergency Medicine Score (REMS) was designed to predict in-hospital mortality using variables that are available in the prehospital setting. The objective of this article is to critically appraise the development and summarize the evidence regarding the measurement properties (sensitivity, reliability and validity) of the REMS.

METHODS

A literature search was performed identifying all studies describing the REMS. The original validation study was critically appraised for its development. All other studies that reported any measurement properties of the REMS were also appraised for evidence of calibration, reliability, and validity.

RESULTS

In total, 26 studies reported on the measurement properties of the REMS. Overall, the REMS was developed with robust methodology and has good sensibility with adequate content and face validity. It is easy to understand and feasible to be calculated within minutes of patient assessment. The REMS has the necessary measurement properties to be both a predictive and evaluative clinical index to measure prehospital severity of illness; however, no studies have adequately addressed the intra or inter-rater reliability of the score.

CONCLUSIONS

There is evidence to support the use of the REMS as a predictive or evaluative instrument. In most studies, it performed as well or better than other illness severity scores in predicting mortality.

Comparing the effectiveness of three scoring systems in predicting adult patient outcomes in the emergency department

This study aimed to evaluate the performance of the rapid acute physiology score (RAPS), the rapid emergency medicine score (REMS), and the modified early warning score (MEWS) in predicting the outcomes of adult patients presenting to the emergency department (ED).A retrospective review was undertaken between February 2014 and February 2018 in an adult ED of a 3300-bed university hospital. The RAPS, REMS, and MEWS were calculated to assess their capability to predict hospital admission, length of hospital stay, and in-hospital mortality, using area under receiver operating characteristic analysis. Multivariate analysis was used to identify variables that were independent predictors of the outcomes.We included 39,977 patients who had presented to the ED during 48 consecutive months, of whom 4857 were admitted and 213 died in hospital. The predictabilities of REMS, RAPS, and MEWS for hospital admission were 0.76, 0.59, and 0.55, respectively; the predictability of REMS, RAPS, and MEWS for hospital mortality were 0.88, 0.72, and 0.73, respectively; and the predictability of REMS, RAPS, and MEWS for length of hospital stay were 0.76, 0.67, and 0.65, respectively. Multivariate analysis showed that the Glasgow coma scale (GCS) (odds ratio (OR), 1.61; P < .001), age (OR, 1.50; P < .001), and MAP (OR, 1.27; P < .001) were independent predictors for hospital admission; GCS (OR, 2.92; P < .001), respiratory rate (RR) (OR, 2.69; P < .001), peripheral oxygen saturation (OR, 2.67; P < .001), MAP (OR, 2.11; P < .001), age (OR, 1.75; P < .001), and pulse rate (PR) (OR, 1.73; P < .001) were independent predictors for in-hospital mortality; and RR (OR, 1.41; P < .001), temperature (OR, 1.05; P = .01), and PR (OR, 0.96; P = .04) were independent predictors for length of hospital stay.Our study evaluated and confirmed the REMS as a powerful predictor of ED adult patient outcomes, including hospital admission, length of hospital stay, and in-hospital mortality compared to RAPS and MEWS.

Performance Assessment of the Mortality in Emergency Department Sepsis Score, Modified Early Warning Score, Rapid Emergency Medicine Score, and Rapid Acute Physiology Score in Predicting Survival Outcomes of Adult Renal Abscess Patients in the Emergency Department

Background

Renal abscess is a relatively uncommon yet debilitating and potentially fatal disease. There is no clearly defined, objective risk stratification tool available for emergency physicians' and surgeons' use in the emergency department (ED) to quickly determine the appropriate management strategy for these patients, despite early intervention having a beneficial impact on survival outcomes.

Objective

This case control study evaluates the performance of Mortality in Emergency Department Sepsis Score (MEDS), Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), and Rapid Acute Physiology Score (RAPS) in predicting risk of mortality in ED adult patients with renal abscess. This will help emergency physicians, surgeons, and intensivists expedite the time-sensitive decision-making process.

Methods

Data from 152 adult patients admitted to the EDs of two training and research hospitals who had undergone a contrast-enhanced computed tomography scan of the abdomen and was diagnosed with renal abscess from January 2011 to December 2015 were analyzed, with the corresponding MEDS, MEWS, REMS, RAPS, and mortality risks calculated. Ability to predict patient mortality was assessed via receiver operating curve analysis and calibration analysis.

Results

MEDS was found to be the best performing physiologic scoring system, with sensitivity, specificity, and accuracy of 87.50%, 88.89%, and 88.82%, respectively. Area under receiver operating characteristic curve (AUROC) value was 0.9440, and negative predictive value was 99.22% with a cutoff of 9 points.

Conclusion

Our study is the largest of its kind in examining ED patients with renal abscess. MEDS has been demonstrated to be superior to MEWS, REMS, and RAPS in predicting mortality for this patient population. We recommend its use for evaluation of disease severity and risk stratification in these patients, to expedite identification of critically ill patients requiring urgent intervention.