title: Internal emergency department validation of the simplified MISSED score.
abstract: BACKGROUND
  The MISSED score was derived and validated in emergency department (ED) patients with sepsis who were admitted to the ICU. This score has now been refined and simplified. The independent variables associated with mortality are age at least 65 years, serum albumin 27 g/l or less, and an international normalized ratio at least 1.3. The simplified MISSED score ranges from 0 to 3 depending on the number of variables present.
  
  
  OBJECTIVE
  The primary objective is to validate the simplified MISSED score for predicting all-cause mortality in the ED population admitted with sepsis. The secondary end-point is to validate the risk stratification for ICU admission.
  
  
  METHODS
  This is a pragmatic retrospective study of prospectively collected data. ED patients admitted with a diagnosis of sepsis in the year 2012 were studied. Those on warfarin were excluded. The simplified MISSED score was calculated for each patient. The test characteristics for mortality of the simplified MISSED score and the odds ratios of the high-risk groups for the secondary end-point were calculated.
  
  
  RESULTS
  In total, 674 patients, including 65 deaths, were studied. The area under the curve for the simplified MISSED score was 0.74 [95% confidence interval (CI) 0.70-0.77; P<0.0001]. The test characteristics for mortality were as follows: sensitivity 93.9% (95% CI 85-98.3), specificity 37.9% (95% CI 34.1-41.9), positive predictive value 13.9% (95% CI 10.8-17.5), and negative predictive value 98.3% (95% CI 95.7-99.5). The odds ratio for mortality for a score 2 or more was 5.01 (95% CI 2.93-8.57; P<0.0001), and that for ICU admission was 3.00 (95% CI 1.70-5.28; P=0.0001).
  
  
  CONCLUSIONS
  The simplified MISSED score could be used to risk stratify septic patients in the ED.
authors.affiliation: Departments of aEmergency Medicine bIntensive Care Medicine, St George's Healthcare NHS Trust and St George's University of London, London, UK.
authors.forename: Narani
authors.initials: N
authors.lastname: Sivayoham
authors.forename: Paul
authors.initials: P
authors.lastname: Holmes
authors.forename: Maurizio
authors.initials: M
authors.lastname: Cecconi
authors.forename: Andrew
authors.initials: A
authors.lastname: Rhodes
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019540:Area Under Curve; D002423:Cause of Death; D015331:Cohort Studies; D016001:Confidence Intervals; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D004638:Emergency Treatment / Q000379:methods; D005260:Female; D017052:Hospital Mortality; D006784:Hospitals, Teaching; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007388:Internal Medicine; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012372:ROC Curve; D012189:Retrospective Studies; D018805:Sepsis / Q000175:diagnosis* / Q000401:mortality* / Q000628:therapy; D012720:Severity of Illness Index; D012772:Shock, Septic / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D018709:Statistics, Nonparametric; D006113:United Kingdom