title: Intensive care unit scoring systems outperform emergency department scoring systems for mortality prediction in critically ill patients: a prospective cohort study.
abstract: BACKGROUND
  Multiple scoring systems have been developed for both the intensive care unit (ICU) and the emergency department (ED) to risk stratify patients and predict mortality. However, it remains unclear whether the additional data needed to compute ICU scores improves mortality prediction for critically ill patients compared to the simpler ED scores.
  
  
  METHODS
  We studied a prospective observational cohort of 227 critically ill patients admitted to the ICU directly from the ED at an academic, tertiary care medical center. We compared Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, Simplified Acute Physiology Score (SAPS) II, Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), Prince of Wales Emergency Department Score (PEDS), and a pre-hospital critical illness prediction score developed by Seymour et al. (JAMA 2010, 304(7):747-754). The primary endpoint was 60-day mortality. We compared the receiver operating characteristic (ROC) curves of the different scores and their calibration using the Hosmer-Lemeshow goodness-of-fit test and visual assessment.
  
  
  RESULTS
  The ICU scores outperformed the ED scores with higher area under the curve (AUC) values (p = 0.01). There were no differences in discrimination among the ED-based scoring systems (AUC 0.698 to 0.742; p = 0.45) or among the ICU-based scoring systems (AUC 0.779 to 0.799; p = 0.60). With the exception of the Seymour score, the ED-based scoring systems did not discriminate as well as the best-performing ICU-based scoring system, APACHE III (p = 0.005 to 0.01 for comparison of ED scores to APACHE III). The Seymour score had a superior AUC to other ED scores and, despite a lower AUC than all the ICU scores, was not significantly different than APACHE III (p = 0.09). When data from the first 24 h in the ICU was used to calculate the ED scores, the AUC for the ED scores improved numerically, but this improvement was not statistically significant. All scores had acceptable calibration.
  
  
  CONCLUSIONS
  In contrast to prior studies of patients based in the emergency department, ICU scores outperformed ED scores in critically ill patients admitted from the emergency department. This difference in performance seemed to be primarily due to the complexity of the scores rather than the time window from which the data was derived.
authors.affiliation: Department of Medicine, Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, UHN67, Portland, OR 97239, USA.
authors.forename: Erika M
authors.initials: EM
authors.lastname: Moseson
authors.affiliation: Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, San Francisco, CA 94143, USA.
authors.forename: Hanjing
authors.initials: H
authors.lastname: Zhuo
authors.affiliation: Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, San Francisco, CA 94143, USA.
authors.forename: Jeff
authors.initials: J
authors.lastname: Chu
authors.affiliation: Department of Emergency Medicine, Sutter Medical Center of Santa Rosa, Santa Rosa 95404, USA.
authors.forename: John C
authors.initials: JC
authors.lastname: Stein
authors.affiliation: Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, San Francisco, CA 94143, USA ; Department of Anesthesia, University of California, San Francisco, San Francisco, CA 94143, USA ; Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA 94143, USA.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Matthay
authors.affiliation: Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA 94143, USA.
authors.forename: Kirsten N
authors.initials: KN
authors.lastname: Kangelaris
authors.affiliation: Department of Anesthesia, University of California, San Francisco, San Francisco, CA 94143, USA ; Department of Medicine, Division of Nephrology, University of California, San Francisco, San Francisco, CA 94143, USA.
authors.forename: Kathleen D
authors.initials: KD
authors.lastname: Liu
authors.affiliation: Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, San Francisco, CA 94143, USA ; Department of Anesthesia, University of California, San Francisco, San Francisco, CA 94143, USA.
authors.forename: Carolyn S
authors.initials: CS
authors.lastname: Calfee
keywords: APACHE; Calibration; Critical illness; Emergency medicine; Intensive care unit; Mortality; SAPS