title: A targeted real-time early warning score (TREWScore) for septic shock.
abstract: Sepsis is a leading cause of death in the United States, with mortality highest among patients who develop septic shock. Early aggressive treatment decreases morbidity and mortality. Although automated screening tools can detect patients currently experiencing severe sepsis and septic shock, none predict those at greatest risk of developing shock. We analyzed routinely available physiological and laboratory data from intensive care unit patients and developed "TREWScore," a targeted real-time early warning score that predicts which patients will develop septic shock. TREWScore identified patients before the onset of septic shock with an area under the ROC (receiver operating characteristic) curve (AUC) of 0.83 [95% confidence interval (CI), 0.81 to 0.85]. At a specificity of 0.67, TREWScore achieved a sensitivity of 0.85 and identified patients a median of 28.2 [interquartile range (IQR), 10.6 to 94.2] hours before onset. Of those identified, two-thirds were identified before any sepsis-related organ dysfunction. In comparison, the Modified Early Warning Score, which has been used clinically for septic shock prediction, achieved a lower AUC of 0.73 (95% CI, 0.71 to 0.76). A routine screening protocol based on the presence of two of the systemic inflammatory response syndrome criteria, suspicion of infection, and either hypotension or hyperlactatemia achieved a lower sensitivity of 0.74 at a comparable specificity of 0.64. Continuous sampling of data from the electronic health records and calculation of TREWScore may allow clinicians to identify patients at risk for septic shock and provide earlier interventions that would prevent or mitigate the associated morbidity and mortality.
authors.affiliation: Department of Computer Science, Johns Hopkins University, Baltimore, MD 21218, USA.
authors.forename: Katharine E
authors.initials: KE
authors.lastname: Henry
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA.
authors.forename: David N
authors.initials: DN
authors.lastname: Hager
authors.affiliation: Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD 21202, USA. Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD 21202, USA. Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Pronovost
authors.affiliation: Department of Computer Science, Johns Hopkins University, Baltimore, MD 21218, USA. Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD 21202, USA. Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA. Department of Applied Math and Statistics, Johns Hopkins University, Baltimore, MD 21218, USA. ssaria@cs.jhu.edu.
authors.forename: Suchi
authors.initials: S
authors.lastname: Saria
mesh_terms: D061345:Early Medical Intervention; D006801:Humans; D007362:Intensive Care Units; D057216:Propensity Score; D012372:ROC Curve; D055502:Secondary Prevention; D012772:Shock, Septic / Q000175:diagnosis* / Q000628:therapy*; D014481:United States