Development and validation of a parsimonious and pragmatic CHARM score to predict mortality in patients with suspected sepsis.
BACKGROUND
We aimed to derive and validate a parsimonious and pragmatic clinical prediction rule using the concepts of Predisposition, Infection, Response, and Organ Dysfunction to predict in-hospital mortality; and to compare it with other prediction rules, as well as with conventional biomarkers for evaluating the mortality risk of patients with suspected sepsis in the emergency department (ED).


METHODS
We conducted a pragmatic cohort study with consecutive ED patients aged 18 or older with documented diagnostic codes of infection and two sets of blood culture ordered by physicians between 2010 and 2012 in a tertiary teaching hospital.


RESULTS
7011 and 12,110 patients were included in the derivation cohort and the validation cohort for the final analysis. There were 479 deaths (7%) in the derivation cohort and 1145 deaths (9%) in the validation cohort. Independent predictors of death were absence of Chills (odds ratio: 2.28, 95% confidence interval: 1.75-2.97), Hypothermia (2.12, 1.57-2.85), Anemia (2.45, 1.97-3.04), wide Red cell Distribution Width (RDW) (3.27, 2.63-4.05) and history of Malignancy (2.00, 1.63-2.46). This novel clinical prediction rule (CHARM) performed well for stratifying patients into mortality risk groups (sensitivity: 99.4%, negative predictive value 99.7%, receiver operating characteristic area 0.77). The CHARM score also outperformed the other scores or biomarkers such as PIRO, SIRS, MEDS, CURB-65, C-reactive protein, procalcitonin and lactate (all p<.05).


CONCLUSIONS
In patients with suspected sepsis, this parsimonious and pragmatic model could be utilized to stratify the mortality risk of patients in the early stage of sepsis.
Department of Emergency Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan; Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan; Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan. Electronic address: drkfchen@gmail.com.
Kuan-Fu
KF
Chen
Department of Family Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan. Electronic address: shliu41@mail.cgu.edu.tw.
Su-Hsun
SH
Liu
Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan. Electronic address: chhli2002@gmail.com.
Chih-Huang
CH
Li
Department of Emergency Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan. Electronic address: wujinja@gmail.com.
Chin-Chieh
CC
Wu
Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan. Electronic address: m7088@adm.cgmh.org.tw.
Chung-Hsien
CH
Chaou
Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan. Electronic address: istzeng@gmail.com.
I-Shiang
IS
Tzeng
Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA. Electronic address: yhsieh1@jhmi.edu.
Yu-Hsiang
YH
Hsieh
Department of Emergency Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan. Electronic address: gblaney3@gmail.com.
Gerald N
GN
Blaney
Department of Emergency Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan. Electronic address: zhenyingtw@gmail.com.
Zhen-Ying
ZY
Liu
Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan. Electronic address: adrianhst@gmail.com.
Shih-Tsung
ST
Han
Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan. Electronic address: chan.yiling@gmail.com.
Yi-Lin
YL
Chan
D000368:Aged; D000369:Aged, 80 and over; D000740:Anemia / Q000453:epidemiology; D015415:Biomarkers / Q000097:blood; D002097:C-Reactive Protein / Q000378:metabolism; D002116:Calcitonin / Q000097:blood; D023341:Chills / Q000453:epidemiology; D015331:Cohort Studies; D015897:Comorbidity; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital; D004909:Erythrocyte Indices; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007035:Hypothermia / Q000453:epidemiology; D019344:Lactic Acid / Q000097:blood; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000453:epidemiology; D016017:Odds Ratio; D011379:Prognosis; D012372:ROC Curve; D012189:Retrospective Studies; D018805:Sepsis / Q000097:blood / Q000453:epidemiology / Q000401:mortality*; D062606:Tertiary Care Centers
D015415:Biomarkers; D019344:Lactic Acid; D002116:Calcitonin; D002097:C-Reactive Protein
Clinical prediction rule; Mortality; Outcome; Sepsis; Severity of illness index