original article

Wien Klin Wochenschr (2013) 125:508515

DOI 10.1007/s00508-013-0407-2

Wiener klinische Wochenschrift

The Central European Journal of Medicine

Severity illness scoring systems for early

identification and prediction of in-hospital mortality
in patients with suspected sepsis presenting to the
emergency department
FelicitasGeier SteffenPopp YvonneGreve AndreasAchterberg ErikaGlckner
RenateZiegler Hans JrgenHeppner HaraldMang MichaelChrist
Received: 6 March 2013 / Accepted: 14 July 2013 / Published online: 10 August 2013
Springer-Verlag Wien 2013

Summary The in-hospital mortality of patients with

severe sepsis and septic shock (SSSS) is high. In this
study we examined the diagnostic and prognostic
accuracy of the emergency severity index (ESI), the
modified early warning score (MEWS), and the mortality in emergency department (ED) sepsis (MEDS)
score. This is a single-centre, prospective and observational study of 151 consecutive patients presenting
to the ED of the Nuremberg Hospital with suspected
sepsis (age 68.318 years, 54.3% men, 45% with SSSS,
in-hospital mortality of SSSS: 27.8%). In this study,
37.7% of the studied patients had a urinary tract infection (n=57/151), 33.8% a pneumonia (n=51/151),
8.6% an acute abdominal infection (n=13/151), and in
12.6% the focus of infection was not further specified
or identifiable (n=19/151). The diagnostic and prognostic accuracy was analyzed by means of the receiver
operating characteristic (ROC) curve. The areas under curve (AUC) in terms of diagnostic accuracy were
Electronic supplementary material: The online version of this
article (doi: 10.1007/s00508-013-0407-2) contains supplementary
material, which is available to authorized users.
Prof. Dr.M.Christ()F. Geier S.Popp Y.Greve
A.Achterberg E.Glckner H. J. Heppner
Department of Emergency and Critical Care Medicine,
City Hospital Nuremberg, Prof. Ernst Nathan Str. 1,
90419 Nuremberg, Germany
e-mail: michael.christ@klinikum-nuernberg.de
R.Ziegler
Institute for Microbiology and Hygiene, City Hospital Nuremberg,
Nuremberg, Germany
H. J. Heppner
Institute for Biomedicine of Aging, Friedrich-Alexander-University,
Nuremberg-Erlangen, Germany
F.Geier H.Mang
Masters Degree Program, Medical Process Management, FriedrichAlexander-University, Nuremberg-Erlangen, Germany

0.609, 0.641, and 0.778 for the ESI, MEWS, and MEDS
score respectively. The AUCs concerning prognostic accuracy were 0.617, 0.642, and 0.871 for ESI, MEWS, and
MEDS score respectively.
By using the MEDS score systematically, critically ill
patients with sepsis could be detected in the ED. Finally,
the MEDS score provides the basis for a risk adjusted
disposition management that follows objective criteria.
Keywords sepsis emergency department severity
illness scoring systems early identification prognosis

Patienten mit Verdacht auf Sepsis in einer

deutschen Notaufnahme: Risikostratifizierungsinstrumente zur Frherkennung und
Prognoseabschtzung
Zusammenfassung Patienten mit schwerer Sepsis bzw.
septischem Schock (SSSS) weisen eine hohe Krankenhaussterblichkeit auf. In der vorliegenden Untersuchung soll die diagnostische und prognostische Gte
des Emergency Severity Index (ESI), des Modified Early
Warning Scores (MEWS) und des Mortality in Emergency Department Sepsis (MEDS) Scores untersucht
werden. In einer monozentrischen, prospektiven Beobachtungsstudie wurden 151 konsekutive Patienten
eingeschlossen, die sich mit Verdacht auf Sepsis in den
Notaufnahmen des Klinikums Nrnberg vorstellten (Alter 68,318 Jahre, 54,3% Mnner; 45% mit SSSS; Krankenhaussterblichkeit der SSSS: 27,8%). Bei 37,7% der
Patienten lag eine Harnwegsinfektion vor (n=57/151),
bei 33,8% eine Pneumonie (n=51/151), bei 8,6% eine
Infektion der Bauchorgane (n=13/151) und bei 12,6%
wurde der Fokus nicht nher spezifiziert bzw. war nicht
ermittelbar (n=19/151). Die diagnostische und prognostische Gte wurde mithilfe der Receiver Operating
Characteristic (ROC)-Kurve ermittelt. Folgende AUCS

508 Severity illness scoring systems for early identification and prediction of in-hospital mortality

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original article

(area under curve) resultierten fr die diagnostische

Gte von ESI, MEWS bzw. MEDS Score: 0,609, 0,641
bzw. 0,778. Die Berechnung der prognostischen Gte
erbrachte folgende AUCs fr ESI, MEWS bzw. MEDS
Score: 0,617, 0,642 bzw. 0,871.
Die systematische Verwendung des MEDS Scores
knnte dazu beitragen, den schwer erkrankten Sepsispatienten in der Notaufnahme frhzeitig zu erkennen
und die Dispositionsentscheidung risikoadjustiert zu
treffen.
Schlsselwrter Sepsis Notaufnahme Risikostratifizierungsinstrumente Frherkennung Prognose

Introduction
Sepsis is a complex, systemic inflammatory host
immune response to infection [1]. Severe sepsis is associated with a hospital mortality of 55.2% [2]. With 59,344
deaths per year, severe sepsis is the third most common
cause of death in Germany [3]. Furthermore, Martin
et al. [4] provide evidence about significant increases
in the incidence of sepsis in the USA between 1997 and
2000 (164,072 vs. 659,935 newly diagnosed sepsis cases
per year). High mortality rates can be explained by the
presence of a systemic excessive immune response and
the wide variety of causative organisms, both in type and
in pathogenicity [5]. By identifying patients with sepsis
at an early stage and treating it according to the guidelines, the damaging consequences of pathophysiological changes can be limited [6]. However, this constitutes
a great challenge in clinical practice. Due to knowledge
gaps and/or uncertainties concerning the diagnosis of
sepsis, the highly threatened sepsis patient is at risk to
be identified too late. The use of severity illness scoring systems could provide some assistance with regard
to the early and reliable identification of patients with
severe sepsis. For example, the five-level triage system
emergency severity index (ESI) was developed in
order to assess illness severity of patients in emergency
department and according to that, set treatment priorities [7]. In addition the National Institute for Health and
Clinical Excellence in the United Kingdom argues for
using early warning scores [8]. Early warning scores
indicate critical conditions if vital signs are out of normal range.
Our aim is to evaluate the following severity illness
scoring systems concerning their diagnostic accuracy
to detect patients with severe sepsis and septic shock
(SSSS) under patients presenting with suspected sepsis
to the emergency department (ED): emergency severity
index (ESI), modified early warning score (MEWS), mortality in emergency department sepsis (MEDS) score.
Furthermore, our secondary aim is to determine their
prognostic accuracy in predicting the in-hospital mortality of patients with suspected sepsis in ED. In addition,
we calculate the prognostic value of the Charlson comorbidity index (CCI).

13

Materials and methods

Study design
This is a single-centre, prospective, and observational
study of 151 consecutive patients, presenting to the ED
of the Nuremberg Hospital with suspected sepsis from
1August to 30 September 2012. The Nuremberg Hospital,
a university teaching hospital, is a municipal hospital
that provides emergency care at two sites, with a census
of over 90,000 patients per year. Source data of consecutive patients were collected systematically in a registry
and analyzed. A study-related therapeutic or diagnostic
intervention was not carried out. The study design is consistent with the Declaration of Helsinki. In addition, the
study has been approved by the local institutional review
board.

Selection of study patients

Full age patients with suspected sepsis were included into
the study if they entered one of the EDs of the Nuremberg
Hospital during the study period. The inclusion criterion
of suspected sepsis was fulfilled if at least one of the following characteristics was present: either two or more of
the systemic inflammatory response syndrome (SIRS)criteria or a working diagnosis that included a potentially
systemic infection, a SIRS, sepsis, severe sepsis, or septic
shock.
A sepsis screening tool was provided in order to
standardize patient identification during the admission
process of ED physicians and caregivers. In addition to
this point-of-care screening, we researched the previous
day admission documents for patients fulfilling the study
inclusion criteria.

Outcome measures
The primary endpoint was the diagnostic accuracy of
the ESI, MEWS, and MEDS score in detecting critically
ill sepsis patients under those with suspected sepsis. We
also studied the chief complaints of the patients with suspected sepsis. The prognostic accuracy of the mentioned
risk stratification tools and the CCI was our secondary
aim.
Since 2009 we are using the five-level-algorithm ESI
for the assessment of the medical treatment urgency
of emergency patients. ESI level 1 is given to acute lifethreatened ill patients or to patients who require immediate initiation of diagnostics and therapy. Patients in
a high-risk situation are classified as ESI 2, initiation of
diagnostics and therapy has to start within 10min following the initial triage assessment. The higher the ESI level,
the lower the medical treatment urgency [9].
The MEWS is a simple and disease-unspecific scoring
system which can be used bedside. Its scoring system
is based on physiologic parameters of vital functions.

Severity illness scoring systems for early identification and prediction of in-hospital mortality

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Especially in highly frequented care units its use is supposed to identify patients at high risk for rapid deterioration. Its scale ranges between 0 and maximum 14
points [10].
The MEDS score was developed in order to predict
the 28-day mortality of patients presenting with infection to the ED. Its maximum value is 27. The MEDS score
is being calculated by summarizing nine weighted elements: age >65 years, nursing home resident, rapidly
terminal comorbid illness, lower respiratory infection,
bands >5%, tachypnea or hypoxemia, septic shock,
platelet count <150,000/mm3, and altered mental status
[11]. Due to the fact that we do not measure bands routinely in ED, this element was not included in the MEDS
score calculation.
The chief complaints were extracted from the ED
admission document and classified according to the
Canadian Emergency Department Information System
(CEDIS) presenting complaint list [12].
The CCI reflects type and number of comorbid chronic
diseases. If the CCI is high, the 1-year mortality in longterm studies is rather caused by comorbid diseases than
by the studied disease. If the CCI is 5 points, the probability that the patient has died due to his comorbid disease is 85%. The maximum value of the CCI is 37 [13].

Adjusted final diagnosis of sepsis

The adjusted final disease of sepsis was diagnosed using
the criteria of the International Guidelines for Management of Severe Sepsis and Septic Shock [14] of the
Surviving Sepsis Campaign. The diagnosis was made
independently by two experienced physicians of internal
and emergency medicine. Amongst others body temperature, heart frequency, and inflammatory and hemodynamic parameters were used for diagnosis, as well as
parameters that represent organ dysfunction and tissue
perfusion [14].

Statistical analysis
Statistical analyses were carried out with the software
package SPSS Statistics Version 20 (IBM, Munich).
Results are presented as means, standard deviations with
95% confidence intervals and numbers or percentages
respectively. Using the ShapiroWilk test we tested the
variables on their normal distribution. More than two
independent samples were compared using the H-Test
according to Kruskall and Wallis, in case of normal distributed and ordinal variables. The means of nominal
data were compared by means of the Pearsons Chisquared test. The p-values were not corrected according
to Bonferroni. All hypotheses testing were two-tailed,
p-values less than 0.05 indicate statistical significance.
The diagnostic and prognostic values of the respective
risk stratification tools were calculated by means of the
receiver operating characteristic (ROC) curve.

Results
In the course of the observation period we registered 151
patients that entered the ED with suspected sepsis. In
this study, 45% (n=72) of the studied patients received
the adjusted final diagnosis of SSSS; 33.1% (n=53) of
the studied patients had a so-called uncomplicated sepsis, a sepsis without organ dysfunction. Finally 21.9% of
patients (n=26) had no sepsis, but SIRS or locally confined infection.
The mean age of patients with suspected sepsis was
68.3 (18). Fifty-three patients (35.1%) were older than
70 years and 37 patients (24.5%) were older than 80 years;
54.3% of the studied patients were men. Characteristics
of vital signs, laboratory parameters, chronic comorbidities, and sources of infection are shown in Table 1. Inhospital mortality of all registered patients was 14.6%, of
patients with SSSS 27.8%.
An appropriate ESI triage level of 2 was given to
70.8% of patients with SSSS and 45.6% of patients without SSSS were assessed with an ESI level >2. In case of an
ESI level 2, 54.3% of patients actually had a SSSS. In case
of an ESI level >2, 63.2% actually had no severe sepsis.
Table2 shows the detailed characteristics of diagnostic and prognostic accuracy criteria for the ESI, MEWS,
MEDS score, and CCI. Furthermore Fig. 1 pictures the
diagnostic accuracy of the mentioned risk stratification
tools by means of a ROC-curve. With an area under curve
(AUC) of 0.778 (95% CI: 0.7040.853) the MEDS score has
the highest diagnostic accuracy among the considered
instruments. In contrast, the ESI has little diagnostic
accuracy (AUC 0.609; 95% CI: 0.5180.699), similar to the
MEWS (AUC 0.641; 95% CI: 0.5520.730). Mean MEWS
value of patients with SSSS is 3.9 points. Patients with
an uncomplicated sepsis (and patients without sepsis
respectively) show a mean MEWS value of 3.28 (and 1.81
respectively). For further information, the study results
of Subbe et al. indicate a critical status of ED patients
with a MEWS value 5 [10].
Chief complaints of study patients are heterogeneous.
Table 3 lists the most documented chief complaints of
patients who were admitted to the ED with suspected
sepsis. These are fever (21.2%), dyspnea (15.2%), and
unspecified minor complaints (11.9%) which are defined
as a deterioration of the general state of health. There is
no significant difference among the three groups examined concerning the frequency of their chief complaints,
with the exception of the chief complaint altered level
of consciousness (p=0.029), which was more often in
patients with SSSS.
Figure 2 pictures the prognostic accuracy of the ESI,
MEWS, MEDS score, and CCI in predicting the in-hospital mortality of patients with suspected sepsis in the
ED. With an AUC value of 0.871 (95% CI: 0.7960.945) the
MEDS score has the highest prognostic accuracy.
The distribution of the MEDS score calculated risk
groups in patients with suspected sepsis, is as follows:
60.3% of patients have a low risk of 28-day mortality
(MEDS score = 07 points), 25.8% have a moderate risk to

510 Severity illness scoring systems for early identification and prediction of in-hospital mortality

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original article

Table 1 Demographic and baseline characteristics of patients with suspected sepsis, in accordance to their final adjusted
disease
Variables

Overall cohort (n=151)

No sepsis (n=26)

Uncomplicated sepsis (n=53)

SSSS (n=72)

Demography
Age*

68.318

58.817.9

64.520.6

74.613.3

<0.001

Men, n (%)

82 (54.3)

16 (61.5)

28 (52.8)

38 (52.8)

0.718

Vital signs
Respiration rate, 1/min*

207

175

206

218

0.015

Oxygen saturation, %*

945

972

954

935

<0.001

Pulse rate, 1/min*

10121

9019

10518

10123

0.009

Systolic blood pressure,

mmHg*

12828

13028

13821

11931

<0.001

Temperature, C*

381.1

37.70.8

38.50.8

37.81.3

0.001

Laboratory parameters
Leucocytes, 103/L*

14.310.5

11.48

13.14.9

16.313.6

0.005

Thrombocytes, /nl

233.6115.9

268.5130

228.893.7

224.6124.2

0.169

Lactate, mmol/L*

2.31.5

1.60.6

1.60.5

2.91.8

<0.001

Base deficit, mmol/L*

1.15

1.92.6

0.92.2

2.95.8

<0.001

Creatinine, mg/dl*

1.71.5

1.51.6

1.31.2

2.11.7

0.001

CRP, mg/dl

12.610.7

9.27.5

1110.2

1511.7

0.051

Procalcitonin, ng/ml*

9.329.5

0.81.7

3.19.3

14.137.3

0.020

52 (34.4)

7 (26.9)

13 (24.5)

32 (44.4)

0.046

Chronic comorbid diseases

Diabetes, n (%)*
Any tumor (5y), n (%)

42 (27.8)

6 (23.1)

17 (32.1)

19 (26.4)

0.656

Heart failure, n (%)

40 (26.5)

2 (7.7)

16 (30.2)

22 (30.6)

0.058

Dementia, n (%)*

40 (26.5)

4 (15.4)

8 (15.1)

28 (38.9)

0.004

Renal disease, n (%)

40 (26.5)

4 (15.4)

13 (24.5)

23 (31.9)

0.240

Cerebrovascular
disease, n (%)

28 (18.5)

2 (7.7)

7 (13.2)

19 (26.4)

0.051

Pulmonary disease,
n (%)

22 (14.6)

1 (3.8)

9 (17)

12 (16.7)

0.234

Others, n (%)

78 (51.7)

Charlson comorbidity
index

43 [34]

33 [24]

33 [24]

43 [35]

0.052

Urinary tract infection,

n (%)*

57 (37.7)

5 (19.2)

14 (26.4)

38 (52.8)

0.001

Pneumonia, n (%)*

51 (33.8)

1 (3.8)

23 (43.4)

27 (37.5)

0.001

Acute abdominal
infection, n (%)

13 (8.6)

1 (3.8)

5 (9.4)

7 (9.7)

0.635

Tissue/bone, n (%)

10 (6.6)

1 (3.8)

6 (11.3)

3 (4.2)

0.232

Others, n (%)

9 (6)

Source of infection

*A p-value 0.05 indicates statistical significance among the groups no sepsis, uncomplicated sepsis, and SSSS

die within 28 days (MEDS score = 812 points), and 13.2%

of the studied patients have a high risk of 28-day mortality (MEDS score 13 points). Figure 3 illustrates these
different MEDS calculated risk groups and the respective
disposition patterns from ED (this figure was adjusted to
eliminate influences concerning cases in which the will
of the patient or its dependants limited a free and independent decision concerning disposition). While 20.3%
of patients with a low risk of 28-day mortality were admitted to an intensive care unit (ICU) or intermediate care

13

unit (IMC), 46.7% of patients with a high risk to die have

been admitted to usual care wards.

Discussion
This is the first study evaluating the diagnostic and prognostic accuracy of the ESI triage system, the MEWS,
MEDS score, and CCI in patients with suspected sepsis
presenting to a German-speaking ED. The main results

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Table 2 Diagnostic and prognostic accuracy criteria of

different risk stratification tools. Emergency severity index
(ESI, cut-off 2), modified early warning score (MEWS, cutoff 5), mortality in emergency department sepsis (MEDS)
score (cut-off 8) and Charlson comorbidity index (CCI, cutoff 2)
ESI

MEWS

MEDS
score

CCI

Sensitivity

0.708

0.366

0.592

Specificity

0.456

0.798

0.785

Positive predictive value

0.543

0.619

0.712

Negative predictive value

0.632

0.583

0.681

Positive likelihood ratio

1.301

1.808

2.749

Negative likelihood ratio

0.64

0.795

0.520

Sensitivity

0.727

0.429

0.857

0.818

Specificity

0.395

0.744

0.682

0.465

Positive predictive value

0.170

0.214

0.305

0.207

Negative predictive value

0.895

0.889

0.967

0.938

Positive likelihood ratio

1.203

1.675

2.697

1.530

Negative likelihood ratio

0.690

0.768

0.209

0.391

Diagnostic accuracy criteria

Prognostic accuracy criteria

CCI Charlson comorbidity index, ESI emergency severity index, MEDS mortality in emergency department sepsis, MEWS modified early warning score

Fig. 1 Receiver operating characteristic (ROC) curve of the

emergency severity index (ESI), modified early warning score
(MEWS), and mortality in emergency department sepsis
(MEDS) score. The area under the curve (AUC) pictures the
diagnostic accuracy of the mentioned tools in identifying patients with severe sepsis and septic shock (SSSS) under those
with suspected sepsis in emergency department

are the following: (1) while the MEDS score shows a significant diagnostic accuracy in identifying patients with
SSSS, ESI and MEWS do not. (2) The MEDS score is a valid
tool for prediction of in-hospital mortality in patients
with SSSS. The ESI, MEWS, and CCI show low prognostic
accuracy. (3) Patients with suspected sepsis enter the ED
with heterogeneous chief complaints like fever, dyspnea,
or deterioration of general health status. (4) About half of
patients with a high risk of 28-day mortality are admitted
to a unit of higher care like ICU or IMC.
In contrast to the MEDS score, ESI and MEWS do not
show high values of diagnostic accuracy in identifying
the critically ill sepsis patient. There are several reasons
for the low diagnostic accuracy. For being identified as
urgent emergency patient in the ESI triage assessment,
either a life-saving procedure or a high-risk situation
in terms of a potentially life-threatening symptom
is required. If the patient is confused, lethargic, disorientated, or suffers from pain, an ESI level of 2 is
indicated too. However, not every critically ill patient
with SSSS exhibits this features. Let us look at the
example of a 73-year-old man that enters the ED with
cough, yellowish secretion, and a body temperature of
39.2C. The patient actually has an organ dysfunction
of his kidney, but this is not evident at the time point
of triage assessment. According to the decision rules
of the ESI system, the patient is correctly assessed
with an ESI level of 3. Valuable minutes or even hours
can pass till physicians are able to assess the severity
of patients health status by themselves and therefore
initiate the necessary procedures. Our results indicate
that the ESI triage system has weaknesses with regard
to the early identification of critically ill patients with
severe sepsis. Patients with acute, sepsis-associated
encephalopathy or septic shock are identified reliably
by the ESI system and its criteria; sepsis patients with
acute kidney failure or strongly increased lactate levels
probably not.
The MEWS, which shows no diagnostic accuracy as
well, seldom achieves high values in our patient cohort.
Only 36.6% of patients with SSSS show a MEWS value
5 points. The average MEWS score of the critically ill
sepsis patient is 3.9, and therefore much lower than the
proposed cut-off value of 5 from Subbe et al. [10]. The
MEWS relevant values like systolic blood pressure, heart
frequency, respiratory frequency, body temperature, and
status of consciousness may be easily collected in the ED
setting but they do not seem to be out of normal range
in every case of SSSS. Given the fact that only strongly
increased or decreased values result in a high MEWS
value, many cases of SSSS remain undetected. In order
to detect critically ill patients reliably, the weighting of
small deviations could be increased.
The MEDS score calculation is based on parameters
that take greater account of organ dysfunctions. Thereby,
an organ dysfunction is operationalized through tachypnea or hypoxemia, presence of septic shock, a platelet
count lesser than 150,000/mm3, and an altered mental
status. In addition to these clinical criteria, the MEDS

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Table 3 The most documented chief complaints of patients with suspected sepsis at emergency department admission, following the classification of the Canadian Emergency Department Information System (CEDIS) presenting complaint list
Chief complaint at time point of admission

Overall cohort (n=151)

No sepsis (n=26)

Uncomplicated sepsis (n=53)

SSSS (n=72)

Fever, n (%)

32 (21.2)

6 (23.1)

15 (28.3)

11 (15.3)

0.205

Dyspnea/shortness of breath, n (%)

23 (15.2)

2 (7.7)

7 (13.2)

14 (19.4)

0.316

Minor complaints, unspecified, n (%)

18 (11.9)

3 (11.5)

4 (7.5)

11 (15.3)

0.419

Altered level of consciousness, n (%)*

11 (7.3)

2 (7.7)

0 (0)

9 (12.5)

0.029

Extremity weakness/symptoms of CVA, n (%)

7 (4.6)

0 (0)

1 (1.9)

6 (8.3)

**

Abdominal pain, n (%)

7 (4.6)

2 (7.7)

2 (3.8)

3 (4.2)

**

Abnormal lab values, n (%)

6 (4)

1 (3.8)

2 (3.8)

3 (4.2)

**

Nausea and/or vomiting, n (%)

5 (3.3)

3 (11.5)

2 (3.8)

0 (0)

**

Others, n (%)

42 (27.8)

CVA cerebrovascular accident, SSSS severe sepsis and septic shock

*A p-value 0.05 indicates statistical significance among the groups no sepsis, uncomplicated sepsis, and SSSS
**Due to the small group size no significance testing was performed

Fig. 2 Receiver operating characteristic (ROC) curve of the

emergency severity index (ESI), modified early warning score
(MEWS), mortality in emergency department sepsis (MEDS)
score, and Charlson comorbidity index (CCI). The area under
the curve (AUC) illustrates the prognostic accuracy of the
mentioned tools in predicting in-hospital mortality of patients
with suspected sepsis in emergency department

score contains constant data such as age, nursing home

resident, presence of a lower respiratory infection, and
rapidly terminal comorbid illness [11]. Therefore, the
diagnostic accuracy of the MEDS score is of high clinical
importance.
It is quite evident that we need more specific data
for the detection of patients with SSSS than we obtain
through ESI assessment or MEWS calculation. In order
to detect critically ill sepsis patients, nondisease-specific systems like ESI and MEWS could be amended by
disease-specific risk stratification tools like MEDS score.
Instead of using both systems at the same time, the non-

13

specific systems could be extended by disease-specific

features. However, not every MEDS score relevant feature
is available at the time of triage management, such as the
number of platelets or the presence of lower respiratory
infection.
To our knowledge this is the first time that the different types of chief complaints from patients with suspected sepsis in a German-speaking ED are published.
Our analysis shows heterogeneous chief complaints. Due
to the heterogeneousity of presenting complaints it is
doubtful that the triage nurse or the admitting physician
will directly associate the respective chief complaint with
sepsis, which is aggravated by the fact that chief complaints show little sensitivity for sepsis in our cohort.
Furthermore, there is no significant difference between
the groups no sepsis, uncomplicated sepsis, and SSSS
with regard to the frequency of the most listed chief complaints fever, dyspnea, and deterioration of the health
status. The dissemination of symptom classification
systems like the CEDIS presenting complaint list [12] or
the Alpha-ID of the German Institute of Medical Documentation and Information (DIMDI) [15] will result in
a higher classification, analysis, and publication rate of
chief complaints and could therefore be helpful to examine the interaction of chief complaints at presentation
with final adjudicated findings.
According to Subbe et al. [10] a MEWS level 5 is associated with a higher risk of death and a higher rate of ICU
admission. In our cohort, the MEWS shows no prognostic validity, which implies that a high level of MEWS is not
associated with a high level of in-hospital mortality of
patients with suspected sepsis. Similar results have been
found by Ghanem-Zoubi et al. [16]; the AUC of the MEWS
was quite small with 0.695, which is comparable to our
study results.
Comparable to other groups [1719] we conclude
that the MEDS score is an adequate instrument for the
prediction of in-hospital mortality in patients with suspected sepsis. For that reason, the use of the MEDS score
as risk stratification tool in the ED should be considered. As a general rule, each relevant feature for MEDS

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original article
Fig. 3 By means of mortality in
emergency department sepsis
(MEDS) score calculated 28day mortality risk of patients
with suspected sepsis in the
emergency department. The
stacked bar chart shows the
respective disposition pattern
from ED for each mortality risk
group (low risk = MEDS score
07, moderate risk = MEDS
score 812, high risk = MEDS
score 13)

score calculation is available at the time of disposition.

If calculated in this early stage, the level of MEDS score
could indicate a high risk of death and therefore guide
the disposition of ED sepsis patients by means of objective criteria.
With our work we would like to emphasize the importance of accurate risk stratification tools in disposition
management. Currently a MEDS score calculated high
risk of death is not accompanied by a high ICU or IMC
admission rate. One reason may be that ED physicians
are not aware of the high mortality risk because the high
risk is not clinically evident at the time of presentation.
The use of the MEDS score could be a helpful tool to
guide disposition reliably. It is also conceivable that an
ICU or IMC admission is not feasible due to limited ICU/
IMC capacities and therefore strict admission conditions.
The advanced age of the cohort can also be a reason for
the low admission rate to ICU/IMC. It is a general rule

that the ICU admission rate of elderly patients is lower

than in younger patients. According to Garrouste-Orgeas
et al., ED physicians are very reluctant to consider an ICU
admission if the patient is 80 years old, even if criteria
for ICU admission are fulfilled. In case of fulfilled criteria,
30.9% (441) of patients 80 were referred for ICU admission; 52.4% of these patients were actually admitted to
ICU [20]. Furthermore, Esteban et al. [21] indicates that
apart from the age, a considerable proportion of patients
with SSSS is not admitted to ICU anyway (68%). What
is interesting is that there is a group of patients which
was not admitted to a usual care ward but to ICU/IMC,
despite its low MEDS score value (20.3%). Some of these
patients have been probably misjudged. Such misallocations of resources could be avoided by means of MEDS
score calculation.
Our study has certain limitations. First of all it is a
mono-centre trial. In addition, only 151 study patients

514 Severity illness scoring systems for early identification and prediction of in-hospital mortality

13

original article

were enrolled, whereby 72 patients had SSSS. However,

the guaranteed high data quality of the trial enables us
to generate important working hypothesis. This trial
presents the results of an ED sepsis registry, whose
long-term continuation will contribute to further data
specification.

Conclusion
This work shows that the MEDS score is able to detect critically ill sepsis patients under those with suspected sepsis in ED. Furthermore, in-hospital mortality of patients
with suspected sepsis can be predicted by means of the
MEDS score. The application of the MEDS score as risk
stratification tool in ED could therefore facilitate early
risk detection and contribute to a risk adjusted disposition management following objective criteria.
Acknowledgments
The authors thank Rafaela Kljaic for her expert technical
assistance.
Conflict of interest
The authors declare that they have no conflict of interest.

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