ICU Scoring Systems

telemed.shams.edu.eg/moodle

Iman Galal, MD
Pulmonary Medicine Department
E-mail: dr.imangalal@gmail.com
Introduction

► Severity of illness scoring systems are developed to

evaluate delivery of care & provide prediction of
outcome of groups of critically ill patients who are
admitted to ICUs.

► Scoring systems consists of two parts: a severity

score, which is a number (generally the higher this is,
the more severe the condition) & a calculated
probability of mortality.
 Classification of Scoring Systems

► Anatomical scores: depend on the anatomical area involved.

Mainly used for trauma patients [e.g. abbreviated injury score (AIS) &
injury severity score (ISS)].

► Therapeutic weighted scores: based on the assumption that

very ill patients require more complex interventions & procedures than
patients who are less ill e.g., the therapeutic intervention scoring
system (TISS).

► Organ-specific score: similar to therapeutic scoring; the sicker a

patient the more organ systems will be involved, ranging from organ
dysfunction to failure [e.g. sequential organ failure assessment
(SOFA)].
Classification of Scoring Systems

► Physiological assessment: based on the degree of

derangement of routinely measured physiological variables [e.g.
acute physiology and chronic health evaluation (APACHE) &
simplified acute physiology score (SAPS)].

► Simple scales: based on clinical judgment (e.g. survive or die).

► Disease specific: [e.g. Ranson’s criteria for acute pancreatitis,

subarachnoid haemorrhage assessment using the World Federation
of Neurosurgeons score & liver failure assessment using Child-Pugh
or model for endstage liver disease (MELD) scoring].
Types of Scoring Systems

First day scoring systems:

► APACHE scoring systems
► SAPS (simplified acute physiology score)
► MPM (mortality prediction model)

Repetitive scoring systems:

► OSF (organ system failure)
► SOFA (sequential organ failure assessment)
► ODIN (organ dysfunction & infection system)
► MODS (multiple organs dysfunction score)
► LOD (logistic organ dysfunction)
 The Ideal Scoring System

1. On the basis of easily/routinely recordable variables

2. Well calibrated
3. A high level of discrimination
4. Applicable to all patient populations
5. Can be used in different countries
6. The ability to predict functional status or quality of life after ICU
discharge.

No scoring system currently incorporates all these features

Severity scores in Medical & Surgical ICU

• APACHE
• SAPS
1980-85 • APACHE II

• SAPS II
• MPM
1986-1990

•APACHE III
•MODS
•MPM II
1990-95 •ODIN

• SOFA
• CIS
1996-2000

• SAPS III
2000- • APACHE IV
current
Common Scoring Systems

Acute Physiology & Chronic Health

Evaluation (APACHE)
Acute Physiology & Chronic Health Evaluation
(APACHE)

► The APACHE score is the best-known & most widely

used score with good calibration & discrimination.

► The original APACHE score was developed in 1981 to

classify groups of patients according to severity of
illness & was divided into 2 sections: physiology score
to assess the degree of acute illness & preadmission
evaluation to determine the chronic health status of the
patient.
Original APACHE score:

► 34 physiologic measures (0-4)

 Sum of all acute physiology scores (APS)
 Worst of the initial 24 hour after ICU admission

► Chronic health
 A (excellent health)
 B
 C
 D (severe chronic organ system insufficiency)

Crit Care Med 1981; 9:591

 APACHE II score:

► The APACHE II scoring system was released in 1985 and

included a reduction in the number of variables to 12.

► The APACHE II scoring system is measured during the first

24 h of ICU admission with a maximum score of 71. A score
of 25 represents a predicted mortality of 50% and a score of
over 35 represents a predicted mortality of 80%.

► APACHE II score is sum of:

• Acute physiology score
• Age
• Chronic health score
APACHE II score:

► The APACHE II score (0 – 71)

► Total APACHE II = A+B+C

• A → APS points
• B → Age points
• C → Chronic Health points
 APACHE II score:

► Predicted mortality = - 3.517 + (Score Apache II) * 0.146

► Predicted mortality (adjusted) = - 3.517 + (Score Apache II) *

0.146 + diagnostic category weight
 The APACHE II Score
Physiologic Variable High Abnormal Range Low Abnormal Range
+4 +3 +2 +1 0 +1 +2 +3 +4

Rectal Temp (°C) ≥41 39-40.9 38.5-38.9 36-38.4 34-35.9 32-33.9 30-31.9 ≤29.9

Mean Arterial Pressure (mmHg) ≥160 130-159 110-129 70-109 50-69 ≤49

Heart Rate ≥100 140-179 110-139 70-109 50-69 40-54 ≤39

Respiratory Rate ≥50 35-49 25-34 12-24 10-11 6-9 ≤5

Oxygenatation <200
a)FIO2≥0.5 record A-aDO2 ≥500 350-499 200-349
b)FIO2<0.5 record PaO2 PO2>70 PO2 61-70 PO2 55-60 PO2<55

Arterial pH ≥7.7 7.6-7.69 7.5-7.59 7.33-7.49 7.25-7.32 7.15-7.24 <7.15

HCO3 (mEq/l) ≥52 41-51.9 32-40.9 22-31.9 18-21.9 15-17.9 <15

K (mEq/l) ≥7 6-6.9 5.5-5.9 3.5-5.4 3-3.4 2.5-2.9 <2.5

Na (mEq/l) ≥100 160-179 155-159 150-154 130-149 120-129 111-119 ≤110

S. Creat (mqm/dl) ≥3.5 2-3.4 1.5-1.9 0.6-1.4 <0.6

Hematocrit (%) ≥60 50-59.9 46-49.9 30.45.9 20-29.9 <20

TLC (10³/cc) ≥40 20-39.9 15-19.9 3-14.9 1-2.9 <1

GCS

Age -score GCS:

<44 → 0 15 → 0 14 → 1 13 → 2
45-54 → 2 12 → 3 11 → 4 10 → 5
55-64 → 3 9→ 6 8→ 7 7→ 8
65-74 → 5 6→ 9 5 → 10 4 → 11
≥75 → 6 3 → 12 JAMA 1993;270(24):2957-2963
The APACHE II Score
The Glasgow Coma Scale (GCS)

Lancet 1974;304:81-84
APACHE III score:

► APACHE III, released in 1991, was developed with the

objectives of improved statistical power, ability to predict
individual patient outcome, and identify the factors in ICU
that influence outcome variations but it is far more
complex than the 2 previous scoring systems.
► 17 physiological variables & Total score (0 – 299)
► Acid-base disturbances
► GCS score – based on the worst
► Age score
► 7 co-morbidities (cardiac, respiratory & renal failures
excluded)

Chest 1991, 100:1619 - 1636

The APACHE III Score
The APACHE III Scoring for Acid-Base disturbances
The APACHE III Scoring for Age

Age -score

<44 → 0
45-59 → 5
60-64 → 11
65-69 → 13
70-74 → 16
75-85 → 17
≥85 → 24
The APACHE III Score
The APACHE III Score
The APACHE III Scoring for Chronic Health Condition

Chronic health condition (Co-morbid condition)

1) AIDS → 23
2) Hepatic failure → 16
3) Lymphoma → 13
4) Metastatic cancer → 11
5) Leukemia/multiple myeloma → 10
6) Immunosuppression → 10
7) Cirrhosis → 4
 APACHE score

Prediction at
ROC Calibration
50%probability

APACHE II 0.85 85.5

APACHE III version (H) 0.90 88.2 48.7

APACHE III version (I) Unpublished Unpublished 24.2

APACHE III (H) in 2003-04 cohort Unpublished Unpublished 24.2

APACHE IV score:

► The APACHE IV scoring system was published in 2006.

Limitations:

► Complexity – has 142 variables.

► But web-based calculations can be done.
► Developed and validated in ICUs of USA only.

Crit Care Med 2006; 34:1297–1310

Common Scoring Systems

Simplified Acute Physiology Score

(SAPS)
Simplified Acute Physiology Score (SAPS)

► The SAPS score was first released in 1984 as an alternative

to APACHE scoring.

► The original SAPS score is obtained in the first 24 h of ICU

admission by assessment of 14 physiological variables, but
no input of pre-existing disease was included.

► It has been superseded by the SAPS II & SAPS III, both of

which assess the 12 physiological variables in the first 24 h
of ICU admission & include weightings for pre-admission
health status & age.
Simplified Acute Physiology Score (SAPS)

► Predicted mortality = -14.4761 + 0,0844 * SAPS II + 6.6158 *

log (SAPS II+1)

► Area under ROC for SAPS is 0.8 where as SAPS II has a

better value of 0.86

JAMA 1993;270:2957-2963
 SAPS II Score
Parameter Value (score)
HR <40 (11) 40-69 (2) 70-119 (0) 120-159 (4) >160 (7)
SBP <70 (13) 70-99 (5) 100-199 (0) >200 (2)
Temp <39°C (0) >39°C (3)
PaO2/FIO2 <100 (11) 100-199 (9) >200 (6)
UO (ml) <500 (11) >500 (4) >1000 (0)
S. Urea <28 (0) 28-83 (6) >84 (10)
TLC (10³/cc) <1 (12) 1-20 (0) >20 (3)
K <3 (3) 3-4.9 (0) >5 (3)
Na <125 (5) 125-144 (0) >145 (1)
Bicarb <15 (6) 15-19 (3) >20 (0)
Bil <4 (0) 4-5.9 (4) >6 (9)
GCS <6 (26) 6-8 (13) 9-10 (7) 11-13 (5) 14-15 (0)

Age -score
Chronic disease:
<40 → 0 Type of admission:
40-59 → 7
60-69 → 12 Metastatic cancer → 9 Sched. Surgical → 0
70-74 → 15 Hemat.malig → 10 Medical → 6
75-79 → 16 AIDS → 17 Emer.surgical → 8
≥80 → 18 JAMA 1993;270(24):2957-2963
 SAPS III

► Scores based on data collected within 1st hour of entry to ICU.

► Allows predicting outcome before ICU intervention occurs.

► Better evaluation of individual patient rather than an ICU.

► Limitations:
 Time for collecting data
 Can have greater missing information

Intensive Care Med 2005; 31:1345–1355

Common Scoring Systems

Sequential Organ Failure Assessment

(SOFA)
 Sequential Organ Failure Assessment (SOFA)
► Previously known as Sepsis-related Organ Failure
Assessment because it was initially developed in 1994 to
describe the degree of organ dysfunction associated with sepsis
in a mixed, medical-surgical ICU patients.

► Nowadays, it has since been validated to describe the degree of

organ dysfunction in various ICU patient groups with organ
dysfunctions not due to sepsis.

► The SOFA score involves six organ systems (respiratory,

cardiovascular, renal, hepatic, central nervous, coagulation), and
the function of each is scored from 0 (normal function) to 4 (most
abnormal), giving a possible score of 0 to 24.
Sequential Organ Failure Assessment (SOFA)

► Mortality rate increases as number of organs with

dysfunction increases.

► Unlike other scores, the worst value on each day is

recorded.

► A key difference is in the cardiovascular component;

instead of the composite variable, the SOFA score uses a
treatment-related variable (dose of vasopressor agents).
Sequential Organ Failure Assessment (SOFA)

► Maximal (highest total) SOFA score: is the sum of highest

scores per individual during the entire ICU stay. A score of >15
predicted mortality of 90%.

► Mean SOFA score (ΔSOFA): is the average of all total SOFA

scores in the entire ICU stay. ΔSOFA for 1st 10 days is significantly
higher in non-survivors.

► Delta SOFA score: maximum SOFA – admission SOFA

Crit Care Med 1998;26:1793-1800

SOFA Score

Crit Care Med 1998;26:1793-1800

Common Scoring Systems

Multiple Organ Dysfunction Score

(MODS)
 Multiple Organ Dysfunction Score (MODS)
► The MODS scores six organ systems: respiratory (PO2/FIO2 in
arterial blood); renal (serum creatinine); hepatic (serum
bilirubin); cardiovascular (pressure-adjusted heart rate);
haematological (platelet count) & CNS (Glasgow Coma Score)
with weighted scores (0–4) awarded for increasing abnormality
of each organ systems.

► Scoring is performed on a daily basis.

► Total score ranges from 0-24.

► Area under ROC 0.936.

► ΔMODS predicts mortality to a greater extent than Admission

MODS score .

Crit Care Med. 1995; 23:1638-52

 MODS

System 0 1 2 3 4

Respiratory PO2/FiO2 >300 226-300 151-225 76-150 <75

Renal Serum Creatinine (μmol/L) <100 101-200 201-350 351-500 >500

Hepatic Serum bilirubin (μmol/L) <20 21-60 61-120 121-240 >240

Cardiovascular (PAR) <10 10.1-15 15.1-20 20.1-30 >30

Hematological Platelet count (100/ μL) >120 120-80 80-50 50-20 <20

Neurological (GCS) 15 14-13 12-10 9-7 <7

Crit Care Med. 1995; 23:1638-52

 MODS

Score ICU Mortality Hospital Mortality

0 0% 0%

1-4 1-2% 7%

5-8 3-5% 16%

9-12 25% 50%

13-16 50% 70%

17-20 75% 82%

21-24 100% 100%

Crit Care Med. 1995; 23:1638-52

 Common Scoring Systems

Logistic Organ Dysfunction System

(LODS)
Logistic Organ Dysfunction System (LODS)

► Worst values in 1st 24 hrs of ICU stay.

► Worst value in each of 6 organ systems.

► Total score ranges from 0-22.

► Good calibration and discrimination (area under ROC 0.85)

JAMA 1996;276:802-810
 LODS

System Value (Score)

Neurological GCS 14,15 (0) 13-9 (1) 8-6 (3) 5-3 (5)

HR >140 (1) 140-30 (0) <30 (5)

Cardiovascular
SBP >270 (3) 240-269 (1) 70-89 (1) 69-40 (3) <40(5)
TLC (1000/cc) <1 (3) 1-2.4 (1) 2.4-50 (0) >50 (1)
Hematological
Platelet (10³/cc) <50 (1) >50 (0)

Respiratory PO2 <150 (3) >150 (1)

Bilirubin (mg/dl) <2 (0) >2 (1)

Hepatic
PT 0-2.9 s (0) 3 s (1)
Urea (mg/dl) >120 (5) 119-60 (3) 59-35 (1) <35 (0)
Renal Creatinine (mg/dl) >1.16 (3) 1.59-1.2 (1) <1.2 (0)
UO (L/24 hr) >10 (3) 10-0.75 (0) 0.75-0.5 (3) <0.5 (5)

JAMA 1996;276:802-810
Common Scoring Systems

Clinical Pulmonary Infection Score

(CPIS)
Clinical Pulmonary Infection Score (CPIS)

► A score developed to establish a numerical value of clinical,

radiographic, and laboratory markers of pneumonia.

► Serial measurements of the CPIS could be used to identify

survivors versus non-survivors as early as day 3 of therapy.

► The CPIS correlated with mortality rate.

► CPIS scores > 6 suggest pneumonia.

► CPIS is an important variable to monitor during VAP therapy.

Patients with VAP having CPIS ≤ 6 can safely discontinue
antibiotics after 3 days.

AJRCCM 2000;162:501-511
 Clinical Pulmonary Infection Score (CPIS)

Score 0 1 2
Temperature ≥36.5 & ≤38.4 ≥38.5 & ≤38.9 ≥39 & ≤36.4
TLC ≥4 & ≤11 <4 or >12
Tracheal Secretions None Non-purulent Purulent
Oxygenation
>240 or ARDS ≤240 & no ARDS
PaO2/FIO2 mmHg
Diffuse (patchy)
Chest Radiograph No opacity Localized opacity
opacities
Progression (after
Progression of
No progression HF & ARDS
Radiograpgic Opacities
excluded)

Pathogenic bacteria Pathogenic bacteria

Culture of Tracheal
cultured in rare/few cultured in moderate
Aspirate
quantities or no growth or heavy quantity

AJRCCM 2000;162:501-511
Common Scoring Systems

Mortality Probability Model (MPM)

 Mortality Probability Model (MPM)

► Not applicable for patients <14yrs, patients with burns, cardiac/

cardiac surgery patients.

► MPM score:
 Admission MPM (MPM0) →11 variables
 MPM at 24 Hrs (MPM24) → 14 variables
 MPM at 48 Hrs (MPM48) → 11 variables
 MPM over the time (MPMOT) → (MPM24-MPM0)
(MPM48-MPM24)

► Probability is derived directly from these variables.

► MPMOT predicted better than MPM0 for long term patients.

Crit care med 1988;16:470-477

 MPM0
Variable 1 0
Level of consciousness Coma / deep stupor No coma/deep stupor
Admission Emergency Elective
Prior CPR Yes No
Cancer Present Absent
CRF Present Absent
Infection Probable Not probable
Previous ICU admission in 6 mo Yes No
Surgery before ICU admission Yes No
SBP
HR 10 beat/min relative risk
Age 10 years relative risk
 Common Scoring Systems

Therapeutic Intervention Scoring System

(TISS)
Therapeutic Intervention Scoring System (TISS)

► Measuring sickness severity based on type & amount of

treatment received.

► Both clinical & administrative applications:

 assessing severity of illness
 Determining resource requirements
 Assessing use of critical care facilities & function
 Not standardised

► Daily data collected from each patient on 76 possible clinical

interventions
 TISS

Four classes of pt recognised: Class I < 10 points does not require ICU
Class II 10-19 points 1:2 nurse : pt ratio
Class III 20-39 points 1 ICU nurse
Class IV > 40 points 1:1 nurse : pt ratio
 Other Scores
Scores for surgical patients:
Thoracoscore (thoracic surgery)
Scores for Pediatric patients:
Lung Resection Score (thoracic surgery)
EUROSCORE (cardiac surgery) PRISM (Pediatric RISk of Mortality)
ONTARIO (cardiac surgery) P-MODS (Pediatric MODS)
Parsonnet score (cardiac surgery) DORA (Dynamic Objective Risk Assessment)
System 97 score (cardiac surgery) PELOD (Pediatric Logistic Organ Dysfunction)
QMMI score (coronary surgery) PIM II (Paediatric Index of Mortality II)
Early mortality risk in redocoronary artery PIM (Paediatric Index of Mortality)
surgery
MPM for cancer patients

Scores for trauma patients:

Trauma Score
Revised Trauma Score
Trauma and injury Severity score (TRISS)
A Severity Characterization of trauma (ASCOT)
 Which score to use?

► APACHE, SAPS, MPM → only of historic significance

► APACHE II → most widely used in USA

► SAPS II → commonly used in Europe

► APACHE III → not in public domain

► SAPS III, APACHE IV → better design

► MODS & LODS → uncommonly used

THANK YOU