ICU Scoring Systems

22nd June 2007 Ulster Hospital Gail Browne

ICU Scoring Systems

Why are scoring systems needed? Classifying scoring systems History of scoring systems Examples of scoring systems Recent developments Selecting a scoring system Discussion

Its more important to know what sort of person this disease has, than what sort of disease this person has.
William Osler 1849-1919

Why are scoring systems needed?

Scoring systems can provide:
Case-mix adjustment for evaluative research A tool for comparative audit - SMR A mechanism to decide resource allocation An aid for the clinical management of patients

Scoring Systems
Specific or generic Anatomical or physiological Anatomical systems assess extent of injury (eg injury severity score) Physiological systems assess impact of injury on function (eg GCS)

First Scoring Systems

Developed for trauma pts Specific anatomical methods:
- abbreviated injury score 1969 - Burns score 1971 - Injury severity score 1974

Specific physiological methods:

trauma index 1971 Glasgow coma scale 1974 Trauma score 1981 Sepsis score 1983

Scoring Systems
Later scoring systems generic Measuring severity by treatment TISS (Therapeutic Intervention Scoring System) 1974 Measuring severity of organ dysfunction based on type & amount of tx received Measuring severity by patient characteristics & physiological measurements - SAPS, APACHE, MPM

Scoring System Development

Pt variables that influence survival collected by consensus or statistical analysis Scoring model developed from large cohort & validated on another cohort

Classifying Scoring Systems

General Scores Specialised & Surgical Intensive Care Preop evaluation
Lung resection score EUROSCORE ONTARIO Parsonnet score System 97 score QMMI score POSSUM (physiologic & operative severity score for the enUmeration of mortality & morbidity) IRISS score GCS

Trauma Scores

Therapeutic Intervention Nursing Scores

TISS (therapeutic intervention scoring system) TISS 28 (simplified TISS)

SAPS II expanded &

predicted mortality APACHE II & predicted mortality SOFA (Sequential Organ Failure Assessment) MODS (Multiple Organ Dysfunction Score) ODIN (Organ Dysfunctions &/or Infection) MPM (Mortality Probability Model) LODS (Logistic Organ Dysfunction System) TRIOS (Three days recalibrated ICU outcome Score)

ISS (Injury Severity Score) RTS (revised trauma score) TRISS (trauma injury severity score) ASCOT (a severity characterizatio n of trauma) 24h ICU Trauma Score

History
1953 Virginia Apgar 1974 Glasgow Coma Scale Quantifying relationship between disease severity and outcome
1980s acute physiology and chronic health evaluation (APACHE) & simplified acute physiological score (SAPS)

History
APACHE & SAPS physiologically based classification systems General severity scores Aim at stratifying patients based on their severity 1985 1993: general outcome prediction models 1991 APACHE III 1993 SAPS II 2005 SAPS III (www.saps3.org) 2006 APACHE IV During process of evolution of models, main prognostic determinants of outcome changed

APACHE
William Knaus Initially 34 physiological variables 1985 APACHE II 12 variables APACHE II allows probability of death before hospital discharge to be estimated Standardised mortality ratio

APACHE II score = (acute physiology score) + (age points) + (chronic health points)

Scores range from 0 71 Score risk of hospital death

SAPS (Simplified Acute Physiology Score)

Le Gall reduced former 34-variable APACHE score to 14 parameters

SOFA (Sequential Organ Failure Assessment) Score

MPM (Mortality Prediction Models)

Developed by Stanley Lemeshow Uses data collected during first hour of ICU admission; 24 hours; 72 hours Series of true/false questions Weighted according to their individual contribution to mortality

TISS (Therapeutic Intervention Scoring System)

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 pt on 76 possible clinical interventions

TISS (Therapeutic Intervention Scoring System)

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 Scoring Systems

CPIS (Clinical Pulmonary Infection) Score

Early Warning Physiological Scoring Systems

MERIT study SOCCER study The Worthing physiological scoring system BJA June 2007

The Worthing PSS

Ventilatory Frequency Pulse 101 102 SBP 100 99 Temp 35.3 < 35.3 Oxygen 96 - 100 94 - <96 92 - < 94 < 92 Sat in air AVPU Alert Other
2,3,4 be alert! 5 urgent doctor review (Duckitt et al, 2007)

0 19

1 20-21

2 22

Recent developments - New Models

SAPS III admission model chronic health & circumstances of ICU admission now responsible for approx. prognostic power of model.
APACHE IV Model Jack Zimmerman MPM III Model ICNARC Model

Selecting a Scoring System

Depends on proposed use Validity Reliability Calibration Discrimination Outcome from ICU? Other scoring systems eg sedation scores, sepsis bundles,CPIS, early warning physiological scoring systems, POSSUM..

Discussion