OfficialreprintfromUpToDate

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Predictivescoringsystemsintheintensivecareunit
Author
MarkAKelley,MD

SectionEditor
ScottManaker,MD,PhD

DeputyEditor
GeraldineFinlay,MD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Dec2015.|Thistopiclastupdated:Nov19,2015.
INTRODUCTIONPredictivescoringsystemshavebeendevelopedtomeasuretheseverityofdiseaseandtheprognosisofpatientsintheintensivecareunit
(ICU).Suchmeasurementsarehelpfulforclinicaldecisionmaking,standardizingresearch,andcomparingthequalityofpatientcareacrossICUs.
Fourvalidatedpredictivescoringsystemsaredescribedhere.TheyincludetheAcutePhysiologicandChronicHealthEvaluation(APACHE)system,Simplified
AcutePhysiologicScore(SAPS),MortalityPredictionModel(MPM),andSequentialOrganFailureAssessmentscore(SOFA).
HOWPREDICTIVESCORINGSYSTEMSWORKCriticalcarepredictivescoringsystemsderiveanumericalvalue,orseverityscore,fromavarietyofclinical
variables.Thederivedscorequantifiestheseverityofillnessandisenteredintoamathematicalequationwhosesolutionisthelikelihoodofmortalityduringthat
hospitalization.
Therelationshipbetweentheseverityscoreandtheoutcomeisdeterminedempiricallyfromlargedatasets.Predictivescoringsystemscannotpredictoutcomesfor
populationsthatwerenotincludedinthederivationdatasets.Thus,ICUpredictivescoringsystemsarenotreliableforevaluatingpatientsoutsideofthecritical
caresetting.
CHARACTERISTICSOFPREDICTIVESCORINGSYSTEMSTherearetwoprinciplesthatareimportanttoconsiderwhenassessingapredictivescoring
system.First,aninstrumentshouldmeasureanimportantoutcome.ThemostwidelyusedICUscoringsystemspredictthelikelihoodofhospitalmortalityfor
patientsadmittedtothecriticalcareunit.Second,aninstrumentshouldbeeasytouse,sincecollectingdataoncriticallyillpatientscanbetimeconsumingand
costly.
Discriminationandcalibrationaretwocharacteristicsusedtojudgeapredictivesystem:
Discriminationdescribestheaccuracyofagivenprediction.Asanexample,ifascoringinstrumentpredictsamortalityof90percent,discriminationisperfect
iftheobservedmortalityis90percent.
Calibrationdescribeshowtheinstrumentperformsoverawiderangeofpredictedmortalities.Intheexampleabove,apredictiveinstrumentwouldbehighly
calibratedifitwereaccurateatmortalitiesof90,50,and20percent.
PREDICTIVESCORINGSYSTEMSThefourmajorICUpredictivescoringsystemsaretheAcutePhysiologicandChronicHealthEvaluation(APACHE)
scoringsystem,theSimplifiedAcutePhysiologicScore(SAPS),theMortalityPredictionModel(MPM),andtheSequentialOrganFailureAssessment(SOFA).
AcutePhysiologicandChronicHealthEvaluation(APACHE)TheAPACHEscoringsystemiswidelyusedintheUnitedStates[1].Themostrecent
versionsincludeAPACHEIIthroughIV.

APACHErequirestheinputofmanyclinicalvariables,fromwhichaseverityscoreisderived.Theresultingseverityscoreisenteredintoalogisticalregression
equation,whichpredictshospitalmortality.Therequiredvariablesdifferamongtheversions,butgenerallyincludefactorssuchasage,diagnosis,priortreatment
location,andnumerousacutephysiologicandchronichealthvariables.APACHEusestheworstvaluesfromtheinitial24hoursofICUadmission.
AlloftheAPACHEinstrumentshaveexcellentdiscrimination,butlessimpressivecalibration.Likemostpredictivemodels,APACHErequiresperiodicretesting,
revising,andupdatingbecauseitsaccuracydecreasesastreatmentsandotherfactorsinfluencingmortalitychange.
ThemostfrequentlycitedAPACHEmodelsareAPACHEIIandIII,althoughAPACHEIVhasalsobeenvalidated:
APACHEIIThevariablesusedtocalculatetheAPACHEIIseverityscoreareshowninthecalculator(calculator1).TheAPACHEIIseverityscoreis
basedupontheworstvariablesduringtheinitial24hoursintheICU.However,aseverityscorebaseduponICUadmissiondataappearstobeanacceptable
alternative[2].
TheAPACHEIIscoringsystemisimperfect.Outcomecannotbeaccuratelypredictedforanyspecificpatientsubgroup(eg,liverfailure,sepsis,etc)andthe
predictedmortalityislessthantheobservedmortalityamongICUpatientswhoaretransferredfromotherinpatientfacilities[3,4].
APACHEIIIAPACHEIIIresemblesAPACHEII,exceptthatseveralvariableshavebeenadded(eg,diagnosis,priortreatmentlocation)[5].Aunique
featureoftheAPACHEIIIscoringsystemisthatitusesdailyupdatesofclinicalinformationtorecalculateestimatedmortalityonadailybasis[5].Thishas
greaterpredictivepowerthanasingleprojectionbaseduponthefirst24hoursofICUadmission[6].Howeverthereisnoevidencethatthisinformation
improvesclinicaldecisionmakingforphysicians,patients,andtheirfamilies[7].
APACHEIVAPACHEIVusesanewlogisticalregressionequation,adifferentsetofvariables,andnewstatisticalmodeling.Thevalueofthisversionwas
illustratedbyanobservationalstudyof110,588consecutiveICUadmissionsthatfoundthatAPACHEIVpredictedmortalitymoreaccuratelythanAPACHE
III[8].AsimilarstudyfoundthatAPACHEIVpredictedICUlengthofstay[9].
SimplifiedAcutePhysiologicScore(SAPS)TheSAPSstreamlinesdatacollectionandanalysiswithoutcompromisingdiagnosticaccuracy.TheSAPSIIis
themostwidelyusedversion.Itcalculatesaseverityscoreusingtheworstvaluesmeasuredduringtheinitial24hoursintheICUfor17variables.Thevariables
arelistedinthetable(table1).
Severalofthevariables(ie,AIDS,metastaticcancer,hematologicalmalignancy)aredichotomous,meaningthattheyareeitherpresentorabsent.Theothersare
continuousvariablesthathavebeenmadecategoricalbyassigningpointstorangesofvalues.Asanexample,asystolicbloodpressure200mmHgisworth2
points,100to199mmHgisworth0points,70to99mmHgisworth5points,and<70mmHgisworth13points.
HigherSAPSscoresindicatemoresevereillnessandallscoresareenteredintoamathematicalformula,whichpredictshospitalmortality.
TheSAPSIIwasbasedupondatafrom8500patientsandwasvalidatedonasampleof4500patients[10].Ithasexcellentdiscriminationandcalibration[11].It
mayalsobesuitableforuseintheintermediatecareunitsetting[12].However,theSAPSIImaybelessaccurateamongpatientswhoareadmittedtotheICUfor
noncardiovasculardisease[13].
Anupdatedversion,theSAPSIII,wasvalidatedusingdatafrompatientsinmorethan100ICUsinmultiplecountries[14].Asubsequentstudyofmorethan28,000
patientsfrom147ICUsinonecountryfoundthattheSAPSIIIhadgooddiscrimination,butpoorcalibration[15].Thisfindinghasbeenreplicatedinmorerecent

studies[16].
MortalityPredictionModel(MPM)TheMortalityPredictionModelII(MPM0II)isthemostcommonversionoftheMPM.Aseverityscoreiscalculatedfrom15
variables,asassessedatthetimeofICUadmission(hencetheterm"0").Thevariablesarelistedinthetable(table2).
Exceptforage,allofthevariablesaredichotomous.Inotherwords,theyareeitherpresentorabsent.Asanexample,asystolicbloodpressure90mmHgisworth
onepoint,whileallothersystolicbloodpressurevaluesareassignedzeropoints.Thefinalscoreisenteredintoamathematicalformulawhosesolutionprovidesthe
predictedmortality.
TheMPM0IIseverityscorethatismeasuredonadmissioncanberefinedafter24hours(MPM24II)byupdatingsevenoftheadmissionvariablesandaddingsix
variables.Theupdatedadmissionvariablesincludecoma,intracranialmasseffect,mechanicalventilation,metastaticdisease,cirrhosis,typeofadmission,and
patientage.Theadditionalvariablesincludethefollowing:

Creatinine>2mg/dL
Urineoutput<150mLovereighthours
Confirmedinfection
Vasoactivemedicationsfor1hour
Arterialoxygentension(PaO2)<60mmHg
Prothrombintimegreaterthanthesumofthestandardplusthreeseconds

AnadvantageoftheMPM24IIisthatitcanbecomparedtotheSAPSandAPACHE,sinceallthreescoresaredeterminedafterthefirst24hoursofadmission.
TheMPM0IIisbasedupondatafromover12,500patients[17].Ithasexcellentcalibrationanddiscrimination[11,17,18].Theupdatedversion,theMPM0III,has
excellentcalibration,asvalidatedonalargecohortofover55,000ICUpatients[19].MPM0IIIincludesthephysiologicvariablesofMPM0IIandaddstimebefore
ICUadmissionandcode(resuscitation)status.ThereissomeevidencethatMPM0IIIprovidesmoreaccuratepredictionofICUmortality[20].
SequentialOrganFailureAssessment(SOFA)TheSOFAusessimplemeasurementsofmajororganfunctiontocalculateaseverityscore.Thescoresare
calculated24hoursafteradmissiontotheICUandevery48hoursthereafter.Themeanandthehighestscoresaremostpredictiveofmortality.Inaddition,scores
thatincreasebyabout30percentareassociatedwithamortalityofatleast50percent[21].
TheSOFAseverityscoreisbaseduponthefollowingmeasurementsoforganfunction:
Respiratorysystem:theratioofarterialoxygentensiontofractionofinspiredoxygen(PaO2/FiO2)
Cardiovascularsystem:theamountofvasoactivemedicationnecessarytopreventhypotension
Hepaticsystem:thebilirubinlevel
Coagulationsystem:theplateletconcentration
Neurologicsystem:theGlasgowcomascore
Renalsystem:theserumcreatinineorurineoutput

TheoriginalSOFAinstrumentwasderivedfromacohortof1449patientsadmittedto40ICUsin16countries[22].
COMPARISONOFTHEPREDICTIVESCORINGSYSTEMSThefourmajorICUpredictivescoringsystems(APACHE,SAPS,MPM,SOFA)andtheirmost
recentupdatesallhaveacceptablediscriminationandcalibration[18,20,23,24].However,thereareimportantlimitationsandmethodologicaldifferencesamong
theseinstruments,includingthecollectionofdata,calculationofmortality,efficacy,andcost[25,26].
DatacollectionThetypesofvariablesthataremeasuredandthetimingofthosemeasurementsvaryamongthepredictivescoringsystems:
VariablesmeasuredTheAPACHEscoringsystemrequirescollectionofawiderangeofphysiologicalandgeneralhealthdata,whiletheotherinstruments
useconciseandeasilymeasuredphysiologicalcategoriestofacilitatedatarecording[27].
TimingofthemeasurementsTheAPACHEandSAPSinstrumentsusetheworstphysiologicvaluesmeasuredwithin24hoursofadmissiontotheICU.The
updatedversionsofMPMusedatacollecteduponICUadmissionandthenmodified24hourslater,whiletheSOFAinstrumentusesdatacollected24hours
afteradmissionandevery48hoursthereafter.
CalculationsAllfourpredictiveinstruments(APACHE,SAPS,MPM,andSOFA)provideaseverityscoretodescribeeachpatient.Thisscoreisthesumof
categoricalvariablesdescribedabove.TheseverityscoreismostcommonlyusedtodescribeandcomparethelevelofillnessinICUpatients.Thisisparticularly
usefulindesigningclinicaltrialsandotherinterventions.
Predictedmortalitycanalsobeassessedfromtheseseverityscores.ForAPACHE,apredictedmortalityiscalculatedfromthecomputersoftwaredescribed
above.ForSAPSandMPM,theseverityscoreisenteredintoanequationthatcalculatesapredictedmortality.ForSOFA,sequentialseverityscoresplotthe
trajectoryoftheclinicalcoursetoprovideasemiquantitativeassessmentofmortality,baseduponmultiorganfailure.
EfficacyTherehavebeennolarge,prospectivestudiesthatrigorouslycomparethefourmajorICUpredictivescoringsystems(APACHE,SAPS,MPM,SOFA).
Thefollowingstudiesillustratetheexistingevidence:
Oneretrospectivestudyof11,300ICUpatientsfrom35hospitalscomparedtheMPMIII,SAPSII,andAPACHEIVinstruments[27].APACHEIVofferedthe
bestpredictiveaccuracy.However,MPM0IIIprovedtobeaneffectivealternativewhencostandthecomplexityofdatacollectionwereconsidered[27].
AsystemicreviewoftheSOFA,SAPSII,APACHEII,andAPACHEIIIscoringsystemsfoundthattheAPACHEsystemswereslightlysuperiortothe
SAPSIIandSOFAsystemsinpredictingICUmortality[23].TheaccuracyofboththeSAPSIIandAPACHEinstrumentsimprovedwhencombinedwiththe
assessmentofsequentialSOFAscores.
CostTheAPACHEIIIandIVpredictivescoringsystemsrequireproprietarycomputertechnologyandsubstantialdatacollection.Incontrast,APACHEII
calculationsoftwareisavailabletothepublic(calculator1).TheMPM,SAPS,andSOFAscoringsystemsareavailabletothepublic,requirelessdatacollection,
andrequirenocomputerinvestment.Calculationsareeasilymadefrompublishedequations.
USESFORPREDICTIVESCORINGSYSTEMSWhiledeterminingprognosiswastheoriginalgoalofthesesystems,theseverityscoresalonehaveproven
mostuseful[28]:
Severityscoresfacilitateevaluationofvariousinterventionsbyensuringthatpatientswithsimilarbaselineriskarebeingcompared[29].Thisisparticularly
commonamongtrialsofpotentialtherapiesforsepsis[30,31]oracuterespiratorydistresssyndrome[32,33].

 Severityscoresfacilitateevaluationofthequalityofcarebyensuringthatpatientswithsimilarbaselineriskarebeingcompared.Asexamples,studiesthat
comparedopenwithclosedICUs[3439],theoutcomesofdifferentICUswithinahospital[40],andtheoutcomesofICUsindifferenthospitals[4042]have
usedpredictivescoringsystems(usuallyAPACHE)toensurethatpatientswithsimilarbaselineriskwerecompared.
Severityscoreshavebeenusedtomanagehospitalresources,assigningpatientswithlowerseverityscorestolessexpensivesettings[43].
LIMITATIONSOFPREDICTIVESCORINGSYSTEMSTheICUistheidealsettingforpredictivescoringsystemsbecausethepopulationiswelldefined,
patientcareiswellcircumscribed,andtheseverityofillnessintheICUisthemajordeterminantofhospitalmortality.Despitethis,predictivescoringsystemshave
importantlimitations[44,45]:
DiseasesubsetsPredictivescoringsystemsaredevelopedfromlargedatasetsofICUpatients.However,thesedatasetsaretoosmalltoassess
diseasesseparately.Asaresult,thepredictedmortalityofpatientswithcertaindiseases(eg,liverfailure,obstetricaldiseases,AIDS)maybeinaccurate[46
48].ThismayalsoapplytospecializedICUswheresomeinvestigatorshaveusedtheirownvalidationsubsetstoadjustforthisflaw[49].
UncertainaccuracybeyondtheICUTheseinstrumentsweredevelopedfrom,andvalidatedon,patientsadmittedtoICUsacrossmanyinstitutions.The
scoringsystemshavenotbeenvalidatedonotherhospitalizedpatients.
LeadtimebiasPatientswhoaretransferredfromotherhospitalsandICUshaveamortalitythatishigherthanpredictedbytheAPACHEIIsystem,a
phenomenonknownasleadtimebias[3].Toaddressthisflaw,treatmentlocationwasaddedasavariabletoAPACHEIII.Itisuncertainhowleadtimebias
affectstheotherpredictivescoringsystems(ie,SAPS,MPM,orSOFA).
NeedforupdatesAllofthepredictivescoringsystemsmustbeperiodicallyupdatedusingmorecurrentdataortheymayfailtocapturetheeffectsofnew
technology,practicepatterns,orstandardsofcare.Failuretoupdatepredictivescoringsystemscanleadtograduallossofcalibration.Thisresultsin
overestimatingmortalityforanygivenseverityscore[16].
SUMMARYANDRECOMMENDATIONS
ICUpredictivescoringsystemsderiveaseverityscorefromavarietyofclinicalvariables.Thisscorequantifiestheseverityofillnessandcanbeenteredinto
amathematicalequationwhosesolutionisthelikelihoodofhospitalmortality.(See'Howpredictivescoringsystemswork'above.)
Thefourmajorintensivecareunit(ICU)predictivescoringsystemsaretheAcutePhysiologicandChronicHealthEvaluation(APACHE)scoringsystem,
SimplifiedAcutePhysiologicScore(SAPS),MortalityPredictionModel(MPM),andSequentialOrganFailureAssessment(SOFA).Allhavebeenvalidated
anddeterminedtobereliable.(See'AcutePhysiologicandChronicHealthEvaluation(APACHE)'aboveand'SimplifiedAcutePhysiologicScore(SAPS)'
aboveand'MortalityPredictionModel(MPM)'aboveand'SequentialOrganFailureAssessment(SOFA)'aboveand'Comparisonofthepredictivescoring
systems'above.)
ThemostcommonuseoftheICUpredictivescoringsystemsistocomparepatientsinclinicaltrialsortoassessICUquality.TheroleofICUscoring
systemsinclinicaldecisionmaking,especiallyinendoflifecare,remainsunclear.(See'Usesforpredictivescoringsystems'above.)
TheaccuracyofpredictinghospitalmortalityislesscertainforICUpatientswithspecificdiseases(eg,liverfailure,obstetricaldisorders,AIDS),andmaybe
limitedbyleadtimebias.ThepredictivemodelingisnotaccurateforpatientsoutsidetheICU.

 ICUscoringsystemsmustbereassessedandupdatedperiodicallytoreflectcontemporarypracticeandpatientdemographics.Otherwise,thecalibrationof
thepredictivemodelcandecline,leadingtooverestimationofpredictedmortality.(See'Limitationsofpredictivescoringsystems'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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Topic1655Version10.0

GRAPHICS
SimplifiedacutephysiologicscoreII(SAPSII)
Variable
Patientage

Typeofadmission

Temperature

Systolicbloodpressure

Heartrate

Glasgowcomascale

Range

Points

<40years

4059years

6069years

12

7074years

15

7579years

16

80years

18

Scheduledsurgery

Medical

Unscheduledsurgery

<39C,<102.2F

39C,102.2F

200mmHg

100199mmHg

7099mmHg

<70mmHg

13

160bpm

120159bpm

70119bpm

4069bpm

<40bpm

11

1415

1113

Urineoutput

Whitebloodcellcount

Bloodureanitrogen

Potassiumlevel

Sodiumlevel

Bicarbonatelevel

Bilirubinlevel

PaO2/FiO2(ifmechanicallyventilatedorreceivingCPAP)

910

68

13

<6

26

1L/24hr

0.50.999L/24hr

<0.5L/24hr

11

<1000/mm 3

12

100019,000/mm 3

20,000/mm 3

30mmol/L,84mg/dL

10

1029.9mmol/L,2883mg/dL

<10mmol/L,<28mg/dL

<3mEq/L

34.9mEq/L

5mEq/L

<125mEq/L

125144mEq/L

145mEq/L

<15mEq/L

1519mEq/L

20mEq/L

<4mg/dL,<68.4micromol/L

45.9mg/dL,68.4102.5micromol/L

6mg/dL,102.6micromol/L

<100mmHg

11

100199mmHg

200mmHg

Yes

17

No

Yes

No

Yes

10

No

AIDS

Metastaticcarcinoma

Hematologicmalignancy

Datafrom:LeGall,JR,Lemeshow,S,Saulnier,F,etal.Anewsimplifiedacutephysiologyscore(SAPSII)basedonaEuropean/NorthAmerican
multicenterstudy.JAMA1993270:2957.
Graphic53023Version1.0

MortalitypredictionmodelII(MPMII)
Variable

Response

Points

Patientage*

Medicalorunscheduledsurgicaladmission?

Yes

No

Yes

No

Coma(Glasgowcomascale35)?

Yes

(Doesnotincludepatientswhosecomaisduetooverdoseorwhoreceivedneuromuscularblockingagents)

No

Heartrate150bpm?

Yes

No

Yes

No

Yes

No

Acuterenalfailure?

Yes

(Doesnotincludeprerenalazotemia)

No

Cardiacdysrhythmias?

Yes

No

Yes

No

Yes

No

Yes

No

Cardiopulmonaryresuscitationpriortoadmission?

Systolicbloodpressure90mmHg?

Mechanicalventilation?

Cerebrovascularaccident?

Intracranialmasseffect?

Gastrointestinalbleeding?
Metastaticcarcinoma?

Yes

No

Yes

No

Chronicrenalinsufficiency?

Yes

(Creatinine>2mg/dLchronically)

No

(Distantmetastasesonlydoesnotincludelocallymphnodeinvolvement)

Cirrhosis?

*Patientagedoesnotreceivepointswhencalculatingtheseverityscorehowever,itisusedintheformulatocalculatepredictedmortality.
Datafrom:Lemeshow,S,Teres,D,Klar,J,etal.Mortalityprobabilitymodels(MPMII)basedonaninternationalcohortofintensivecareunitpatients.
JAMA1993270:2478.
Graphic77798Version2.0

Disclosures
Disclosures:MarkAKelley,MDNothingtodisclose.ScottManaker,MD,PhDConsultant/Advisoryboards:Expertwitnessinworkers'compensationandinmedicalnegligencematters[General
pulmonaryandcriticalcaremedicine].EquityOwnership/StockOptions(Spouse):Johnson&JohnsonPfizer(Numerousmedicationsanddevices).OtherFinancialInterest:DirectorofACCP
Enterprises,awhollyownedforprofitsubsidiaryofACCP[Generalpulmonaryandcriticalcaremedicine(ProvidingpulmonaryandcriticalcaremedicineeducationtononmembersofACCP)].
GeraldineFinlay,MDNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsfor
referencestobeprovidedtosupportthecontent.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
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