Introduction:
Emergency Department is a dynamic environment. The treatment and evaluation usually went hand in hand. People used to be very anxious about their patients. To prognosticate about the patient and continue care at the same time is very difficult.
There are numerous scores available for prognostication but few scores are there for emergency departments e.g. REMS, RAPS, APACHE, etc some of them are disease-specific (GCS)1,2.
Sowe designed a score that included vitals, biochemical and subject oriented severity of disease or trauma to predict outcome in ED.
Objective:
To validate the DISS in patients presented to the emergency department.
Design:
Prospective observational study.
Setting:
It is done in tertiary level multidisciplinary hospital located in suburban area in north east India.
Materials and Method:
The DISS score is given below:
| Parameters | Score | ||||
| 3 | 1 | 0 | 1 | 3 | |
| Sensorium (S) | Not Responding | Drowsy but responding | Normal | Restless | Combative |
| Systolic Blood Pressure (SBP) | < 90 mmHg | 90-100 mmHg | 101-160 mmhg | 161-180 mmhg | >180 mmhg |
| Pulse (P) | <50/min | 50-60/min | 61-100/min | 101-120/min | >120/min |
| Respiratory Rate(RR) | <8/min | 8-10/min | 11-20/min | 21-30/min | >30/min |
| Temperature (T) | <96F | 96-97F | 97.1-100F | 100.1-101F | >101F |
| Base Excess | >-9 | -4 to -8 | Upto -3 | ||
| Lactate | >4 | 2-4 | <2 | ||
| Pre existing disease | Presence of any one or more pre existing disease | ||||
| Trauma | Head,chest,abdomen,spine,long bone, crush injury limb | ||||
| Age | >65 | <65 | |||
| Any obvious life threatening conditions the score will be always >4 Pre existing diseases are DM, HTN, COPD,CKD,CAD,CLD,CCF,Stoke, ILD | |||||
Inclusion Criteria:
It includes all adult patients with age >18 yrs presentingto ED.
Exclusion Criteria:
Age <18 yrs, Obstetric cases, burns and psychiatricpatient.The following is the data collection proforma and DISS. (ABG is taken only when there is clinical indication)
Results:
| Total Score | Number of cases |
| 0-4 | 359 |
| 5-10 | 109 |
| 11-15 | 25 |
| 16-20 | 4 |
| 20+ | 3 |
| Total | 500 |
Table 1: Breakdown of number of patient in each total score group.
| Total Score 0-4 | Whether Admitted to ICU or not | Not Admitted | 169 |
| Admitted | 190 | ||
| Whether died in ICU | Left Alive | 180 | |
| ICU Mortality | 10 | ||
| Ward Mortality | Discharged Alive | 344 | |
| Ward Mortality | 5 |
Table 2: Breakdown of score 0-4
| Total Score 5-10 | Whether Admitted to ICU or not | Not Admitted | 17 |
| Admitted | 92 | ||
| Whether died in ICU | Left Alive | 65 | |
| ICU Mortality | 27 | ||
| Ward Mortality | Discharged Alive | 75 | |
| Ward Mortality | 7 |
Table 3: Breakdown of score 5 – 10
| Total Score 11-15 | Whether Admitted to ICU or not | Not Admitted | 5 |
| Admitted | 20 | ||
| Whether died in ICU | Left Alive | 9 | |
| ICU Mortality | 11 | ||
| Ward Mortality | Discharged Alive | 10 | |
| Ward Mortality | 4 |
Table 4: Breakdown of Score 11-15
| Total Score 16-20 | Whether Admitted to ICU or not | Not Admitted | 2 |
| Admitted | 2 | ||
| Whether died in ICU | Left Alive | 0 | |
| ICU Mortality | 2 | ||
| Ward Mortality | Discharged Alive | 0 | |
| Ward Mortality | 0 |
Table 5: Breakdown of score 16-20
| Total Score 20+ | Whether Admitted to ICU or not | Not Admitted | 1 |
| Admitted | 2 | ||
| Whether died in ICU | Left Alive | 0 | |
| ICU Mortality | 2 | ||
| Ward Mortality | Discharged Alive | 0 | |
| Ward Mortality | 0 |
Table 6: Breakdown of score > 20
The analysis of data revealed increasing score has strong correlation with mortality. In 0-4 category out of 359 patient 169 got discharged from ED itself and mortality 4.17%.In 5-10 category out of 109 patient only 17 got discharged with a mortality of 31.2%.In 11-15 category out of 25 patient only 5 got discharge with a mortality rate of 60%.In 16-20 category out of 4 patient 2 got discharged and mortality rate of 100%.Also in category of 20 and above the mortality rate is again 100%.All the cases who didn’t get admitted in the last two categories went leave against medical advice.
Conclusion:
We found strong correlation between increasing score and mortality as evident in the above tables. The cut off score of 4 is taken as mortality above any score above 4 has significant mortality(4.17% Vs 31.2%, 60%, 100%).The limitation of this validation study as it is a single centre study, further multi-centre study involving larger population is required to validate it further.
REFERENCES:
1. Olsson T1, Terent A, Lind L.2004 May;255(5):579-87.
Rapid Emergency Medicine score: a new prognostic tool for in-hospital mortality in nonsurgical emergency department patients.
2. Duc T Ha et all, Int J Emerg Med.2015; 8:18
Author:
1. Dr. Apurba Kumar Borah (Consultant & HOD, CCEM, Narayana Superspeciality Hospital, Guwahati)
2. Dr Pawandeep Kaur (Fellow, Emergency Medicine, Narayana Superspeciality Hospital, Guwahati)
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