Archives of Academic Emergency Medicine. 2021; 9(1): e64 OR I G I N A L RE S E A RC H Physiologic Scoring Systems versus Glasgow Coma Scale in Predicting In-Hospital Mortality of Trauma Patients; a Di- agnostic Accuracy Study Farhad Heydari1, Reza Azizkhani1∗, Omid Ahmadi1, Saeed Majidinejad1, Mohammad Nasr-Esfahani1, Ahmad Ahmadi1 1. Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Received: July 2021; Accepted: August 2021; Published online: 23 September 2021 Abstract: Introduction: In recent years, several scoring systems have been developed to assess the severity of trauma and predict the outcome of trauma patients. This study aimed to compare Rapid Emergency Medicine Score (REMS), Modified Early Warning Score (MEWS), Injury Severity Score (ISS), and Glasgow Coma Scale (GCS) in predicting the in-hospital mortality of trauma patients. Methods: This diagnostic accuracy study was done on adult patients admitted to the emergency department (ED) between June 21, 2019, and September 21, 2020, following multiple trauma. Patients were followed as long as they were hospitalized. The REMS, MEWS, GCS, and ISS were calculated after data gathering and comprehensive assessment of injuries. Receiver operating characteristics (ROC) analysis was performed to examine the prognostic performance of the four different tools. Results: Of the 754 patients, 32 patients (4.2%) died and 722 (95.8%) survived after 24 hours of admission. The mean age of the patients was 38.54 ± 18.58 years (78.9% male). The area under the ROC curves (AUC) of REMS, MEWS, ISS, and GCS score for predicting in-hospital mortality were 0.942 (95% CI [0.923-0.958]), 0.886 (95% CI [0.861-0.908]), 0.866 (95% CI [0.839-0.889]), and 0.851 (95% CI [0.823-0.876]), respectively. The AUC of REMS was significantly higher than GCS (p=0.035). The sensitivities of GCS ≤ 11, ISS ≥ 13, REMS ≥ 4, and MEWS ≥ 3 scores for in-hospital mortality were 0.56, 0.97, 0.81, and 0.94, respectively. Also, the specificities of GCS, ISS, REMS, and MEWS scores for in-hospital mortality were 0.93, 0.82, 0.81, and 0.85, respectively. Conclusion: It seems that REMS is more accurate than GCS, ISS, and MEWS in predicting in-hospital mortality ≥ 24 hours of multiple trauma patients. Keywords: Multiple trauma; Injury severity score; scoring system/ Clinical Decision Rules; Emergency service, hospital; Patient outcome assessment; Prognosis Cite this article as: Heydari F, Azizkhani R, Ahmadi O, Majidinejad S, Nasr-Esfahani M, Ahmadi A. Physiologic Scoring Systems versus Glas- gow Coma Scale in Predicting In-Hospital Mortality of Trauma Patients; a Diagnostic Accuracy Study. Arch Acad Emerg Med. 2021; 9(1): e64. https://doi.org/10.22037/aaem.v9i1.1376. 1. Introduction Trauma and unintentional injuries kill more than 175,000 Americans each year and are the leading cause of death in people under 45 years of age (1). Also, trauma causes se- vere complications, disability, and financial and social costs (2, 3). Early diagnosis and appropriate triage and immedi- ate treatment decrease in-hospital mortality and are cost- effective (4). In recent years, several scoring systems have ∗Corresponding Author: Reza Azizkhani; Department of Emer- gency Medicine, Alzahra Hospital, Sofeh Ave, Keshvari Blvd., Isfahan, Iran. Email: r_azizkhani@med.mui.ac.ir, Tel: +989131367643, ORCID: http://orcid.org/0000-0002-5823-4374. been implemented to assess the severity of the injuries and determine which patients need intensive observation, treat- ment, and appropriate allocation of healthcare resources (3, 5, 6). National Early Warning Score (NEWS), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), Worthing Physiological Scoring System (WPSS), and Modified Early Warning Score (MEWS) are some of the most commonly used scoring systems. Glasgow Coma Scale (GCS) is used to assess a person’s level of consciousness and head injury severity. This scale is used by emergency medical services, nurses, and physicians, and is applied for all acute medical and trauma patients (7). Injury Severity Score (ISS) is an established medical score to assess trauma severity. It is an anatomy-based scoring sys- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem F. Heydari et al. 2 tem to predict the outcome of victims with multiple injuries (3). REMS, which is a powerful predictor of in-hospital mortality among medical (non-trauma) patients admitted to the hos- pital was developed in 2004 (8). REMS consists of six key pa- rameters: patient’s age, mean arterial pressure (MAP), heart rate, respiratory rate, SpO2, and Glasgow Coma Scale. Also, MEWS can be used to identify patients who are at risk of clinical deterioration and who may require a higher level of care (9). MEWS comprises five physiological parameters: systolic blood pressure (SBP), Heart rate, respiratory rate, temperature, and AVPU Score. This study aimed to compare the diagnostic accuracy of 3 physiologic scoring systems including Rapid Emergency Medicine Score (REMS), Modified Early Warning Score (MEWS), and Injury Severity Score (ISS), as well as Glas- gow Coma Scale (GCS) in predicting in-hospital mortality of trauma patients. 2. Methods 2.1. Study design and setting This was a prospective diagnostic accuracy study of adult multiple trauma patients admitted to Al-Zahra and Kashani Hospitals, two university educational hospitals, affiliated with Isfahan University of Medical Sciences, Isfahan, Iran. This study was approved by the Ethics Committee of Isfahan University of Medical Sciences (IR.MUI.MED.REC.1398.340) and an informed consent form was obtained from patients. 2.2. Participants All multiple trauma patients (two or more body region in- juries), who were aged 18 years and older and were admitted to the emergency department (ED) between June 21, 2019, and September 21, 2020, were included in the study. Pa- tients were enrolled regardless of trauma severity. Exclusion criteria were patients with missing data necessary to calcu- late scores, discharge or death in less than 24 hours from ad- mission, patients transferred from other hospitals, burn or drowning-related injuries, pregnancy, and discharge against medical advice. ISS was calculated after complete evaluation of the patient and receiving the results such as imaging results, interven- tion findings, and operative records, so comprehensive as- sessment of injuries could take substantial time, therefore hospitalization for at least 24 hours was considered to cal- culate ISS in all patients. 2.3. Data gathering After multiple trauma patients arrived at the ED, the triage nurse evaluated them on the basis of Emergency Severity In- dex (ESI) version 4, and then, the patients were transferred to the emergency room according to the level of the triage. Then all participants were examined by emergency medicine residents upon their arrival and they took over the patient’s treatment and follow-up. Sampling was performed using the convenience method. Age, sex, systolic blood pressure (SBP), diastolic blood pres- sure (DBP), respiratory rate (RR), heart rate (HR), GCS, AVPU score, temperature, oxygen saturation, length of hospital stay, mechanism of injury, triage level based on ESI and in- hospital mortality, were collected for each patient. Patients were followed during their hospital stay to evaluate their fi- nal outcome. The in-hospital mortality was defined as death during the present hospital stay. REMS consists of 6 parameters, 5 physiological and 1 age (8). The highest score is 26 with higher values being indicative of a worse prognosis. MEWS consists of 5 physiological pa- rameters (9). The range of MEWS total score is from 0 to a maximum of 14. ISS is an anatomical scoring system for pa- tients with multiple injuries. ISS is based on Abbreviated In- jury Scale (AIS), which divides the body into six regions. ISS is calculated as the sum of the squares of the highest AIS code in each of the three most severely injured body regions and has a range from 0 to 75 (3). REMS and MEWS scores were calculated according to the physiological criteria that were evaluated on admission to ED. ISS scores were calculated af- ter data gathering and comprehensive assessment of injuries. 2.4. Statistical analysis Considering the 5.2% prevalence of in-hospital mortality in trauma patients (10) and area under the curve of GCS in pre- dicting in-hospital mortality being 0.88 (11) and marginal er- ror of 0.05, the minimum required sample size was calculated to be 337 patients. SPSS version 25.0 (IBM, Armonk, NY) was used to analyze the variables. Categorical variables were de- scribed as frequency and percentage and continuous vari- ables were described as mean and standard deviation (SD) or median and interquartile ranges (IQR). Chi-square or Fisher’s exact test were used for the comparisons between categorical variables and independent samples t-test or Mann-Whitney U test were used for the comparisons between continuous variables. The predictive values of REMS, MEWS, ISS, and GCS in pre- dicting in-hospital mortality were compared using the area under the receiver operating characteristic curve (AUC) with a 95% confidence interval (CI). Sensitivity, specificity, posi- tive and negative likelihood ratios, and positive and negative predictive values with 95% CI were reported for each score. P- values less than 0.05 were considered statistically significant. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2021; 9(1): e64 Table 1: Comparison of demographic and clinical characteristics of multiple trauma patients according to in-hospital mortality after ≥ 24 hours of admission Characteristics Total (n=754) Survived (n=722) Non-Survived (n=32) P value Age, (year) Mean ± SD 38.54±18.58 38.13±18.09 47.75±28.31 0.1331 Sex, n(%) Female 159 (21.1) 155 (21.5) 4 (12.5) 0.2232 Male 595 (78.9) 567 (78.5) 28 (87.5) Mechanism, n (%) Road injuries 529 (70.3) 507 (70.3) 22 (68.7) Fall 124 (16.5) 114 (15.8) 10 (31.3) 0.1162 Assault 95 (12.7) 95 (13.1) 0 (0.0) Others 6 (0.5) 6 (0.8) 0 (0.0) Triage level, n (%) 1 158 (21.0) 130 (18.0) 28 (87.5) 2 396 (52.5) 392 (54.3) 4 (12.5) <0.0012 3 200 (26.5) 200 (27.7) 0 (0.0) Glasgow coma scale, n (%) 3-8 40 (5.3) 20 (2.8%) 20 (62.5%) 9-12 30 (4.0) 26 (3.6%) 4 (12.5%) <0.0012 13-14 24 (3.2) 24 (3.3%) 0 (0.0%) 15 660 (87.5) 652 (90.3%) 8 (25.0%) Length of stay, (day) Mean ± SD 6.25±5.78 6.31±5.84 5.14±5.11 0.6251 Vital signs* HR, (bpm) 87.42±14.19 87.03±13.74 96.24±20.45 0.0141 SBP, (mmHg) 129.87±19.31 130.34±16.87 119.18±17.45 <0.0011 MAP, (mmHg) 90.23±13.13 90.85±32.70 76.15±11.48 <0.0011 RR, (bpm) 19.20±3.68 19.18±3.48 19.68±7.54 0.7851 Temp, (°c) 36.97±0.31 36.99±0.31 36.88±0.16 0.5971 O2 SAT, (%) 94.58±3.11 94.57±2.99 94.88±5.03 0.5841 Injury severity (median (IQR))* ISS 9 (5-14) 9 (5-14) 23 (15-29) <0.0013 GCS 15 (14-15) 15 (14-15) 11 (4-15) <0.0013 MEWS 1 (1-2) 1 (1-2) 4 (3-4.75) <0.0013 REMS 0 (0-3) 0 (0-3) 8 (6-10.5) <0.0013 IQR: Interquartile range, SD: standard deviation, HR: Heart Rate; SBP: Systolic Blood Pressure; Mean Arterial Pressure; RR: Respiratory Rate; Temp: Temperature; SAT: saturation; ISS: Injury Severity Score; GCS: Glasgow Coma Scale; MEWS: Modified Early Warning Score; REMS: Rapid Emergency Medicine Score. 1 Analyzed using via independent-samples t test. 2 Analyzed using Fisher’s exact test. 3 Analyzed using Mann-Whitney U test. * These data were evaluated at the time of admission to emergency department. 3. Results Of the 754 patients included in this study, 32 patients (4.2%) died and 722 patients (95.8%) were discharged from hospital (Figure 1). The mean age of the patients was 38.54 ± 18.58 (18 –94) years (78.9% male). Road injuries were the main cause of trauma (70.3%) followed by falls (16.5%). 391 patients (51.9%) required surgery and 185 patients (24.5%) were admitted to the ICU. The median GCS, ISS, REMS, and MEWS scores (IQR) were 15 (14-15), 9 (5-14), 0 (0-3) and 1 (1-2), respectively. According to the emergency severity index (ESI) triage system, 21.0%, 52.5%, and 26.5% of the patients were categorized as levels I, II, and III, respectively. The mean duration of hospital stay was 6.28 ± 5.78 days. Mean vital sign measures of the patients and other baseline characteristics have been reported in ta- ble 1. The area under the ROC curves of REMS, MEWS, ISS, and GCS scores in predicting the in-hospital mortality of trauma patients were 0.942 (95% CI: 0.923-0.958), 0.886 (95% CI: 0.861-0.908), 0.866 (95% CI: 0.839-0.889) and 0.851 (95% CI: 0.823-0.876), respectively (figure 2). The optimal cut-off val- ues for the mentioned scores were ≥4 for REMS, ≥3 for MEWS score, ≥13 for ISS, and ≤11 for GCS. The sensitivities of GCS, ISS, REMS, and MEWS scores in these cutoff points were 0.56, 0.97, 0.81, and 0.94, respectively. Also, the speci- ficities of GCS, ISS, REMS, and MEWS scores for in-hospital This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem F. Heydari et al. 4 Table 2: Screening performance characteristics of physiologic scoring systems (REMS, MEWS, ISS) and Glasgow coma scale (GCS) in predic- tion of in-hospital mortality Variables REMS MEWS ISS GCS Cut-off ≥4 ≥3 ≥13 ≤ 11 Sensitivity 96.87 (83.8 - 99.9) 93.75 (79.2 - 99.2) 81.25 (54.4-96.0) 56.25 (37.7 - 73.6) Specificity 81.30 (78.3 - 84.1) 84.76 (81.9 - 87.3) 81.59 (77.1-85.5) 93.35 (91.3 - 95.1) PPV 16.2 (8.7-26.6) 21.3 (11.9-33.7) 16.7 (9.2-26.8) 37.0 (19.4-57.6) NPV 98.6 (96.6-99.6) 99.0 (97.2-99.8) 99.0 (97.0-99.8) 98.2 (96.2-99.4) PLR 5.18 (4.4 - 6.1) 6.15 (5.1 - 7.5) 4.41 (3.2-6.1) 8.46 (5.6 - 12.7) NLR 0.04 (0.01 - 0.3) 0.07 (0.02 - 0.3) 0.23 (0.08-0.6) 0.47 (0.3 - 0.7) AUC 0.942 (0.923-0.958) 0.886 (0.861-0.908) 0.866 (0.839-0.889) 0.851 (0.823-0.876) Data are presented with 95% confidence interval. Abbreviations: REMS: Rapid Emergency Medicine Score; MEWS: Modified Early Warning Score; ISS: Injury Severity Score; GCS: Glasgow Coma Scale; PPV: Positive predictive value; NPV: Negative predictive value; AUC; Area Under Curve; PLR: Positive Likelihood Ratio, NLR: Negative Likelihood Ratio. Table 3: Comparison of the area under the receiver operating characteristic (ROC) curve of studied scores Scores REMS MEWS GCS ISS REMS 0.107 0.035 0.010 MEWS 0.456 0.528 GCS 0.723 ISS ISS: Injury Severity Score; GCS: Glasgow Coma Scale; MEWS: Modified Early Warning Score; REMS: Rapid Emergency Medicine Score. Figure 1: CONSORT Flow Diagram. mortality were 0.93, 0.82, 0.81, and 0.85, respectively (Table 2). GCS was similar to MEWS (p=0.456) and ISS (p=0.723) in predicting in-hospital mortality. However, REMS was signif- icantly better than GCS (p=0.035) in predicting in-hospital mortality (Table 3). 4. Discussion Based on the results of this study, REMS was better than MEWS, ISS, and GCS in predicting in-hospital mortality oc- curring ≥ 24 hours after admission among adult multiple trauma patients referring to ED. Based on calculated AUCs, the results showed REMS was an excellent predictor of in- hospital mortality (AUC = 0.94), and MEWS, ISS, and GCS were good predictors of in-hospital mortality (AUC = 0.89, 0.87, and, 0.85). Despite advances in injury prevention and medical care, trauma deaths remain a major public health problem world- wide. To improve overall survival and management out- comes, it is important to quickly and accurately determine the severity of trauma in patients admitted to the ED. Vari- ous scoring systems have been developed for the classifica- tion of injuries, which include physiologic and anatomic sys- tems (12). Each of these systems has its specific limitations and advan- tages, but an efficient scoring system should have fewer vari- ables, be easy to use and be accurate, especially in emer- gency settings. One of the oldest trauma scores is ISS. Several studies have shown that ISS is a valid predictor of in-hospital mortality (3, 5, 6, 8, 9). One of the important limitations of ISS is the inability to be calculated in the initial evaluation of the patient. ISS can be calculated after a comprehensive as- sessment of the patient and identification of all injuries. Sev- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2021; 9(1): e64 Figure 2: Receiver operating characteristic (ROC) curves of Injury Severity Score (ISS); Glasgow Coma Scale (GCS); Modified Early Warning Score (MEWS); and Rapid Emergency Medicine Score (REMS) for predicting in-hospital mortality (≥ 24 hours) of multiple trauma patients. eral scoring systems have been developed to objectively mea- sure the initial condition of a trauma patient, and these may also serve as prognostic indicators for specific patients (9- 12). REMS and MEWS have acceptable predictive values for in-hospital mortality and are good choices for use in emer- gency settings. It seems that REMS and MEWS scores are superior to other predictors because they both include vital signs (e.g., SBP and RR) and neurological variables (e.g., AVPU, Motor, and Speech), which are strongly related to mortality risk. AUCs of REMS and MEWS were more than GCS, this indicates that adding parameters such as BP, HR, RR, O2 saturation, and body temperature to the level of consciousness, which is usu- ally assessed using GCS, increases the efficiency of GCS in predicting the outcomes of traumatic patients. Some of the REMS and MEWS parameters (MAP or SBP, GCS or AVPU and HR) were significantly associated with mortality risk, while age, oxygen saturation, temperature and RR were indepen- dent predictors of in-hospital mortality. In most previous studies, REMS has been used to predict mortality in non-surgical patients. In the study conducted by Olsson et al., the REMS was found to be a strong predictor of both in-hospital and long-term mortality in non-surgical patients in the ED (8). Goodacre et al. compared REMS and RAPS scores in predicting in-hospital mortality of 5583 pa- tients who were brought by the emergency ambulance and hospitalized. They found that REMS is effective in predicting mortality among medical patients (13). REMS can be rapidly determined in 20 minutes and has been shown to be compatible with mortality rate prediction in pa- tients with trauma in previous studies. Imholff et al. showed that a higher REMS score is associated with an increase in the mortality rate of trauma patients (10). Nakhjavan-Shahraki et al. suggested that REMS could be used to predict mortal- ity (AUC=0.93) and poor outcomes (p=0.001) in patients with trauma in emergency settings (14). The findings of the cur- rent study are consistent with those of the previous studies, which found that REMS is a simple and accurate predictor of in-hospital mortality for multiple trauma patients. MEWS has been used to initially identify the risk of mor- tality and to predict the clinical outcomes of patients (15- 17). Several studies showed that MEWS is useful in pre- dicting the severity of trauma among patients. In a previ- ous study, MEWS was a fair predictor of in-hospital mortal- ity (AUC, 0.79; 95% CI, 0.74-0.83) (18). In contrast, in another study, MEWS was a good predictor of in-hospital mortality (AUC, 0.90; 95% CI, 0.88-0.92) in trauma patients (18). Con- sistently, our results showed that MEWS is a good predictor (AUC=0.89) of in-hospital mortality in multiple trauma pa- tients. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem F. Heydari et al. 6 Bulut et al. reported that the prognostic value of REMS model for mortality of medical and surgical patients referring to EDs was significantly higher than = MEWS (9). The results of the current study showed that REMS is superior to MEWS and GCS in predicting in-hospital mortality for trauma pa- tients. Although the sensitivity of REMS ≥ 4 and MEWS ≥ 3 (96.87% and 93.75) in predicting in-hospital mortality were higher than GCS ≤ 11, the specificity of GCS (93.35%) was higher than other scores. When specificity is high, it is less likely to give a false-positive. On the other hand, the sensitiv- ity of GCS was only 56.25 %, which means that there are many false-negative results. In serious and life threatening condi- tions we should use tests or methods with high sensitivity to decrease false negative rates. Also, in the present study, the PPV was reported to be low and the NPV was reported to be high. This could be due to the low prevalence of in-hospital mortality. In this study, in-hospital mortality was 4.2%. PPV and NPV are directly related to prevalence. 5. Limitations Our study has some limitations. First, convenience sampling method was used and the researcher was present in the ED, which may have caused selection bias. Second, patients who died in less than 24 hours and those who died upon arrival were excluded; the lack of information on these patients may have caused a spectrum bias. 6. Conclusion The findings of this study revealed that REMS is an excellent predictor of in-hospital mortality ≥ 24 hours after admission and MEWS, GCS, and ISS are good alternatives for predicting in-hospital mortality in multiple trauma patients. 7. Declarations 7.1. Acknowledgments The authors would like to express their gratitude to the staff of the EDs of Al-Zahra and Kashani Hospitals, Isfahan, Iran. 7.2. Funding This study was conducted with the support of Isfahan Uni- versity of Medical Sciences. 7.3. Author contribution F.H., S.M., A.A., M.N.E., O.A., and R.A. contributed to the con- ception, study design, and data collection and evaluation. F.H., R.A., and A.A. contributed to statistical analysis, and in- terpretation of data. F.H. and R.A. were responsible for over- all supervision. 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Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Methods Results Discussion Limitations Conclusion Declarations References