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The H1N1 pandemic has highlighted the importance of reliable and valid triage instruments for scarce resources during periods of high demand. Christian and colleagues have proposed a triage protocol that utilizes a Sequential Organ Failure Assessment (SOFA) score >11 to exclude patients from critical care resources quoting an associated mortality of more than 90% . We sought to assess the hospital mortality associated with this SOFA threshold and the resource implications of such a triage protocol.
This retrospective cohort study included consecutive ICU patients admitted to any one of our three tertiary-care adult multisystem ICUs from January 2003 to December 2008. Patients were excluded if they were admitted for routine postoperative monitoring (ICU stay <48 hours) or postoperative cardiac surgery. SOFA was collected daily by an electronic bedside clinical information system (QS; GE Medical Systems).
A total of 10,204 patients (69,913 patient-days) were included. Mean age was 59. Mean admission APACHE was 19.1. Mortality was 25%. Median ICU LOS was 4 days. A total 13.4% of the cohort (representing 9% of total patient-days) had an initial SOFA >11. Mortality in patients with an initial SOFA score >11 was 59% (95% CI 56%, 62%). Figure Figure11 demonstrates increased mortality associated with SOFA >11 during the ICU stay to a maximum of 78% (95% CI 68%, 86%) on day 14. The mortality associated with an initial SOFA >11 across diagnostic categories (ICNARC) varied from 29% for poisoning to 67% for neurological patients. Mortality associated with an initial SOFA >11 was lowest for those patients 18 to 20 years old (37%) and highest for those >80 years old (75%). Mortality exceeded 90% when the initial SOFA was >20. However, only 0.2% of patients had an initial SOFA >20.
A SOFA score >11 was not associated with a hospital mortality >90% at any time during the ICU stay. Age and diagnostic category represent potential modifying factors in the association of SOFA >11 and hospital mortality. Only a small proportion of patients have the extreme initial SOFA values associated with a hospital mortality >90%, limiting the usefulness of SOFA as a triage instrument for pandemic planning.