Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. External validation of the MISSED score to predict mortality in patients with severe sepsis and septic shock in the emergency department Seung Mok Ryoo, Shin Ahn,Won Young Kim and Kyoung Soo Lim Objective The Mortality in Severe Sepsis in the Emergency Department (MISSED) score was derived to predict in-hospital mortality in septic patients in the emergency department (ED). The present study aimed to validate the MISSED score in patients receiving early goal-directed therapy (EGDT). Methods Data were analyzed from 280 patients who received EGDT in a tertiary center ED in Korea. Age 65 years and above, albumin level 27 g/l or less, and international normalized ratio of at least 1.2 were variables included in the MISSED score. Results With a cutoff point of 5.5, the odds ratio for death was 2.17 (95% confidence interval 1.18–4.02). Mortality rates with MISSED scores of 0, < 5.5, and Z 5.5 were 4.5, 13.4, and 25.2%, respectively. Although the score was less discriminatory in patients who had EGDT commenced in the ED, a MISSED score higher than 5.5 remained significant. Conclusion Further studies are required to validate the MISSED score in more diverse patients. European Journal of Emergency Medicine 00:000–000  c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. European Journal of Emergency Medicine 2014, 00:000–000 Keywords: clinical prediction rule, emergency medicine, mortality, sepsis, septic shock Department of Emergency Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea Correspondence to Shin Ahn, MD, Department of Emergency Medicine, Asan Medical Center, College of Medicine, University of Ulsan, 388-1, Pungnap-dong, Songpa-gu, Seoul, 138-736, Korea Tel: + 82 2 3010 5327; fax: + 82 2 3010 3360; e-mail: ans1023@gmail.com Received 15 December 2013 Accepted 24 March 2014 Introduction Despite advances in modern antibiotics and resuscitation therapies, severe sepsis and septic shock remain a major cause of morbidity and mortality in critically ill patients [1]. Various prognostic scores have been developed to predict the outcomes of these critically ill patients, including one system specifically conceived for emergency department (ED) patients [2–6]. Recently, a group from a tertiary hospital in the UK used the pooled datasets of patients with severe sepsis and septic shock who were admitted to the ICU within 7 days of ED attendance, including those who received early goal-directed therapy (EGDT) in the ED, to derive and internally validate a clinical prediction rule to predict Mortality in Severe Sepsis in the Emergency Department, termed the MISSED score [7]. Three independent variables were identified to predict a high risk of death – age at least 65 years, albumin level up to 27 g/l, and an international normalized ratio (INR) of 1.2 or more – and points of 2.5, 3, and 3.5 were allocated, respectively, to reach a total summed score. The score ranged from 0 to 9, with a cutoff point of 5.5, and it showed an equivalent performance to that of other prognostic scores in terms of predicting mortality. The main goal of the scoring system was to determine which severe sepsis patients are at a high risk of death and require more active resuscitation measures. The primary goal of this study was to determine whether the MISSED score could also be applied to independent patients receiving EGDT. The secondary goal was to compare the performance of the MISSED score with that of the Sepsis-related Organ Failure Assessment (SOFA) score. Methods Since January 2010, data on adult patients with sepsis visiting the ED of Asan Medical Center and receiving EGDT have been prospectively collected. Sepsis was defined as the presence of infection together with its systemic manifestations. The decision for implementa- tion of EGDT was made on the basis of the Surviving Sepsis Campaign guidelines for the management of severe sepsis and septic shock, and patients who had hypotension (systolic blood pressure <90 mmHg or mean arterial pressure <70 mmHg or a systolic blood pressure decrease >40 mmHg) persisting after initial fluid chal- lenge or a blood lactate concentration of at least 4 mmol/l had EGDTcommenced [8]. From this registry, using the convenience sampling method, we retrospectively ana- lyzed 1333 patients visited between January 2010 and December 2012. The hospital research ethics board approved the protocol. The same exclusion criteria as the original derivation study were adopted, and patients with active malignancy or patients on vitamin K antagonists were excluded. The primary outcome was 28-day mortality during the treatment period. For those who were discharged before Original article 1 0969-9546  c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI: 10.1097/MEJ.0000000000000156