Question 4

Outline  the  principles  of  illness  severity  scoring  systems  used  in  the  critically  ill patient,  and using examples outline their relationship to clinical outcome.

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College Answer

Scoring systems stratify groups of critically ill patients by severity, compare groups of patients in research trials, compare ICUs, and predict mortality for individuals and groups. Most measure physiological variables, some measure interventions. Derived by logistic regression from large demographic data sets of critically ill patients. Commonly used systems include:
•    APACHE II. Commonly used in Australia to measure patient severity. Uses 12 physiological variables and previous health estimate. Requires measure of worst values in first 24 hours in ICU, so affected if ICU admission delayed. Not reliable for predicting outcome in individuals. Limited by derivation from an historical data set.
•    APACHE III. Better outcome predictions by using additional variables and a more recent data set for comparisons. Outcome predictions for Australian patients more accurate.
•    GCS. Used to quantify severity of coma. Scale from 3-15. Eye (1-4), Verbal (1-5), and Motor (1-6) components. Key score for outcome prediction after head injury. Affected by alcohol and sedation. Should be scored in non-sedated non-paralysed patients.  Important component of other scoring systems eg APACHE 11.
•    TISS. System to score patient severity by counting procedures done. Less widely used.
Physician dependent, so less useful to compare ICUs.
•    SOFA. Organ dysfunction scores. Often a secondary endpoint in research trials.


Here is a link to the LITFL article on ICU scoring systems.

Here are some links to the seminal articles which describe these systems:


How are these scoring systems useful?

  • They (try to) predict outcome and length of stay
  • They can be used to compare predicted and observed outcome
  • They stratify patients for clinical trials, according to disease severity
  • They assess ICU performance
  • They allow resources to be allocated to ICUs according to the illness severity of their patients
  • They allow a comparison of ICUs

Some examples:


APACHE stands for Acute Physiology, Age and Chronic Health Evaluation (I-IV).

  • APACHE II is the most commonly used one
  • 12 variables are measured
  • Scores range from 0 to 71
  • The risk of hospital death is computed by combining APACHE II score with Knaus' weighted coefficient for different types of disease entities. A score of 25 represents a predicted mortality of 50% and a score of over 35 represents a predicted mortality of 80%.
  • Derived from histrical data set


SOFA stands for Sequential Organ Failure Assessment .

  • 6 organ systems are scored according to their function
  • The degree of organ support is taken into account
  • Used to analyse secondary endpoints in clinical trials

There is a defined score of 1-4 for each organ system, which is collected daily. This not a predictive model- there are no mortality algorithms here. A higher SOFA score can be said to relate to increased mortality, but there is no mathematical model to help us figure out exactly how the total score relates to survival.

TISS: Therapeutic Interventions Scoring System

  • 76 variables (interventions and treatments)
  • Collected daily
  • Indicates nursing and medical workload
  • Does not indicate severity of illness
  • Most useful for accountants

SAPS: Simplified Acute Physiology Score

  • SAPS 1 only looked at physiology, and was used by French ICUs
  • SAPS 2 added chronic health conditions, and was used in Europe and North America
  • SAPS 3 had 20 variables and was used worldwide

MPM: Mortality Prediction Models

  • MPM measures variables at admission and in the first 24 hours
  • It calcuates the risk of in-hospital death on the basis of these variables, using a logistic regression model.
  • MPM II was based on the same historical data set as SAPS 2 and predicts mortality at 24, 48 and 7 hours.

POSSUM: = Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity

  • 12 physiological parameters for surgeons
  • Used by surgeons as a risk adjustment tool
  • Different subspecialties have their own: V-POSSUM is for vacular surgeons, Cr-POSSUM is for colorectal, etc


Gunning, Kevin, and Kathy Rowan. "Outcome data and scoring systems." Bmj319.7204 (1999): 241-244.


Liddell, F. D. "Simple exact analysis of the standardised mortality ratio."Journal of Epidemiology and Community Health 38.1 (1984): 85-88.


Wolfe, Robert A. "The standardized mortality ratio revisited: improvements, innovations, and limitations.American Journal of Kidney Diseases 24.2 (1994): 290-297.


Gaffey, William R. "A critique of the standardized mortality ratio." Journal of Occupational and Environmental Medicine 18.3 (1976): 157-160.



Balci, C., et al. "[APACHE II, APACHE III, SOFA scoring systems, platelet counts and mortality in septic and nonseptic patients]." Ulusal travma ve acil cerrahi dergisi= Turkish journal of trauma & emergency surgery: TJTES 11.1 (2005): 29-34.


Halim, Dino Adrian, Tri Wahyu Murni, and Ike Sri Redjeki. "Comparison of Apache II, SOFA, and Modified SOFA scores in predicting mortality of surgical patients in intensive care unit at Dr. Hasan Sadikin General Hospital." Critical Care & Shock 12 (2009): 157-169.


Knaus, William A., et al. "APACHE II: a severity of disease classification system." Critical care medicine 13.10 (1985): 818-829.


Vincent, J-L., et al. "The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure." Intensive care medicine 22.7 (1996): 707-710.


Ferreira, Flavio Lopes, et al. "Serial evaluation of the SOFA score to predict outcome in critically ill patients." Jama 286.14 (2001): 1754-1758.


Vincent, Jean-Louis, and Rui Moreno. "Clinical review: scoring systems in the critically ill." Crit Care 14.2 (2010): 207.


Livingston, Brian M., et al. "Assessment of the performance of five intensive care scoring models within a large Scottish database." Critical care medicine28.6 (2000): 1820-1827.


Wong, David T., et al. "Evaluation of predictive ability of APACHE II system and hospital outcome in Canadian intensive care unit patients." Critical care medicine 23.7 (1995): 1177-1183.


Cullen, David J., et al. "Therapeutic intervention scoring system: a method for quantitative comparison of patient care." Critical care medicine 2.2 (1974): 57-60.


Le Gall, Jean-Roger, Stanley Lemeshow, and Fabienne Saulnier. "A new simplified acute physiology score (SAPS II) based on a European/North American multicenter study." Jama 270.24 (1993): 2957-2963.


Lemeshow, Stanley, et al. "Mortality Probability Models (MPM II) based on an international cohort of intensive care unit patients." Jama 270.20 (1993): 2478-2486.


Neary, W. D., B. P. Heather, and J. J. Earnshaw. "The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM)." British journal of surgery 90.2 (2003): 157-165.