Severity Of Illness Scoring Systems Research Articles

Severity of illness scoring systems in patients with bacteraemic pneumococcal pneumonia: implications for the intensive care unit care

Severity of illness scoring systems are useful for decisions on the management of patients with community-acquired pneumonia (CAP), including assessing the need for intensified therapy and monitoring, or for intensive care unit (ICU) admission. We compared the accuracy of the Pneumonia Severity Index (PSI), the CURB-65 and CRB-65 score, the modified-American Thoracic Society score (ATS), the IDSA/ATS guidelines and the Pitt Bacteraemia score (PBS) in evaluating severity of illness in 766 patients with bacteraemic pneumococcal pneumonia. We evaluated the sensitivity and specificity, the positive predictive value (PPV) and the negative predictive value (NPV) and the accuracy of the classification in predicting 14-day mortality. The PSI and the IDSA/ATS guidelines were the most sensitive whereas the PBS and modified-ATS scoring systems were the most specific in predicting mortality. The NPV was comparable for all four scoring systems (all above 90%), but the PPV was highest for PBS (54.2%) and lowest for PSI (23.2%). The predictive accuracy and discriminating power as measured by the receiver-operating characteristic (ROC) curve was highest for the PBS. Both the modified-ATS and the PBS scoring systems identified those patients who might benefit most from intensified care and monitoring. The PBS and modified-ATS proved superior to the IDSA/ATS guidelines, CURB-65 and CRB-65 with respect to their specificity and PPV. The low PPV of the PSI rendered it not usable as a parameter for decision-making in severely-ill patients with pneumococcal bacteraemia.

International comparisons in critical care: a necessity and challenge

Understanding variation in critical care resources, and delivery of care between countries will allow for improved disaster planning, evaluation of research findings, and assessment of the utility of critical care itself. This review describes the available data for international comparisons and the many factors that need to be addressed for an appropriate interpretation of results. Recent studies on subgroups of critical care patients include data from many different countries. These new studies provide important information on the overall incidence of these disease states, but most of these international studies do not take into account the critical care resources of the countries being discussed. For an appropriate interpretation of findings the relevant baseline critical care resources, prevalence of diseases, and cultural practices, need to be quantified. The existence of these other factors prevents the use of a severity of illness scoring system alone to account for differences between countries. Many recent critical care studies include data from multiple countries. With continued movement towards international studies, and improvements in data collection systems, comparisons between countries are becoming easier. These findings need to be interpreted in the context of all the relevant country information.

Performance of Severity of Illness Scoring Systems in Emergency Department Patients with Infection

Performance of Severity of Illness Scoring Systems in Emergency Department Patients with Infection

Performance of Severity of Illness Scoring Systems in Emergency Department Patients with Infection

To validate the Mortality in Emergency Department Sepsis (MEDS) score, the Confusion, Urea nitrogen, Respiratory rate, Blood pressure, 65 years of age and older (CURB-65) score, and a modified Rapid Emergency Medicine Score (mREMS) in patients with suspected infection. This was a prospective cohort study. Adult patients with clinically suspected infection admitted from December 10, 2003, to September 30, 2004, in an urban emergency department with approximately 50,000 annual visits were eligible. The MEDS and CURB-65 scores were calculated as originally described, but REMS was modified in neurologic scoring because a full Glasgow Coma Scale score was not uniformly available. Discrimination of each score was assessed with the area under the receiver operating characteristics curve (AUC). Of 2,132 patients, 3.9% (95% confidence interval [CI] = 3.1% to 4.7%) died. Mortality stratified by the MEDS score was as follows: 0-4 points, 0.4% (95% CI = 0.0 to 0.7%); 5-7 points, 3.3% (95% CI = 1.7% to 4.9%); 8-12 points, 6.6% (95% CI = 4.4% to 8.8%); and > or = 13 points, 31.6% (95% CI = 22.4% to 40.8%). Mortality stratified by CURB-65 was as follows: 0 points, 0% (0 of 457 patients); 1 point, 1.6% (95% CI = 0.6% to 2.6%); 2 points, 4.1% (95% CI = 2.3% to 6.0%); 3 points, 4.9% (95% CI = 2.8% to 6.9%); 4 points, 18.1% (95% CI = 11.9% to 24.3%); and 5 points, 28.0% (95% CI = 10.4% to 45.6%). Mortality stratified by the mREMS was as follows: 0-2 points, 0.6% (95% CI = 0 to 1.2%); 3-5 points, 2.0% (95% CI = 0.8% to 3.1%); 6-8 points, 2.3% (95% CI = 1.1% to 3.5%); 9-11 points, 7.1% (95% CI = 4.2% to 10.1%); 12-14 points, 20.0% (95% CI = 12.5% to 27.5%); and > or = 15 points, 40.0% (95% CI = 22.5% to 57.5%). The AUCs were 0.85, 0.80, and 0.79 for MEDS, mREMS, and CURB-65, respectively. In this large cohort of patients with clinically suspected infection, MEDS, mREMS, and CURB-65 all correlated well with 28-day in-hospital mortality.

Adult congenital heart disease: intensive care management and outcome prediction

Improved patient survival and increasingly complex surgery have expanded the requirement for specialist care for patients with adult congenital heart disease (ACHD). Despite the recent publications of management guidelines for ACHD, data concerning optimal patterns of care in the peri-operative/critical care period of this challenging population are sparse. The aims of the current study were to therefore to determine the pattern of intensive care unit (ICU) management, resource utilisation and predictors of mortality in critically ill ACHD patients. Data were collected prospectively for patients with ACHD stratified for complexity of disease admitted to the ICU of a tertiary cardiothoracic centre (1997-2002). Multivariate analysis of pre-operative indices as predictors of mortality was performed. Of 342 ACHD admissions (total mortality 4.4%, simple 0%, moderate/complex 10.6%), the requirement for specialist investigations and interventions was high, reflected in ICU admission costs per patient (simple $5391+/-130, moderate $13218+/-261, complex $30074+/-689). Standard severity of illness scoring systems did not accurately predict mortality; however, abnormal pre-operative thyroid function (p=0.0048), creatinine (p=0.0032) and bilirubin (p=0.0021) were highly predictive of mortality. Peri-operative mortality in patients with ACHD is low overall but varies with disease complexity. Such patients have a high requirement for specialist ICU investigation/intervention. Although standard severity of illness scoring is unhelpful, simple pre-operative parameters may predict peri-operative mortality. These findings reflect the requirement for specialist care, and have implications for planning service provision, training and operative consent in ACHD patients.

Combining various severity of illness scoring systems to improve outcome prediction: pilot experience in the critically ill obstetric population

No perfect severity score exists to predict ICU mortality, thus the search for new systems is still a preoccupation.

Comparison of severity of illness scoring systems for patients with nosocomial bloodstream infection due to Pseudomonas aeruginosa

BackgroundSeveral acute illness severity scores have been proposed for evaluating patients on admission to intensive care units but these have not been compared for patients with nosocomial bloodstream infection (nBSI). We compared three severity of illness scoring systems for predicting mortality in patients with nBSI due to Pseudomonas aeruginosa.MethodsWe performed a historical cohort study on 63 adults in intensive care units with P. aeruginosa monomicrobial nBSI.ResultsThe Acute Physiology, Age, Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), and Simplified Acute Physiologic Score (SAPS II), were calculated daily from 2 days prior through 2 days after the first positive blood culture. Calculation of the area under the receiver operating characteristic (ROC) curve confirmed that APACHE II and SAPS II at day -1 and SOFA at day +1 were better predictors of outcome than days -2, 0 and day 2 of BSI. By stepwise logistic regression analysis of these three scoring systems, SAPS II (OR: 13.03, CI95% 2.51–70.49) and APACHE II (OR: 12.51, CI95% 3.12–50.09) on day -1 were the best predictors for mortality.ConclusionSAPS II and APACHE II are more accurate than the SOFA score for predicting mortality in this group of patients at day -1 of BSI.

Risk Adjustment of Clinical Performance Quality Data to Facilitate Outcomes Comparison of Physicians and Hopitals

Despite the growing national concerns for healthcare quality and patient safety, there is limited success in using clinical performance data to compare the performance of physicians and hospitals. This results in a chilling effect on achieving transparency of quality of care for the healthcare system in the U.S. A significant reason for this limitation is the argument that patient outcomes cannot be meaningfully compared because of clinical differences in patient-mix, including the underlying severity of illness. The limitation to make such comparisons valid and clinically meaningful has also adversely impacted the ability to use such data in many legal settings including litigation in medical malpractice, obtaining informed consent, and public reporting of healthcare quality. Risk adjustment provides a mechanism to overcome this limitation. This paper includes the results of the experience from the National Outcomes Center, using the pediatric critical care setting as an illustration, for successfully applying risk adjustment when making comparisons of Pediatric Intensive Care Units (PICUs) across the U.S. The National Outcomes Center has partnered with the National Association of Children's Hospital and Related Institutions (NACHRI), and the Children's Hospital of Los Angeles to develop the Virtual Pediatric Intensive Care Unit System (VPS). The VPS currently includes clinical performance data from 56 U.S. hospitals representing over 56,000 patients. Outcomes analyses comparing the performance over time for PICUs within specific hospitals, and also comparisons of performance between hospitals, have been completed (N=12). This comparison includes risk adjustment using unconditional logistic regression modeling with severity of illness scoring systems. Results emerging from this national endeavor have been met with significant buy-in and acceptance by physicians and administrators. The findings from this study support that risk adjustment provides a mechanism to overcome the barrier of using clinical performance data to make comparisons of the quality and outcomes of physicians and hospitals.

Chronic inhaled corticosteroids do not affect the course of acute severe asthma exacerbations in children

Chronic therapy with inhaled corticosteroids (ICS) suppresses airway inflammation and increases airway responsiveness to beta(2)-adrenergic receptor agonists. We hypothesized that the chronic use of ICS would be associated with shorter duration of hospitalization in severely ill children with status asthmaticus. An 8-year retrospective chart review was conducted of all children admitted to the ICU with status asthmaticus. During the study period, 241 children were admitted, and 44% reported the use of chronic ICS. ICS use was associated with increased baseline asthma severity, previous hospitalization for asthma, and public insurance status. However, ICS use had no effect on hospital or ICU length of stay, type, and duration of treatments received, or the rate of recovery determined by a standard severity of illness scoring system. In the subsets of patients including children with persistent asthma and those who received intravenous terbutaline, there was also no improvement in outcomes with the use of chronic ICS showing that the chronic use of ICS did not improve response to beta(2)-adrenergic receptor agonists in severely ill children with status asthmaticus. Although useful as a preventive therapy, the chronic use of ICS does not appear to affect the course of severe acute asthma exacerbations in pediatric patients once hospitalized.

Three generations of mortality prediction models: accuracy for outcome prediction in the critically ill obstetric patient

Mortality prediction models (MPM) [1-3] are generalistic severity of illness scoring systems. No score is computed, and a logistic regression equation directly provides a probability of hospital mortality. Three generations of MPM scores are already available, and assess mortality at admission to the ICU (first hour).

The reliability and validity of the therapeutic activity index

Purpose To assess the psychometric properties of the Simplified Therapeutic Intervention Scoring System (TISS 28) scale. Materials and Methods A prospective observational design was used. Patients were recruited from a medical-surgical intensive care unit (ICU) and 4 rehabilitation wards of 2 university-affiliated hospitals in Hong Kong. Results Data necessary for the calculation of the TISS 28, the Therapeutic Intervention Scoring System (TISS 76), and severity of illness scoring system (Simplified Acute Physiology Score [SAPS II]) were recorded for each patient during the first 24 hours after his/her admission to an ICU. A significant positive correlation was found between the TISS 76 and the TISS 28 scores as well as the TISS 28 and the SAPS II scores. There was a significant difference between the TISS 28 scores among ICU patients and patients in rehabilitation wards. A significant correlation was found between the TISS 28 scores of the first and second set of TISS 28 scores. Conclusions Although the findings supported the validity and reliability of the TISS 28, there were limitations of the TISS 28 in measuring nursing workload in ICUs. Hence, continued amendment and validation of the TISS 28 on larger samples in different ICUs would be required so as to provide clinical nurses with a valid and reliable assessment of nursing workload.

Comparison of the severity of illness scoring systems for critically ill cirrhotic patients with renal failure

Mortality rates of cirrhotic patients with renal failure admitted to the medical intensive care unit (ICU) are high. End-stage liver disease is frequently complicated by disturbances of renal function. This investigation is aimed to compare the predicting ability of acute physiology, age, chronic health evaluation II and III (APACHE II and III), sequential organ failure assessment (SOFA), and Child-Pugh scoring systems, obtained on the first day of ICU admission, for hospital mortality in critically ill cirrhotic patients with renal failure. Sixty-seven patients with liver cirrhosis and renal failure were admitted to ICU from April 2001-March 2002. Information considered necessary for computing the Child-Pugh, SOFA, APACHE II and APACHE III score on the first day of ICU admission was prospectively collected. The overall hospital mortality rate was 86.6%. Liver disease was most commonly attributed to hepatitis B viral infection. The development of renal failure was associated with a history of gastrointestinal bleeding. Goodness-of-fit was good for SOFA, APACHE II and APACHE III scores. The APACHE III and SOFA models reported good areas under receiver operating characteristic curve (0.878 +/- 0.050 and 0.868 +/- 0.051, respectively). Renal failure is common in critically ill patients with cirrhosis. The prognosis for cirrhotic patients with renal failure is poor. APACHE III and SOFA showed excellent discrimination power in this group of patients. They are superior to APACHE II and Child-Pugh scores in this homogenous group of patients.

Severity of illness scoring systems

Data collection on the ICU is necessary to facilitate research, quality assurance and resource management. Severity of illness scoring systems aid the case-mix adjusted collection of such data. However, none is perfect and their use to triage individual patients or to compare the quality of care in different ICUs is severely limited. An appreciation of their limitations and the statistical methods of assessing their goodness of fit are vital if the information that they provide is to be used appropriately. Potential uses for scoring systems include: • case-mix adjustment for entry into randomized controlled trials • audit and comparison of ICU performance • a mechanism to decide resource allocation. Scoring systems use a logistic regression equation based, variably, on disease severity, age and diagnosis to derive the probability of hospital death (on a scale of 0 to 1, where 0 = survival and 1 = death). The standardized mortality ratio (SMR) describes the ratio of expected to observed deaths. Case-mix variation and the need to derive binary (live or die) data from a probability estimate, limit the use of such systems to evaluate ICU performance.

A comparison of severity of illness scoring systems for patients with liver cirrhosis presenting with acute upper gastrointestinal bleeding

Objective To evaluate the predictive abihty of three severity scoring systems: the acute physiology and chronic health evaluation (APACHE I1), the model for end stage liver disease (MELD) and the Child-Turcotte-Pngh (CTP) in patients w~th cirrhosis and acute upper gastrointestinal bleeding Design: Retrospective cohort study Setting: Medical [Cls at 2 University a{ldiated hospitals Patients: We identffmd 48 patients w~th a history of cirrhosis on adimssion, trom 192 patients admitted to the medical ICU between Janua~ T 1999 to June 2002 for acute UG[ bleeding. Patients who developed in-hospital bleedmg were excluded. Methods: l'he perfnrmance of MELD, CTP and APACHE lI scores in predicting in-hospital mortality rates was assessed using the receiver operating characteristic (ROC) curves The prediction accuracy was quantified using the concordance index (c-index). Measuretnents and results: The actual mortality observed was 29.0% (95% C1, 158% to 425%) The mean length of stay in medical ICU was 4.2 d (95% CI, 30 d to 6.1 d) and the mean length of stay in the hospital was 100 d (95% CI, 71 d to 130 d) The area under the ROC curve for MEID, CPP and APACHE i[ scores were 083 (95% CI, 068 to 097), 081(95% C1,066 to 095) and 061 (95% CI, 043 to 077) respectively There was significant difference between the c-index tor APACHE-II vs MELD (p=0.03). There was no difference among the MELD and (TP scores (p = 078) and between APACHE-II vs CTP scores (p=O 08) Conclusions: MELD score was hmnd to be equivalent to the CTP score m Fvdictmg inhospital patient mortality, adding to its roIe in determining prognosis tor cirrhotic patients

Recent innovations in intensive care unit risk-prediction models.

During the past 20 years, ICU risk-prediction models have undergone significant development, validation, and refinement. Among the general ICU severity of illness scoring systems, the Acute Physiology and Chronic Health Evaluation (APACHE), Mortality Prediction Model (MPM), and the Simplified Acute Physiology Score (SAPS) have become the most accepted and used. To risk-adjust patients with longer, more severe illnesses like sepsis and acute respiratory distress syndrome, several models of organ dysfunction or failure have become available, including the Multiple Organ Dysfunction Score (MODS), the Sequential Organ Failure Assessment (SOFA), and the Logistic Organ Dysfunction Score (LODS). Recent innovations in risk adjustment include automatic physiology and diagnostic variable retrieval and the use of artificial intelligence. These innovations have the potential of extending the uses of case-mix and severity-of-illness adjustment in the areas of clinical research, patient care, and administration. The challenges facing intensivists in the next few years are to further develop these models so that they can be used throughout the IUC stay to assess quality of care and to extend them to more specific patient groups such as the elderly and patients with chronic ICU courses.

Validity of the updated pediatric risk of mortality score (PRISM III) in predicting the probability of mortality in a pediatric intensive care unit.

This study assessed the validity of the PRISM III scoring system in accurately predicting the probability of mortality in a pediatric intensive care unit (PICU) in Taiwan. We collected data from consecutive patients admitted to our PICU during a one-year period from November 1999 through October 2000. Our PICU had 412 admissions including 385 patients (202 boys and 183 girls) with an average age of 53.9 +/- 58.2 months (range: 1 month to 18 years). The most common reason for admission was respiratory failure (26.2%). Almost 60% of the patients had at least one underlying chronic disease. The average duration of stay was 4.52 +/- 8.43 days (range 1 day to 81 days). The average PRISM III score was 5.06 +/- 6.95 (range 0-44). The overall mortality rate in the PICU was 8.17%. The mortality rate was not significantly different from the predicted rate (7.56%) (p=0.65). The efficiency of care was 32.5% and the standardized PICU length of stay ratio (SLOSR) was 1.33. The SLOSR ratio was significantly higher than the predicted rate (p value < 0.001). The PRISM III score was validfor assessing mortality risk of PICU patients in this hospital in Taiwan. However, the SLOSR ratio obtained in this study was higher than predicted. Differences in the patterns of practicing medicine may play an important role in observed PICU length of stay. Special caution is needed in adopting a severity of illness scoring system to assess performance of care, particularly in contexts different from the ones in which the instrument was originally developed. Further study including more pediatric intensive care units and other regions would enable greater generalization of the validity of this instrument.

Intensive care unit outcomes for patients with thrombotic thrombocytopenic purpura

Objective: To determine the validity of severity of illness scoring systems for patients with thrombotic thrombocytopaenic purpura (TTP) treated in an intensive care unit (ICU) and to determine ICU outcomes in this population. Design: Retrospective, cohort analysis. Setting: Tertiary care, university affiliated medical center. Subjects: Nine consecutive patients with TTP and a control cohort of six subjects who underwent autologous haematopoietic stem cell transplantation (AHSCT) and were admitted to the ICU during the same 3 year time period. Interventions: Patient surveillance and data collection. Endpoints: Survival to hospital discharge and need for mechanical ventilation (MV), and mortality. Measurements and results: The study cohort included nine TTP patients (mean age 45.3 years, 88.9% female); 3 (33.3%) survived. No subject requiring mechanical ventilation (n = 6) survived (p = 0.012). Only the need for MV separated TTP survivors from nonsurvivors. At both admission to the ICU and on ICU day three, no index of disease activity (haemoglobin, platelet count, lactate dehydrogenase, or creatinine) differed between survivors and non-survivors. The APACHE II score was significantly lower in TTP subjects (13.1 ± 1.8 vs. 29.3 ± 6.1, p &lt; 0.001) as was the Multiple Organ Dysfunction Score (5.8 ± 1.0 vs. 9.8 ± 1.3, p&lt;0.001). However, overall mortality and the need for MV were similar between the TTP and AHSCT groups. Conclusions: Patients with TTP requiring ICU care face significant mortality. Outcomes for patients with TTP who require MV are dismal. Severity of illness scoring systems may underestimate mortality for patients with TTP.

Multicenter study of obstetric admissions to 14 intensive care units in southern England.

To identify pregnant and postpartum patients admitted to intensive care units (ICUs), the cause for their admission, and the proportion that might be appropriately managed in a high-dependency environment (HDU) by using an existing database. To estimate the goodness-of-fit for the Simplified Acute Physiology Score II, the Acute Physiology and Chronic Health Evaluation (APACHE) II, and the APACHE III scoring systems in the obstetrical population. Retrospective analysis of demographic, diagnostic, treatment, and severity of illness data. Fourteen ICUs in Southern England. Pregnant or postpartum (<42 days) admissions between January 1, 1994, and December 31, 1996. None. We identified 210 patients, constituting 1.84% (210 of 11,385) of all ICU admissions and 0.17% (210 of 122,850) of all deliveries. Most admissions followed postpartum complications (hypertensive disease of pregnancy [39.5%] and major hemorrhage [33.3%]). Seven women were transferred to specialist ICUs. There was considerable variation between ICUs with respect to the number and type of interventions required by patients. Some 35.7% of patients stayed in ICU for <2 days and received no specific ICU interventions; these patients might have been safely managed in an HDU. There were seven maternal deaths (3.3%); fetal mortality rate was 20%. The area under the receiver operator characteristic curve and the standardized mortality ratio were 0.92 (confidence interval [CI], 0.85-0.99) and 0.43 for the Simplified Acute Physiology Score II, 0.94 (CI, 0.86-1.0) and 0.24 for APACHE II, and 0.98 (CI, 0.96-1.0) and 0.43 for APACHE III, respectively. Existing databases can both identify critically ill obstetrical patients and provide important information about them. Obstetrical ICU admissions often require minimal intervention and are associated with low mortality rates. Many might be more appropriately managed in an HDU. The commonly used severity of illness scoring systems are good discriminators of outcome from intensive care admission in this group but may overestimate mortality rates. Severity of illness scoring systems may require modification in obstetrical patients to adjust for the normal physiologic responses to pregnancy.

Tools for predicting risk of mortality in the ICU setting: do we need a crystal ball or rose colored glasses?

Hematopoietic stem cell transplantation (HSCT) applied to children is associated with high risk for organ failure, ICU admission, morbidity and mortality. "Respiratory failure" after HSCT carries a historically grave prognosis. Factors associated with high risk for critical care complications in HSCT patients have been identified, but are dependent on timing and intensity of interventions. Several ICU severity of illness scoring systems predict prognosis on the basis of physiologic stability, organ system involvement, and intensity of supportive measures; but these tend to underestimate post-transplantation mortality risk. Adjustment of scoring systems and logistic regression factor analysis are promising adjuncts, but have not been adequately validated. Specific endpoints such as death, length of ICU or hospital stay, and neurologic function are relatively easy to quantify; but, quality of life is difficult to assess and report. What constitutes "heroic therapy" in one institution may qualify as "routine" care in another. Therefore, tools to predict mortality in the pediatric HSCT recipient requiring intensive care are difficult to apply to the individual patient, and remain more an art than science. This manuscript attempts to briefly define and review the pertinent types of PICU severity of illness and mortality prognosis scoring systems, and their application to pediatric HSCT patients. Pitfalls in application of physiology, organ system failure, therapeutic intensity, disease specific, and history-based scoring systems are discussed. Prospective validation studies for severity of illness systems and the evolution to concurrent registry-style data collection and analysis are necessary for the HSCT patient requiring ICU care.

Using a severity of illness scoring system to assess intensive care unit admissions for diabetic ketoacidosis.

To determine the appropriateness of intensive care unit (ICU) admissions for patients with the diagnosis of diabetic ketoacidosis (DKA) at our institution. Retrospective chart review. Tertiary care inner-city hospital. All subjects admitted to the medical intensive care unit (MICU) from September 1996 to June 1997 with a diagnosis of DKA were included. None. A grading system for the severity of DKA (grades 0-IV) from a previously published work was modified. Admissions to the MICU that were deemed appropriate a priori included patients with grade III or IV DKA, patients with grade II DKA who were older than 65 yrs of age, or patients with special situations normally warranting intensive care. Sixty-seven cases of DKA were reviewed. Two thirds of the patients had type I diabetes mellitus, and approximately 50% were men. No deaths occurred. Forty-four patients (66%) met the a priori ICU admission criteria. The average hospital stay for all patients was 4.2 (+/-3.6) days. The mean ICU stay was significantly longer in those with DKA grade III or IV, although the total hospital stay did not differ by severity of illness score. One third of the patients admitted to our MICU to receive treatment for DKA did not warrant ICU treatment based on the admission criteria. These individuals had an approximate MICU length of stay of 1 day. A prospective study of the severity of illness score will be undertaken to evaluate the safety, validity, and potential resource savings of applying these DKA ICU admission criteria within our institution.