Revised trauma scoring system to predict in-hospital mortality in the emergency department: Glasgow Coma Scale, Age, and Systolic Blood Pressure score

Abstract

IntroductionOur aim in this study was to assess whether the new Glasgow Coma Scale, Age, and Systolic Blood Pressure (GAP) scoring system, which is a modification of the Mechanism, Glasgow Coma Scale, Age, and Arterial Pressure (MGAP) scoring system, better predicts in-hospital mortality and can be applied more easily than previous trauma scores among trauma patients in the emergency department (ED).MethodsThis multicenter, prospective, observational study was conducted to analyze readily available variables in the ED, which are associated with mortality rates among trauma patients. The data used in this study were derived from the Japan Trauma Data Bank (JTDB), which consists of 114 major emergency hospitals in Japan. A total of 35,732 trauma patients in the JTDB from 2004 to 2009 who were 15 years of age or older were eligible for inclusion in the study. Of these patients, 27,154 (76%) with complete sets of important data (patient age, Glasgow Coma Scale (GCS) score, systolic blood pressure (SBP), respiratory rate and Injury Severity Score (ISS)) were included in our analysis. We calculated weight for the predictors of the GAP scores on the basis of the records of 13,463 trauma patients in a derivation data set determined by using logistic regression. Scores derived from four existing scoring systems (Revised Trauma Score, Triage Revised Trauma Score, Trauma and Injury Severity Score and MGAP score) were calibrated using logistic regression models that fit in the derivation set. The GAP scoring system was compared to the calibrated scoring systems with data from a total of 13,691 patients in a validation data set using c-statistics and reclassification tables with three defined risk groups based on a previous publication: low risk (mortality < 5%), intermediate risk, and high risk (mortality > 50%).ResultsCalculated GAP scores involved GCS score (from three to fifteen points), patient age < 60 years (three points) and SBP (> 120 mmHg, six points; 60 to 120 mmHg, four points). The c-statistics for the GAP scores (0.933 for long-term mortality and 0.965 for short-term mortality) were better than or comparable to the trauma scores calculated using other scales. Compared with existing instruments, our reclassification tables show that the GAP scoring system reclassified all patients except one in the correct direction. In most cases, the observed incidence of death in patients who were reclassified matched what would have been predicted by the GAP scoring system.ConclusionsThe GAP scoring system can predict in-hospital mortality more accurately than the previously developed trauma scoring systems.

Choice of injury scoring system in low- and middle-income countries: Lessons from Mumbai

“…Similarly, when stratifying GAP scores as low (19)(20)(21)(22)(23)(24), intermediate (11)(12)(13)(14)(15)(16)(17)(18) and high (3-10) risk for death, the in-hospital mortality rates were uniformly higher than in the original validation cohort of the GAP score in Japan. The area under the ROC curve for the GAP score in the Japanese validation cohort was 0.93, compared with 0.85 the subset of patients with sufficient data to calculate a GAP value in this population [17].…”

“…MGAP values ranged from 10 to 29, with a median value of 23 . GAP values ranged from 6 to 24, with a median value of 19 (IQR [14][15][16][17][18][19][20][21][22].…”

“…In fact, the accuracy of the MGAP and GAP scores at Lokmanya Tilak Municipal General Hospital approached their performances in high-income countries. As in the original validation cohort for the GAP score, penetrating mechanisms account for less than 10% of injuries at Lokmanya Tilak Municipal General Hospital [17]. In this study, when adjusting for GAP score, penetrating mechanism was associated with a 76% decrease in in-hospital mortality rate compared with blunt injuries, suggesting that GAP score may reflect the clinical reality of trauma at Lokmanya Tilak Municipal General Hospital better than MGAP score (which predicts a worse prognosis in patients with penetrating injuries).…”

“…Other data including disposition and in-hospital mortality were recorded during the hospital stay. [11,12,14,15,17].…”

“…The GAP score modifies the MGAP score to exclude injury mechanism -the acronym GAP represents ''GCS, age, (systolic blood) pressure.'' The GAP score was validated in a sample from the Japan Trauma Data Bank [17].…”