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Critical Care

Volume 17 Supplement 4

Sepsis 2013

Open Access

Increasing number of organ dysfunctions is an excellent predictor of in-hospital mortality in emergency department patients with suspected infection: an internal and external prospective validation study

  • Marie K Jessen1, 2,
  • Simon Skibsted1, 2 and
  • Nathan I Shapiro2
Critical Care201317(Suppl 4):P24

Published: 5 November 2013


Emergency DepartmentOrgan DysfunctionEmergency Department PatientCharlson IndexSuspected Infection


Conscious assessment for organ dysfunction in infected patients is not uniformly performed since the prognostic performance of organ dysfunction has not been validated. We hypothesize that the number of organ dysfunctions is a prognostic marker in emergency department (ED) patients with suspected infection and that an increasing number of organ dysfunctions correlates with in-hospital mortality.

Materials and methods

A prospective observational study of adult (18+ years) ED patients with suspected infection presenting to one of two urban, academic medical center EDs. The inclusion criterion was clinically suspected infection at ED presentation. At Beth Israel Deaconess Medical Center (BIDMC), Boston, USA, consecutive patients were enrolled over a 1-year period (internal validation set) and at Aarhus University Hospital (AUH), Aarhus, Denmark, a case-control study was performed (external validation set). Laboratory and clinical data were collected at enrollment to assess organ dysfunction. Primary outcome was in-hospital mortality. Logistic regression was performed to determine the independent mortality odds.


Four thousand, nine hundred and fifty-two patients were enrolled at BIDMC and 483 patients at AUH. Overall mortality rates were 4% and 11% with mean ages of 58 ± 21 and 69 ± 16 years, respectively. The mortality rate increased with increasing number of organ dysfunctions: BIDMC: 0 organ dysfunctions, 0.6% mortality; 1 dysfunction, 3.3%; 2 dysfunctions, 7.8%; 3 dysfunctions, 15.9%; and ≥4 dysfunctions, 34.3%; and AUH: 2.2%, 6.7%, 17%, 41%, and 57% mortality (Figure 1). The number of organ dysfunctions remained an independent predictor after adjustment for age and Charlson Index (Table 1). The AUCs for the models were 0.82 and 0.87, respectively (Figure 2). The effect of specific types of organ dysfunction on mortality was largest for respiratory dysfunction (OR 3.57 (95% CI 2.5 to 5.1)) in the internal and for hematologic dysfunction (OR 33.57 (8.56 to 127.3)) in the external validation set (Table 2).

Figure 1

Table 1

Effect of number of organ dysfunctions on in-hospital mortality adjusted for age and Charlson Comorbidity score

Number of organ dysfunctions

Internal validation set in-hospital mortality

External validation set in-hospital mortality


4.5 (2.3 to 8.6)

3.1 (0.9 to 10.4)


9.3 (4.8 to 18.1)

7.3 (2.1 to 24.7)


18.0 (8.8 to 36.9)

33.6 (8.56 to 127.3)


50.5 (22.0 to 115.8)

45.0 (8.56 to 236.2)


39.0 (8.9 to 170.7)

285.9 (16.9 to 483.2)

Data presented as OR (95% CI).

Figure 2

Table 2

Effect of organ dysfunctions on mortality adjusted for age and Charlson Index


Internal in-hospital mortality

External in-hospital mortality


3.4 (2.2 to 5.2)

29.0 (7.1 to 116.9)


3.6 (2.5 to 5.1)

1.4 (0.8 to 2.6)


3.2 (0.9 to 11.5)

18.5 (7.3 to 46.8)


3.0 (2.2 to 4.0)

6.7 (2.9 to 11.2)


2.4 (1.7 to 3.4)

8.9 (4.7 to 17.1)


2.1 (1.4 to 3.0)

5.4 (2.7 to 10.9)


2.2 (1.4 to 3.4)

4.5 (1.1 to 18.2)

Data presented as OR (95% CI).


Using readily available criteria in the ED to assess the number of organ dysfunctions is a reliable tool in predicting in-hospital mortality in both validation sets and could assist in risk prognostication and aid with earlier, targeted therapy.

Authors’ Affiliations

Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
Research Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA


© Jessen et al.; licensee BioMed Central Ltd. 2013

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.