Score for Emergency Risk Prediction (SERP): An Interpretable Machine Learning AutoScore–Derived Triage Tool for Predicting Mortality after Emergency Admissions
Authors: Xie Feng , Ong Marcus Eng Hock , Hui Liew Johannes Nathaniel Min , Tan Kenneth Boon Kiat , Ho Andrew Fu Wah , Nadarajan Gayathri Devi , Low Lian Leng , Kwan Yu Heng , Goldstein Benjamin Alan , Matchar David Bruce , Chakraborty Bibhas , Liu Nan 
Published: February 2021

AbstractImportanceTriage in the emergency department (ED) for admission and appropriate level of hospital care is a complex clinical judgment based on the tacit understanding of the patient’s likely acute course, availability of medical resources, and local practices. While a scoring tool could be valuable in triage, currently available tools have demonstrated limitations.ObjectiveTo develop a tool based on a parsimonious list of predictors available early at ED triage, to provide a simple, early, and accurate estimate of short-term mortality risk, the Score for Emergency Risk Prediction (SERP), and evaluate its predictive accuracy relative to published tools.Design, Setting, and ParticipantsWe performed a single-site, retrospective study for all emergency department (ED) patients between January 2009 and December 2016 admitted in a tertiary hospital in Singapore. SERP was derived using the machine learning framework for developing predictive models, AutoScore, based on six variables easily available early in the ED care process. Using internal validation, the SERP was compared to the current triage system, Patient Acuity Category Scale (PACS), Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), Cardiac Arrest Risk Triage (CART), and Charlson Comorbidity Index (CCI) in predicting both primary and secondary outcomes in the study.Main Outcomes and MeasuresThe primary outcome of interest was 30-day mortality. Secondary outcomes include 2-day mortality, inpatient mortality, 30-day post-discharge mortality, and 1-year mortality. The SERP’s predictive power was measured using the area under the curve (AUC) in the receiver operating characteristic (ROC) analysis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated under the optimal threshold, defined as the point nearest to the upper-left corner of the ROC curve.ResultsWe included 224,666 ED episodes in the model training cohort, 56,167 episodes in the validation cohort, and 42,676 episodes in the testing cohort. 18,797 (5.8%) of them died in 30 days after their ED visits. Evaluated on the testing set, SERP outperformed several benchmark scores in predicting 30-day mortality and other mortality-related outcomes. Under cut-off score of 27, SERP achieved a sensitivity of 72.6% (95% confidence interval [CI]: 70.7-74.3%), a specificity of 77.8% (95% CI: 77.5-78.2), a positive predictive value of 15.8% (15.4-16.2%) and a negative predictive value of 98% (97.9-98.1%).ConclusionsSERP showed better prediction performance than existing triage scores while maintaining easy implementation and ease of ascertainment at the ED. It has the potential to be widely applied and validated in different circumstances and healthcare settings.Key pointsQuestionHow does a tool for predicting hospital outcomes based on a machine learning-based automatic clinical score generator, AutoScore, perform in a cohort of individuals admitted to hospital from the emergency department (ED) compared to other published clinical tools?FindingsThe new tool, the Score for Emergency Risk Prediction (SERP), is parsimonious and point-based. SERP was more accurate in identifying patients who died during short or long-term care, compared with other point-based clinical tools.MeaningSERP, a tool based on AutoScore is promising for triaging patients admitted from the ED according to mortality risk.