Must Know Clinical Scoring Systems For Learners In Hospital Medicine

Sandeep Bala
MD Candidate, Class of 2021
University of Central Florida College of Medicine

Must Know Clinical Scoring Systems for Learners in Hospital Medicine
Scroll to the bottom for a PDF of scoring systems for reference on the wards.

As I began my clinical rotations, I quickly realized the importance of maturing from being able to recognize textbook presentations to interpreting more complicated scenarios and formulating a corresponding treatment plan.

Scoring systems and risk calculators became very useful tools to help guide my thinking and make evidence-based decisions. While not commonly taught during the preclinical years, it is essential to know these systems to thrive in clinical rotations.

As an example from my internal medicine inpatient rotation, I had the pleasure of caring for a kind, elderly woman in her late 70s, whom I will call Mrs. Johnson. Mrs. Johnson presented to the emergency department after three episodes of tarry, black stools. She had been instructed by her primary care physician five days prior to take ibuprofen up to the maximum daily dose to alleviate her pain from a recent shoulder injury. She had a history of atrial fibrillation, high blood pressure, and gastroesophageal reflux disease. For the atrial fibrillation, she was taking warfarin and aspirin.

Given her clinical presentation, it was most likely that Mrs. Johnson was suffering from an upper gastrointestinal (GI) bleed. Mrs. Johnson was taking warfarin and aspirin to prevent blood clots from her atrial fibrillation causing an embolic stroke. Ibuprofen can be an effective tool for acute pain management, albeit with an increased risk of bleeding. The addition of ibuprofen for pain management to the combination of aspirin and warfarin likely led to the development of peptic ulcer disease, causing her upper GI bleed. Endoscopy subsequently confirmed the diagnosis.

I learned that the addition of aspirin to warfarin for atrial fibrillation may not have been clinically indicated. To further help prevent this episode, how could the primary care physician have assessed Mrs. Johnson’s need for warfarin, and to what degree did warfarin increase her risk of bleeding?
As an early third-year medical student, seeing such patients for the first time, the answer was not initially clear. However, I found two scoring systems to help answer these questions. Firstly, the CHA₂DS₂-VASc score helps determine the need for anticoagulation therapy in patients with atrial fibrillation, while the HAS-BLED score assesses the risk of bleeding on anticoagulation.

Mrs. Johnson’s age, gender, and high blood pressure support the use of anticoagulation per CHA₂DS₂-VASc, estimating a 6.7% risk of stroke/TIA/systemic embolism per year. However, the HAS-BLED score signals a warning. Her age and use of aspirin and ibuprofen both put her at a moderate risk of bleeding (approximately 4.1% per year). The use of these calculators in addition to shared decision making with the patient led us to the plan of eventually restarting her anticoagulation after discharge with cessation of her aspirin and ibuprofen.

Listed below are a sampling of the many similar tools and calculators that are extremely useful in guiding clinical decision-making and for communicating risk to other providers. It is also attached as a PDF that can be printed for reference in the wards.  Mastering these will not only help you in your rotations, but more importantly, will help you to make the right decisions in your management of patients.

Centor Score Estimates probability of strep pharyngitis in acute pharyngitis of < 3 days onset and recommends next steps. To determine need for testing and empiric antibiotic treatment for acute pharyngitis secondary to Streptococcal pyogenes.
CHA2DS2-VASc Estimates stroke risk for patients with atrial fibrillation and suggests need for pharmacotherapy. To risk stratify patients with atrial fibrillation by risk of stroke and to guide the decision to start anticoagulation. Helpful to compare to HAS-BLED score (see below).
Child-Pugh Estimates prognosis of patients with cirrhosis and approximates abdominal surgery peri-operative mortality. Used to determine prognosis and in listing for transplantation.
CURB-65 Estimates 30-day mortality of community-acquired pneumonia. To help determine if patients can be treated outpatient versus inpatient, with consideration for ICU admission.
Framingham "Hard" CHD Risk Score Estimates 10-year risk of myocardial infarction (MI) or coronary death in individuals without prior heart disease, intermittent claudication, or diabetes. Used to estimate 10-year risk for MI/death for patients without previous cardiac events; can be helpful in the management of hyperlipidemia and in assessing if primary prevention with aspirin would have benefit
Glasgow Coma Score Mental status assessment based on eye, verbal, and motor responses. With good reliability between observers, used for serial evaluation of mental status; also can be helpful for prognosis in certain conditions. 
HAS-BLED Estimates risk of major bleeding for patients with atrial fibrillation on anti-coagulation. In concert with CHA2DS2-VASc, used to guide the decision to start anti-coagulation in patients with atrial fibrillation.
HEART Estimates 6-week risk of major adverse cardiac events in patients > 21 years-old presenting with symptoms suggesting acute coronary syndrome. To guide decision in emergency department if patients can be discharged or if need additional testing or admission by stratifying patients into low, moderate, and high-risk groups.
Maddrey discriminant function Estimates short term prognosis in patients with alcoholic hepatitis and benefit of steroid therapy. To evaluate severity of alcoholic hepatitis and guide decision on steroid administration.
MELD/MELD-Na Estimates 3-month mortality in patients > 12 years old with end-stage liver disease. For stratification of patients for liver transplantation and prediction of mortality in specific clinical scenarios, such as non-transplantation surgeries.
NIH Stroke Score Quantifies severity of stroke in acute setting based on physical findings alone. Use in acute setting to determine severity and estimates long-term prognosis after an acute stroke.
PERC Rule for Pulmonary Embolism (PE) Estimates risk of PE to be < 2% when all criteria are negative and pre-test probability is low (< 15%). To rule out need for additional testing for PE based on clinical criteria alone.
qSOFA Predicts risk of mortality in hospitalized patients with suspected infection outside of the intensive care unit based on bedside findings. Use at the bedside to prompt additional monitoring,testing, and/or treatment of patients with possible severe infections (sepsis).
Revised Cardiac Risk Index (RCRI) for Pre-Operative Risk Estimates 30-day risk of death, MI, or cardiac arrest after non-cardiac surgery. To help risk stratify patients prior to surgery and to allow for shared decision making, especially in those with additional risk factors.
RIFLE Criteria Classifies severity of acute kidney injury by GFR and urine output. To determine severity and prognosis of acute kidney injury.
SIRS/Sepsis/Septic Shock criteria To classify infection status in patients with suspicion of SIRS, sepsis, or septic shock. Used as a screening or triage tool to identify patients who may need to be initiated on a sepsis protocol.
TIMI Risk Scores Estimates 30-day mortality risk in patients with acute coronary syndrome based on age, blood pressure, and heart rate. Use to risk stratify patients and guide initial therapy.
Wells' Criteria for Deep Vein Thrombosis (DVT) Estimates risk of DVT in patients, particularly in emergency and outpatient settings. Use to exclude need for lower extremity duplex ultrasound in low risk patients.
Wells' Criteria for PE Estimates risk of PE in emergency department settings. To risky stratify patients and exclude need for additional testing such as a CT angiogram in low risk patients

Big thank you to Dr. Alan Hall for his guidance in putting this together.

Attached files
Posted by Sandeep Bala on Dec 22, 2019 8:44 AM America/New_York