To the Editor: The study by Grissom et alReference Grissom, Brown and Kuttler1 demonstrated a high correlation of the Modified Sequential Organ Failure Assessment (MSOFA) with the Sequential Organ Failure Assessment (SOFA) to predict mortality in patients with critical illnesses. The accompanying editorial by Rubinson et alReference Rubinson, Knebel and Hick2 cautioned readers not to rely solely on the SOFA or MSOFA score to prioritize patients during a mass critical care event.
After careful consideration, the Wisconsin Hospital Preparedness Program,3 through the Medical College of Wisconsin Center for Medical Incident Management and Preparedness,Reference Pirrallo and Akuna4 has adapted and incorporated the SOFA score into its clinical management guidelines for hospital health care providers when routine critical care resources are not available. We welcome the work of Grissom and colleagues to simplify our model guidelines.
The Wisconsin guidelines are intended to standardize the establishment of a patient care rank order based on available resources; stated simply, triage. The Wisconsin Multiprincipled Critical Care Resource Allocation System (MCCRAS) is based on the multiprinciple allocation system proposed by White et alReference White, Katz, Luce and Lo5 that includes doing the greatest good for the greatest number of people, maximizing life-years saved and giving individuals an equal opportunity to pass through the stages of life.
Thus, we incorporated the SOFA score as 1 of 3 variables involved in generating a MCCRAS score of 0 to 15. This 16-point scale allows for a greater distribution of scores compared to the SOFA 0 to 4 range. Unless an individual has a known nonsurvivable injury or illness, they would be considered for definitive care. The SOFA score is not relied upon to predict mortality, but it is considered in ranking a “sicker,” high-scoring patient. If adequate critical care resources are available, then patients would receive care; in other words, business as usual. When a resource is limited, the patient who is most likely to benefit from that resource would receive that limited resource first.
The editorial by Rubinson et alReference Rubinson, Knebel and Hick2 warns that the use of SOFA in isolation to determine resource allocation during a disaster could be “catastrophic.” We intend to replace SOFA with MSOFA in calculating a patient's MCCRAS score and invite the disaster medicine community to evaluate the Wisconsin approach critically as an effective disaster patient care triage tool.
