MSOFA: An important step forward, but are we spending too much time on the SOFA?

I n this issue of Disaster Medicine and Public Health Preparedness , Grissom and colleagues 1 present a comparison of the Sequential Organ Failure Assessment (SOFA) 2 physi-ologic score vs a newly derived score, based on SOFA but less dependent on laboratory measurements, which they term the Modified Sequential Organ Failure Assessment (MSOFA). The impetus for the study was that SOFA, which has been used frequently to compare patients in critical care research studies, has been recommended as a means to assist in the objective pri-oritization of patients during mass critical care events, 3-6 but it requires multiple laboratory measurements that may not be available during catastrophic events. Grissom et al empirically developed MSOFA and piloted the use of the score to predict mortality from a retrospective cohort of intensive care unit (ICU) patients at a tertiary care academic medical center. They then prospectively compared SOFA to MSOFA for their ability to predict the need for mechanical ventilation as well as mortality ; this prospective comparison is reported in this issue. Several years ago, the Working Group on Emergency Mass Critical Care considered the use of physiologic scoring systems for prioritizing patients to guide the allocation of scarce clinical resources during a mass critical care event. 7 Working Group members were drawn to the potential " objective " assignment of priority. However, precision and logistical concerns were raised, including the concern that many scores required multiple laboratory diagnostic results, so the group did not achieve consensus regarding use of scoring systems for triage and allocation during severe epidemics. Later, Hick and O'Laughlin described the initial attempt of the state of Minnesota to define a process and criteria for definitive triage during a serious epidemic. 8 Their work showed that objective criteria applied within a standardized decision-making process across hospitals was conceptually palatable to response agencies and incited a number of communities to address allocation of clinical resources during mass critical care. A group from Ontario made the next major contribution, which included use of SOFA, 1 and their model was incorporated with minor modifications into subsequent efforts by the New York State Task Force on Life and the Law and the Task Force for Mass Critical Care. 5,6 SOFA has appeal because it can predict outcomes early in critical illness, has relatively few variables, includes variables that are frequently collected as part of routine clinical care, offers predictive value for …