{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,19]],"date-time":"2026-10-19T18:41:09Z","timestamp":1792435269282,"version":"4.5.0"},"reference-count":26,"publisher":"Oxford University Press (OUP)","license":[{"start":{"date-parts":[[2026,10,12]],"date-time":"2026-10-12T00:00:00Z","timestamp":1791763200000},"content-version":"am","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"funder":[{"name":"the Institute of Health Carlos III"},{"name":"the European Union","award":["DTS23\/00010"],"award-info":[{"award-number":["DTS23\/00010"]}]},{"name":"the European Union","award":["PID2024-160665OA-I00 and PID2024-159268OB-I00"],"award-info":[{"award-number":["PID2024-160665OA-I00 and PID2024-159268OB-I00"]}]},{"name":"the Basque Government","award":["IT1717-22, 2023333042, 2024333037, and 2025333027"],"award-info":[{"award-number":["IT1717-22, 2023333042, 2024333037, and 2025333027"]}]},{"name":"the University of the Basque Country","award":["EHU-N23\/01 for EA and II"],"award-info":[{"award-number":["EHU-N23\/01 for EA and II"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Early recognition of multiple organ dysfunction syndrome (MODS) in the prehospital setting remains challenging and is critical for reducing mortality among critically ill patients. The modified Sequential Organ Failure Assessment (mSOFA) score was developed for prehospital use with point-of-care testing; however, the internal decision architecture of this score remains unexplored.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A prospective, multicenter, observational study was conducted across three emergency medical services (EMS) in Spain and included adults (n\u2009=\u200912\u00a0212) with acute illness transferred to emergency departments with high priority. A decision tree (DT) model was developed using the five components of the mSOFA score, lactate, Glasgow Coma Scale (GCS), oxygen saturation-to-fraction of inspired oxygen ratio (SaFi), mean blood pressure, and creatinine, to predict in-hospital mortality at 2\u2009days. The study followed the STROBE and TRIPOD+AI guidelines.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Cohort mortality was 5.0% (n\u2009=\u2009609). Lactate emerged as the primary decision variable, with a threshold of 3.8\u2009mmol\/l, followed by SaFi, GCS, and creatinine in patients with hyperlactatemia and by GCS and creatinine when lactate was below the threshold.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The DT deconstructs the mSOFA from a static score into a dynamic, interpretable clinical decision framework. By revealing the pathophysiological hierarchy underlying the score, with lactate as the central stratification axis, this approach enables EMS clinicians to identify distinct clinical phenotypes and anticipate deterioration based on the sequential evaluation of organ dysfunction rather than a single numerical threshold.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/qjmed\/hcag287","type":"journal-article","created":{"date-parts":[[2026,10,11]],"date-time":"2026-10-11T11:37:15Z","timestamp":1791718635000},"source":"Crossref","is-referenced-by-count":0,"title":["Deconstructing the modified Sequential Organ Failure Assessment (mSOFA) score: a decision tree analysis reveals the pathophysiological hierarchy of organ dysfunction predictors in prehospital critical care"],"prefix":"10.1093","author":[{"given":"Alberto","family":"L\u00f3pez Ballesteros","sequence":"first","affiliation":[{"name":"Gerencia de Urgencias Emergencias y Transporte, Servicio de Salud de Castilla-La Mancha (SESCAM) , Toledo,","place":["Spain"]},{"name":"Evaluaci\u00f3n de Cuidados de Salud (ECUSAL), Instituto de Investigaci\u00f3n Sanitaria de Castilla-La Mancha (IDISCAM) , Toledo,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erik","family":"Alonso","sequence":"additional","affiliation":[{"name":"Department of Applied Mathematics, University of the Basque Country (UPV\/EHU) , Bilbao,","place":["Spain"]},{"name":"Biobizkaia, Bizkaia Health Research Institute , Barakaldo,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Iraia","family":"Isasi","sequence":"additional","affiliation":[{"name":"Department of Applied Mathematics, University of the Basque Country (UPV\/EHU) , Bilbao,","place":["Spain"]},{"name":"Biobizkaia, Bizkaia Health Research Institute , Barakaldo,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Asier","family":"Losada","sequence":"additional","affiliation":[{"name":"Biobizkaia, Bizkaia Health Research Institute , Barakaldo,","place":["Spain"]},{"name":"Emergency Medical System (Emergentziak-Osakidetza), Basque Health Service , Bilbao,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samantha","family":"D\u00edaz-Gonz\u00e1lez","sequence":"additional","affiliation":[{"name":"Evaluaci\u00f3n de Cuidados de Salud (ECUSAL), Instituto de Investigaci\u00f3n Sanitaria de Castilla-La Mancha (IDISCAM) , Toledo,","place":["Spain"]},{"name":"Technological Innovation Applied to Health Research Group (ITAS Group), Faculty of Health Sciences, University of Castilla-La Mancha , Talavera de la Reina,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1027-389X","authenticated-orcid":false,"given":"Sergio","family":"Rodriguez-Ca\u00f1amero","sequence":"additional","affiliation":[{"name":"Faculty of Health Sciences, University of Castilla-La Mancha (UCLM) , Talavera de la Reina,","place":["Spain"]},{"name":"Grupo de Investigaci\u00f3n Multidisciplinar en Cuidados (IMCU), Universidad de Castilla-La Mancha (IDISCAM) , Toledo,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jos\u00e9 Luis","family":"Mart\u00edn-Conty","sequence":"additional","affiliation":[{"name":"Evaluaci\u00f3n de Cuidados de Salud (ECUSAL), Instituto de Investigaci\u00f3n Sanitaria de Castilla-La Mancha (IDISCAM) , Toledo,","place":["Spain"]},{"name":"Technological Innovation Applied to Health Research Group (ITAS Group), Faculty of Health Sciences, University of Castilla-La Mancha , Talavera de la Reina,","place":["Spain"]},{"name":"Faculty of Health Sciences, University of Castilla-La Mancha (UCLM) , Talavera de la Reina,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bego\u00f1a","family":"Polonio-L\u00f3pez","sequence":"additional","affiliation":[{"name":"Evaluaci\u00f3n de Cuidados de Salud (ECUSAL), Instituto de Investigaci\u00f3n Sanitaria de Castilla-La Mancha (IDISCAM) , Toledo,","place":["Spain"]},{"name":"Technological Innovation Applied to Health Research Group (ITAS Group), Faculty of Health Sciences, University of Castilla-La Mancha , Talavera de la Reina,","place":["Spain"]},{"name":"Faculty of Health Sciences, University of Castilla-La Mancha (UCLM) , Talavera de la Reina,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carlos","family":"del Pozo-Vegas","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University of Valladolid , Valladolid,","place":["Spain"]},{"name":"Valladolid Health Research Institute (IBioVALL) , Valladolid,","place":["Spain"]},{"name":"Emergency Department, Hospital Cl\u00ednico Universitario de Valladolid , Valladolid,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ra\u00fal","family":"L\u00f3pez-Izquierdo","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University of Valladolid , Valladolid,","place":["Spain"]},{"name":"Valladolid Health Research Institute (IBioVALL) , Valladolid,","place":["Spain"]},{"name":"Emergency Department, Hospital Universitario R\u00edo Hortega , Valladolid,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francisco","family":"Mart\u00edn-Rodr\u00edguez","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University of Valladolid , Valladolid,","place":["Spain"]},{"name":"Emergency Department, Hospital Universitario R\u00edo Hortega , Valladolid,","place":["Spain"]},{"name":"Advanced Life Support, Emergency Medical Services (SACYL) , Valladolid,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ancor","family":"Sanz-Garc\u00eda","sequence":"additional","affiliation":[{"name":"Evaluaci\u00f3n de Cuidados de Salud (ECUSAL), Instituto de Investigaci\u00f3n Sanitaria de Castilla-La Mancha (IDISCAM) , Toledo,","place":["Spain"]},{"name":"Technological Innovation Applied to Health Research Group (ITAS Group), Faculty of Health Sciences, University of Castilla-La Mancha , Talavera de la Reina,","place":["Spain"]},{"name":"Faculty of Health Sciences, University of Castilla-La Mancha (UCLM) , Talavera de la Reina,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,10,12]]},"reference":[{"key":"2026101914270302600_hcag287-B1","doi-asserted-by":"crossref","first-page":"1564","DOI":"10.1177\/0885066619871452","article-title":"Multiple organ dysfunction syndrome","volume":"35","author":"Gourd","year":"2020","journal-title":"J Intensive Care Med"},{"key":"2026101914270302600_hcag287-B2","doi-asserted-by":"crossref","first-page":"1283","DOI":"10.1164\/rccm.202209-1831CI","article-title":"Evolving management practices for early sepsis-induced hypoperfusion: a narrative review","volume":"207","author":"Munroe","year":"2023","journal-title":"Am J Respir Crit Care Med"},{"key":"2026101914270302600_hcag287-B3","first-page":"281","article-title":"Impact of point-of-care biomarkers on the improvement of the predictive capacity of early warning scores in prehospital care: a systematic review and meta-analysis","volume":"37","author":"D\u00edaz-Gonz\u00e1lez","year":"2025","journal-title":"Emergencias"},{"key":"2026101914270302600_hcag287-B4","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1016\/j.ajem.2021.06.042","article-title":"Time for a prehospital-modified Sequential Organ Failure Assessment score: an ambulance-based cohort study","volume":"49","author":"Mart\u00edn-Rodr\u00edguez","year":"2021","journal-title":"Am J Emerg Med"},{"key":"2026101914270302600_hcag287-B5","doi-asserted-by":"crossref","first-page":"2090","DOI":"10.1001\/jama.2025.20516","article-title":"Development and validation of the Sequential Organ Failure Assessment (SOFA)-2 score","volume":"334","author":"Ranzani","year":"2025","journal-title":"JAMA"},{"key":"2026101914270302600_hcag287-B6","doi-asserted-by":"crossref","first-page":"103674","DOI":"10.1016\/j.eclinm.2025.103674","article-title":"Performance of a modified Sequential Organ Failure Assessment score in pre-hospital critical care to predict short-term mortality: a prospective, multicentre, validation cohort study","volume":"90","author":"Alonso","year":"2025","journal-title":"EClinicalMedicine"},{"key":"2026101914270302600_hcag287-B7","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1186\/s12911-024-02844-1","article-title":"Enhancing prehospital decision-making: exploring user needs and design considerations for clinical decision support systems","volume":"25","author":"Bai","year":"2025","journal-title":"BMC Med Inform Decis Mak"},{"key":"2026101914270302600_hcag287-B8","doi-asserted-by":"crossref","first-page":"1207","DOI":"10.1093\/jamia\/ocaa347","article-title":"Using machine learning to improve the accuracy of patient deterioration predictions: Mayo Clinic Early Warning Score (MC-EWS)","volume":"28","author":"Romero-Brufau","year":"2021","journal-title":"J Am Med Inform Assoc"},{"key":"2026101914270302600_hcag287-B9","doi-asserted-by":"crossref","first-page":"16180","DOI":"10.1038\/s41598-023-43106-w","article-title":"Prehospital predicting factors using a decision tree model for patients with witnessed out-of-hospital cardiac arrest and an initial shockable rhythm","volume":"13","author":"Tateishi","year":"2023","journal-title":"Sci Rep"},{"key":"2026101914270302600_hcag287-B10","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1186\/s13054-019-2351-7","article-title":"Emergency department triage prediction of clinical outcomes using machine learning models","volume":"23","author":"Raita","year":"2019","journal-title":"Crit Care"},{"key":"2026101914270302600_hcag287-B11","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1097\/MEJ.0000000000000630","article-title":"Persistently elevated early warning scores and lactate identifies patients at high risk of mortality in suspected sepsis","volume":"27","author":"Hargreaves","year":"2020","journal-title":"Eur J Emerg Med"},{"key":"2026101914270302600_hcag287-B12","doi-asserted-by":"crossref","first-page":"e023049","DOI":"10.1136\/bmjopen-2018-023049","article-title":"Prehospital time and mortality in patients requiring a highest priority emergency medical response: a Danish registry-based cohort study","volume":"9","author":"Mills","year":"2019","journal-title":"BMJ Open."},{"key":"2026101914270302600_hcag287-B13","doi-asserted-by":"crossref","first-page":"269","DOI":"10.1111\/acem.12876","article-title":"Prediction of in-hospital mortality in emergency department patients with sepsis: a local big data-driven, machine learning approach","volume":"23","author":"Taylor","year":"2016","journal-title":"Acad Emerg Med"},{"key":"2026101914270302600_hcag287-B14","doi-asserted-by":"crossref","first-page":"13563","DOI":"10.1038\/s41598-023-40661-0","article-title":"Predicting acute clinical deterioration with interpretable machine learning to support emergency care decision making","volume":"13","author":"Boulitsakis Logothetis","year":"2023","journal-title":"Sci Rep"},{"key":"2026101914270302600_hcag287-B15","doi-asserted-by":"crossref","first-page":"263","DOI":"10.1186\/s12916-022-02461-7","article-title":"Modified cardiovascular SOFA score in sepsis: development and internal and external validation","volume":"20","author":"Lee","year":"2022","journal-title":"BMC Med"},{"key":"2026101914270302600_hcag287-B16","doi-asserted-by":"crossref","first-page":"868","DOI":"10.5811\/WESTJEM.59048","article-title":"Prehospital mSOFA score for quick prediction of life-saving interventions and mortality in trauma patients: a prospective, multicenter, ambulance-based, cohort study","volume":"24","author":"Mart\u00edn-Rodr\u00edguez","year":"2023","journal-title":"West J Emerg Med"},{"key":"2026101914270302600_hcag287-B17","doi-asserted-by":"crossref","first-page":"290","DOI":"10.1001\/jama.2016.20328","article-title":"Prognostic accuracy of the SOFA score, SIRS criteria, and qSOFA score for in-hospital mortality among adults with suspected infection admitted to the intensive care unit","volume":"317","author":"Raith","year":"2017","journal-title":"JAMA"},{"key":"2026101914270302600_hcag287-B18","doi-asserted-by":"crossref","first-page":"e1281","DOI":"10.1016\/S2214-109X(22)00277-7","article-title":"Enhanced bedside mortality prediction combining point-of-care lactate and the quick Sequential Organ Failure Assessment (qSOFA) score in patients hospitalised with suspected infection in southeast Asia: a cohort study","volume":"10","author":"Wright","year":"2022","journal-title":"Lancet Glob Health"},{"key":"2026101914270302600_hcag287-B19","doi-asserted-by":"crossref","first-page":"e055752","DOI":"10.1136\/bmjopen-2021-055752","article-title":"Ability of the National Early Warning Score and its respiratory and haemodynamic subcomponents to predict short-term mortality on general wards: a prospective three-centre observational study in Finland","volume":"12","author":"Loisa","year":"2022","journal-title":"BMJ Open."},{"key":"2026101914270302600_hcag287-B20","first-page":"3775670","article-title":"Investigating the utility of the SOFA score and creating a modified SOFA score for predicting mortality in the intensive care units in a tertiary hospital in Jordan","volume":"2023","author":"Abu-Humaidan","year":"2023","journal-title":"Crit Care Res Pract"},{"key":"2026101914270302600_hcag287-B21","doi-asserted-by":"crossref","first-page":"905","DOI":"10.1016\/S2213-2600(18)30300-X","article-title":"Machine learning for real-time prediction of complications in critical care: a retrospective study","volume":"6","author":"Meyer","year":"2018","journal-title":"Lancet Respir Med"},{"key":"2026101914270302600_hcag287-B22","doi-asserted-by":"crossref","first-page":"857","DOI":"10.1111\/crj.13218","article-title":"A mortality analysis of septic shock, vasoplegic shock and cryptic shock classified by the third international consensus definitions (sepsis-3)","volume":"14","author":"Yang","year":"2020","journal-title":"Clin Respir J"},{"key":"2026101914270302600_hcag287-B23","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1186\/s13054-024-05225-2","article-title":"Prehospital lactate analysis in suspected sepsis improves detection of patients with increased mortality risk: an observational study","volume":"29","author":"Andersson","year":"2025","journal-title":"Crit Care"},{"key":"2026101914270302600_hcag287-B24","doi-asserted-by":"crossref","first-page":"e166","DOI":"10.1016\/S2589-7500(23)00243-1","article-title":"Comparison of eight prehospital early warning scores in life-threatening acute respiratory distress: a prospective, observational, multicentre, ambulance-based, external validation study","volume":"6","author":"Castro Villamor","year":"2024","journal-title":"Lancet Digit Health."},{"key":"2026101914270302600_hcag287-B25","doi-asserted-by":"crossref","first-page":"e007678","DOI":"10.1161\/CIRCHEARTFAILURE.120.007678","article-title":"Defining shock and preshock for mortality risk stratification in cardiac intensive care unit patients","volume":"14","author":"Jentzer","year":"2021","journal-title":"Circ Heart Fail"},{"key":"2026101914270302600_hcag287-B26","doi-asserted-by":"crossref","first-page":"1181","DOI":"10.1007\/s00134-021-06506-y","article-title":"Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021","volume":"47","author":"Evans","year":"2021","journal-title":"Intensive Care Med"}],"container-title":["QJM: An International Journal of Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/qjmed\/advance-article-pdf\/doi\/10.1093\/qjmed\/hcag287\/71869273\/hcag287.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/qjmed\/advance-article-pdf\/doi\/10.1093\/qjmed\/hcag287\/71869273\/hcag287.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,19]],"date-time":"2026-10-19T18:27:12Z","timestamp":1792434432000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/qjmed\/advance-article\/doi\/10.1093\/qjmed\/hcag287\/8910351"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,12]]},"references-count":26,"URL":"https:\/\/doi.org\/10.1093\/qjmed\/hcag287","relation":{},"ISSN":["1460-2725","1460-2393"],"issn-type":[{"value":"1460-2725","type":"print"},{"value":"1460-2393","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,12]]},"article-number":"hcag287"}}