The Brazilian risk assessment severity index score: a novel tool for predicting in-hospital mortality in emergency departments

doi:10.5847/wjem.j.1920-8642.2026.036

Abstract

Abstract:

BACKGROUND: Rapid identification of patients at risk of clinical deterioration (in-hospital mortality) in emergency settings is essential for timely and appropriate care. Existing prognostic scores, such as the Acute Physiology and Chronic Health Evaluation IV (APACHE IV), Simplified Acute Physiology Score 3 (SAPS 3), Sequential Organ Failure Assessment (SOFA), and National Early Warning Score 2 (NEWS 2), have limitations in emergency scenarios, particularly in resource-limited settings. We aimed to develop a simple and efficient tool tailored to the Brazilian healthcare system.

METHODS: This retrospective, multicenter, cohort study analyzed data from 50,709 adult patients admitted to 12 hospitals in southern and southeastern Brazil between 2019 and 2020. The BRASIL score (Brazilian Risk Assessment Severity Index and Length of stay) was constructed using demographic and clinical variables available at admission. Logistic regression was used to determine the weight of each variable, and each variable was assigned a point value based on its β-coefficient and clinical relevance, with thresholds defined according to established medical cutoffs and statistical performance. The score’s predictive accuracy was validated using the area under the receiver operating characteristic curve (AUC) with comparative analysis against NEWS 2.

RESULTS: The BRASIL score, including age, sex, respiratory rate, heart rate, oxygen saturation, blood pressure, and body temperature, was derived through variables independently associated with in-hospital mortality in a multicenter cohort. The total score was stratified into three risk categories — low (0-3 points), moderate (4-7 points), and high (>7 points) — using observed inflection points in mortality distribution to optimize discrimination. This stratification demonstrated a stepwise increase in mortality rates across categories and the discriminatory performance, with an overall AUC of 0.743 (95% CI: 0.726-0.761). Compared to NEWS 2 (AUC 0.697, 95% CI: 0.683-0.711), the BRASIL score offered superior early risk identification, supporting timely clinical decision-making and resource allocation in the emergency setting.

CONCLUSION: The BRASIL score is a novel tool for predicting in-hospital mortality in emergency departments. Its predictive performance and ease of use suggest that it has the potential to improve patient outcomes.

Key words: Cohort study, Logistic regression, Severity index, In-hospital mortality, Hospital resource management

Paulo Henrique Reis Negreiros, Mariana Rebello Hilgert, Bruno Guerra, Maurício de Carvalho, Hugo Manuel Paz Morale, Gustavo Lenci Marques. The Brazilian risk assessment severity index score: a novel tool for predicting in-hospital mortality in emergency departments[J]. World Journal of Emergency Medicine, 2026, 17(2): 154-161.

Figures/Tables 6

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Characteristics	Discharge (n= 48,333)	Death (n=2,376)	P-value
Age, years
Mean (SD)	56.2 (17.4)	68.3 (14.8)	<0.001
Median (IQR)	58 (43-69)	69 (60-79)
Sex, n (%)
Female	26,412 (54.6%)	1,141 (48.0%)	<0.001
Male	21,921 (45.6%)	1,235 (52%)
Race, n (%)
White	30,732 (63.6%)	1,502 (63.4%)	0.015
Mixed	10,483 (21.7%)	479 (20.2%)
Black	1,325 (2.7%)	65 (2.7%)
Others	724 (1.5%)	53 (2.2%)
Hospital unit, n (%)
Internal medicine	19,011 (39.3%)	1,836 (77.3%)	<0.001
Surgery	27,647 (57.2%)	505 (21.3%)
Others	1,675 (3.5%)	35 (1.5%)
Length of hospital stay, d
Mean (SD)	4.65 (4.91)	9.33 (6.99)	<0.001
Median (IQR)	2.81 (1.37-5.70)	7.19 (3.57-13.7)
ICU transfer, n (%)
Yes	5,533 (11.4%)	1,176 (49.5%)	<0.001
No	42,800 (88.6%)	1,200 (50.5%)

Characteristics	Discharge (n=48,333)	Death (n=2,376)	P-value
SBP, mmHg
Mean (SD)	121 (15.3)	118 (18.7)	<0.001
Median (IQR)	120 (111-130)	117 (106-128)
MAP, mmHg
Mean (SD)	88.3 (10.4)	85.8 (12.8)	<0.001
Median (IQR)	87.8 (81.4-94.4)	85.3 (77.5-93.3)
Hypotension, n (%)
Yes	21,180 (43.8%)	1,367 (57.5%)	<0.001
No	27,153 (56.2%)	1,009 (42.5%)
Hypertension, n (%)
Yes	2,586 (5.4%)	177 (7.4%)	<0.001
No	45,747 (94.6%)	2,199 (92.6%)
Temperature, ºC
Mean (SD)	36.0 (0.446)	36.1 (0.553)	<0.001
Median (IQR)	36.0 (35.7-36.2)	36.1 (35.8-36.4)
Hypothermia, n (%)
Yes	8,775 (18.2%)	381 (16.0%)	0.009
No	39,558 (81.8%)	1,995 (84.0%)
Hyperthermia, n (%)
Yes	942 (1.9%)	185 (7.8%)	<0.001
No	47,391 (98.1%)	2,191 (92.2%)
HR, beats/min
Mean (SD)	77.8 (12.0)	89.1 (16.6)	<0.001
Median (IQR)	77.0 (69.8-85.0)	87.5 (77.7-99.3)
Bradycardia, n (%)
Yes	12,071 (25.0%)	353 (14.9%)	<0.001
No	36,262 (75.0%)	2,023 (85.1%)
Tachycardia, n (%)
Yes	9,785 (20.2%)	1,233 (51.9%)	<0.001
No	38,548 (79.8%)	1,143 (48.1%)
RR, breaths/min
Mean (SD)	18.0 (2.02)	19.4 (3.12)	<0.001
Median (IQR)	18.1 (17.0-19.0)	19.0 (18.0-20.2)
Bradypnea, n (%)
Yes	2,385 (4.9%)	109 (4.6%)	0.475
No	45,948 (95.1%)	2,267 (95.4%)
Tachypnea, n (%)
Yes	5,762 (11.9%)	911 (38.3%)	<0.001
No	42,571 (88.1%)	1,465 (61.7%)
Arterial oxygen saturation, %
Mean (SD)	96.6 (2.09)	94.9 (3.53)	<0.001
Median (IQR)	97.0 (95.5-98.0)	95.5 (93.3-97.0)

Variables	Odds ratio (95%CI)	β-value	Score	P-value
Systolic blood pressure (mmHg)
111-235	—	—	0	—
60-110	2.01 (1.83-2.20)	0.697	1	<0.001
Respiratory rate (breaths/min)
7-20	—	—	0	—
21-37	3.73 (3.34-4.16)	1.316	1	<0.001
38-50	2.85 (0.93-7.20)	1.047	1	0.041
Arterial oxygen saturation (%)
98-100	—	—	0	—
55-97	1.67 (1.51-1.85)	0.514	1	<0.001
Temperature (ºC)
35.1-37.0	—	—	0	—
32.0-35.0	1.20 (0.92-1.55)	0.184	0.2	0.2
37.1-39.0	2.11 (1.66-2.65)	0.745	1	<0.001
Heart rate (beats/min)
32-90	—	—	0	—
91-130	3.95 (3.60-4.33)	1.373	1	<0.001
131-155	17.3 (9.76-30.5)	2.851	3	<0.001
Age (years)
18-65	—	—	0	—
66-100	3.10 (2.83-3.39)	1.131	1	<0.001
Sex
Female	—	—	0	—
Male	1.33 (1.22-1.45)	0.287	0.3	<0.001