qSOFA Has Poor Sensitivity for Prehospital Identification of Severe Sepsis and Septic Shock

External validation of the quick Sequential Organ Failure Assessment score for mortality and bacteraemia risk evaluation in Japanese patients undergoing haemodialysis: a retrospective multicentre cohort study

OBJECTIVES

We aimed to examine the validity of the quick Sequential Organ Failure Assessment (qSOFA) score for mortality and bacteraemia risk assessment in Japanese haemodialysis patients.

DESIGN

This is a retrospective multicentre cohort study.

SETTING

The six participating hospitals are tertiary-care institutions that receive patients on an emergency basis and provide primary, secondary and tertiary care. The other participating hospital is a secondary-care institution that receives patients on an emergency basis and provides both primary and secondary care.

PARTICIPANTS

This study included haemodialysis outpatients admitted for bacteraemia suspicion, who had blood drawn for cultures within 48 hours of their initial admission.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was overall in-hospital mortality. Secondary outcomes included 28-day in-hospital mortality and the incidence of bacteraemia diagnosed based on blood culture findings. The discrimination, calibration and test performance of the qSOFA score were assessed. Missing data were handled using multiple imputation.

RESULTS

Among the 507 haemodialysis patients admitted with bacteraemia suspicion between August 2011 and July 2013, the overall in-hospital mortality was 14.6% (74/507), the 28-day in-hospital mortality was 11.1% (56/507) and the incidence of bacteraemia, defined as a positive blood culture, was 13.4% (68/507). For predicting in-hospital mortality among haemodialysis patients, the area under the receiver operating characteristic curve was 0.61 (95% CI 0.56-0.67) for a qSOFA score ≥2. The Hosmer-Lemeshow χ² statistics for the qSOFA score as a predictor of overall and 28-day in-hospital mortality were 5.72 (p=0.02) and 7.40 (p<0.01), respectively.

CONCLUSION

On external validation, the qSOFA score exhibited low diagnostic accuracy and miscalibration for in-hospital mortality and bacteraemia among haemodialysis patients.

Classification versus Prediction of Mortality Risk using the SIRS and qSOFA Scores in Patients with Infection Transported by Paramedics

Objective: Identifying patients with sepsis in the prehospital setting is an important opportunity to increase timely care. When assessing clinical tools designed for paramedic sepsis identification, predicted risk may provide more useful information to support decision-making, compared to traditional estimates of classification accuracy (i.e., sensitivity and specificity). We sought to contrast classification accuracy versus predicted risk of a modified version of the Systemic Inflammatory Response Syndrome score (i.e., excluding white blood cell measure which is often unavailable to paramedics; mSIRS) and quick Sepsis Related Organ Failure Assessment (qSOFA) for determining mortality risk among patients with infection transported by paramedics. Methods: A one-year cohort of patients with infections transported to the Emergency Department (ED) by paramedics was linked to in-hospital administrative databases. Scores were calculated using the first reported vital sign measure for each patient. We calculated sensitivity and specificity of mSIRS and qSOFA for classifying hospital mortality at different score thresholds, and estimated discrimination (using the C-statistic) and calibration (using calibration curves). Regression models for predicting hospital mortality were constructed using the mSIRS or qSOFA scores for each patient as the predictor. Results: A total of 10,409 patients with infection who were transported by paramedics were successfully linked, with an overall mortality rate of 9.2%. The mSIRS score had higher sensitivity estimates than qSOFA for classifying hospital mortality at all thresholds (mSIRS ≥ 1: 0.83 vs. qSOFA≥ 1: 0.80, mSIRS ≥ 3: 0.11 vs. qSOFA ≥ 3: 0.08), but the qSOFA score had better discrimination (C-statistic qSOFA: 0.72 vs. mSIRS: 0.63) and calibration. The risk of hospital mortality predicted by the mSIRS score ranged from 8.0 to 19% across score values, whereas the risk predicted by the qSOFA score ranged from 10 to 51%. Conclusion: Assessing the predicted risk for the mSIRS and qSOFA scores instead of classification accuracy reveals that the qSOFA score provides more information to clinicians about a patient's mortality risk, supporting its use in clinical decision-making.

Clinical decision support system to assess the risk of sepsis using Tree Augmented Bayesian networks and electronic medical record data

Early and accurate diagnoses of sepsis enable practitioners to take timely preventive actions. The existing diagnostic criteria suffer from deficiencies, such as triggering false alarms or leaving conditions undiagnosed. This study aims to develop a clinical decision support system to predict the risk of sepsis using tree augmented naive Bayesian network by identifying the optimal set of biomarkers. The key feature of our approach is that we captured the dynamics among biomarkers. With an area under receiver operating characteristic of 0.84, the proposed model outperformed the competing diagnostic criteria (systemic inflammatory response syndrome = 0.59, quick sepsis-related organ failure assessment = 0.65, modified early warning system = 0.75, sepsis-related organ failure assessment = 0.80). The richness of our proposed model is measured not only by achieving high accuracy, but also by utilizing fewer biomarkers. We also propose a left-center-right imputation method suitable for electronic medical record data. This method uses the individual patient’s visit, instead of aggregated (mean or median) value, to impute the missing data.

Clinical Value of Whole Blood Procalcitonin Using Point of Care Testing, Quick Sequential Organ Failure Assessment Score, C-Reactive Protein and Lactate in Emergency Department Patients with Suspected Infection

We investigated the clinical value of whole blood procalcitonin using point of care testing, quick sequential organ failure assessment score, C-reactive protein and lactate in emergency department patients with suspected infection and assessed the accuracy of the whole blood procalcitonin test by point-of-care testing. Participants were randomly selected from emergency department patients who complained of a febrile sense, had suspected infection and underwent serum procalcitonin testing. Whole blood procalcitonin levels by point-of-care testing were compared with serum procalcitonin test results from the laboratory. Participants were divided into two groups-those with bacteremia and those without bacteremia. Sensitivity, specificity, positive predictive value, negative predictive value of procalcitonin, lactate and Quick Sepsis-related Organ Failure Assessment scores were investigated in each group. Area under receiving operating curve of C-reactive protein, lactate and procalcitonin for predicting bacteremia and 28-day mortality were also evaluated. Whole blood procalcitonin had an excellent correlation with serum procalcitonin. The negative predictive value of procalcitonin and lactate was over 90%. Area under receiving operating curve results proved whole blood procalcitonin to be fair in predicting bacteremia or 28-day mortality. In the emergency department, point-of-care testing of whole blood procalcitonin is as accurate as laboratory testing. Moreover, procalcitonin is a complementing test together with lactate for predicting 28-days mortality and bacteremia for patients with suspected infection.

Use of prehospital qSOFA in predicting in-hospital mortality in patients with suspected infection: A retrospective cohort study

Background

The quick sequential organ failure assessment (qSOFA) score has recently been introduced to the emergency department (ED) and wards, and it predicted a higher number of deaths among patients with sepsis compared with baseline risk. However, studies about the application of the qSOFA score are limited in prehospital settings. Thus, this study aimed to assess the performance of prehospital qSOFA score in predicting the risk of mortality among patients with infection.

Methods

This single center, retrospective cohort study was conducted in a Japanese tertiary care teaching hospital between April 2016 and March 2017. We enrolled all consecutive adult patients transported to the hospital by ambulance and admitted to the ED due to a suspected infection. We calculated the prehospital qSOFA score using the first vital sign obtained at the scene by emergency medical service (EMS) providers. The primary outcome was in-hospital mortality. The Cox proportional hazards model was used to assess the association between prehospital qSOFA positivity and in-hospital mortality.

Results

Among the 925 patients admitted to the ED due to a suspected infection, 51.1% (473/925) were prehospital qSOFA-positive and 48.9% (452/925) were prehospital qSOFA-negative. The in-hospital mortality rates were 14.0% (66/473) in prehospital qSOFA-positive patients and 6.0% (27/452) in prehospital qSOFA-negative patients. The Cox proportional hazard regression model revealed a strong association between prehospital qSOFA score and in-hospital mortality (adjusted hazard ratio: 2.41, 95% confidence interval: 1.51–3.98; p <0.01).

Conclusions

Among the patients with suspected infection who were admitted at the ED, a strong association was observed between the prehospital qSOFA score and in-hospital mortality. In order to use this score in clinical practice, future study is necessary to evaluate how infection is suspected in the prehospital arena.

Quantitative capillary refill time predicts sepsis in patients with suspected infection in the emergency department: an observational study

Background

Outcomes in emergent patients with suspected infection depend on how quickly clinicians evaluate the patients and start treatment. This study was performed to compare the predictive ability of the quantitative capillary refill time (Q-CRT) as a new rapid index versus the quick sequential organ failure assessment (qSOFA) score and the systemic inflammatory response syndrome (SIRS) score for sepsis screening in the emergency department.

Methods

This was a multicenter, observational, retrospective study of adult patients with suspected infection. The area under the curve (AUC) of receiver operating characteristic curve analyses and multivariate analyses were used to explore associations of the Q-CRT with the qSOFA score, SIRS score, and lactate concentration.

Results

Of the 75 enrolled patients, 48 had sepsis. The AUC, sensitivity, and specificity of Q-CRT were 0.74, 58%, and 81%, respectively; those for the qSOFA score were 0.83, 66%, and 100%, respectively; those for the SIRS score were 0.61, 81%, and 40%, respectively, for SIRS score; and those for the lactate concentration were 0.76, 72%, and 81%, respectively. We found no statistically significant differences in the AUC between the scores. We then combined the Q-CRT and qSOFA score (Q-CRT/qSOFA combination) for sepsis screening. The AUC, sensitivity, and specificity of Q-CRT/qSOFA combination were 0.82, 83%, and 81%, respectively.

Conclusions

In this study, Q-CRT/qSOFA combination had better sensitivity than the qSOFA score alone and better specificity than the SIRS score alone. There was no significant difference in accuracy between Q-CRT/qSOFA combination and the qSOFA score or lactate concentration. The ability of the Q-CRT to predict sepsis may be similar to that of the qSOFA score or serum lactate concentration; therefore, measurement of the Q-CRT may be an alternative for invasive measurement of the blood lactate concentration in evaluating patients with suspected sepsis.

Electronic supplementary material

The online version of this article (10.1186/s40560-019-0382-4) contains supplementary material, which is available to authorized users.

Epidemiology of Quick Sequential Organ Failure Assessment Criteria in Undifferentiated Patients and Association With Suspected Infection and Sepsis

BACKGROUND

The role of Quick Sequential Organ Failure Assessment (qSOFA) criteria in sepsis screening and management is controversial, particularly as they were derived only in patients with suspected infection. We examined the epidemiology and prognostic value of qSOFA in undifferentiated patients.

METHODS

We identified patients with ≥ 2 qSOFA criteria within 1 day of admission among all adults admitted to 85 US hospitals from 2012 to 2015 and assessed for suspected infection (using clinical cultures and administration of antibiotics) and sepsis (as defined on the basis of Sepsis-3 criteria). We also examined the discrimination of qSOFA for in-hospital mortality among patients with and without suspected infection, using regression models.

RESULTS

Of 1,004,347 hospitalized patients, 271,500 (27.0%) were qSOFA-positive on admission. Compared with qSOFA-negative patients, qSOFA-positive patients were older (median age, 65 vs 58 years), required ICU admission more often (28.5% vs 6.5%), and had higher mortality (6.7% vs 0.8%) (P < .001 for all comparisons). Sensitivities of qSOFA for suspected infection and sepsis were 41.3% (95% CI, 41.1%-41.5%) and 62.8% (95% CI, 62.4%-63.1%), respectively; positive predictive values were 31.0% (95% CI, 30.8%-31.1%) and 17.4% (95% CI, 17.2%-17.5%). The area under the receiver operating characteristic curve for mortality was lower for qSOFA in patients with suspected infection vs those without (0.814 vs 0.875; P < .001).

CONCLUSIONS

Only one in three patients who are qSOFA-positive on admission has suspected infection, and one in six has sepsis. qSOFA also has low sensitivity for identifying suspected infection and sepsis, and its prognostic significance is not specific to infection. More sensitive and specific tools for sepsis screening and risk stratification are needed.

Sequential organ failure assessment score is an excellent operationalization of disease severity of adult patients with hospitalized community acquired pneumonia - results from the prospective observational PROGRESS study

BACKGROUND

CAP (Community acquired pneumonia) is frequent, with a high mortality rate and a high burden on health care systems. Development of predictive biomarkers, new therapeutic concepts, and epidemiologic research require a valid, reproducible, and quantitative measure describing CAP severity.

METHODS

Using time series data of 1532 patients enrolled in the PROGRESS study, we compared putative measures of CAP severity for their utility as an operationalization. Comparison was based on ability to correctly identify patients with an objectively severe state of disease (death or need for intensive care with at least one of the following: substantial respiratory support, treatment with catecholamines, or dialysis). We considered IDSA/ATS minor criteria, CRB-65, CURB-65, Halm criteria, qSOFA, PSI, SCAP, SIRS-Score, SMART-COP, and SOFA.

RESULTS

SOFA significantly outperformed other scores in correctly identifying a severe state of disease at the day of enrollment (AUC = 0.948), mainly caused by higher discriminative power at higher score values. Runners-up were the sum of IDSA/ATS minor criteria (AUC = 0.916) and SCAP (AUC = 0.868). SOFA performed similarly well on subsequent study days (all AUC > 0.9) and across age groups. In univariate and multivariate analysis, age, sex, and pack-years significantly contributed to higher SOFA values whereas antibiosis before hospitalization predicted lower SOFA.

CONCLUSIONS

SOFA score can serve as an excellent operationalization of CAP severity and is proposed as endpoint for biomarker and therapeutic studies.

TRIAL REGISTRATION

clinicaltrials.gov NCT02782013 , May 25, 2016, retrospectively registered.

Use of qSOFA Score in Predicting the Outcomes of Patients With Glyphosate Surfactant Herbicide Poisoning Immediately Upon Arrival at the Emergency Department

AIM

This study aimed to identify whether quick sequential organ failure assessment (qSOFA) performed immediately upon arrival can predict the outcome of patients with glyphosate surfactant herbicide (GlySH) poisoning.

METHODS

Adult patients with GlySH poisoning between January 2006 and April 2017 were included in this retrospective observational study. The qSOFA score (respiratory rate ≥22 breaths per minute, systolic blood pressure <100 mm Hg, and altered mental status) was assessed immediately upon arrival at the emergency department. The primary outcome was in-hospital mortality, and the secondary outcomes were life-threatening complications and organ injury.

RESULTS

Of the 150 patients who ingested GlySH, 14 (9.3%) died. The qSOFA score was significantly higher in the non-survival group (P < 0.001). qSOFA (odds ratio [OR], 2.73; 95% confidence interval [CI], 1.41-5.76) was independently associated with in-hospital mortality. The area under curve value of qSOFA was 0.841 (95% CI, 0.772-0.895). As qSOFA score increased from 0 to 3, the in-hospital mortality significantly increased (P < 0.001). The frequency of life-threatening complications, including organ injury, increased as the qSOFA score increased from 0 to 3 (P < 0.001).

CONCLUSIONS

The qSOFA score measured upon arrival shows good prognostic performance in patients with GlySH poisoning. Moreover, the qSOFA may predict the development of life-threatening complications including organ injury. Thus, more attention should be paid to patients with GlySH poisoning with higher qSOFA scores.

Efficacy of quick Sequential Organ Failure Assessment with lactate concentration for predicting mortality in patients with community-acquired pneumonia in the emergency department

Objective

Community-acquired pneumonia (CAP) is a major cause of sepsis, and sepsis-related acute organ dysfunction affects patient mortality. Although the quick Sequential Organ Failure Assessment (qSOFA) is a new screening tool for patients with suspected infection, its predictive value for the mortality of patients with CAP has not been validated. Lactate concentration is a valuable biomarker for critically ill patients. Thus, we investigated the predictive value of qSOFA with lactate concentration for in-hospital mortality in patients with CAP in the emergency department (ED).

Methods

From January 2015 to June 2015, 443 patients, who were diagnosed with CAP in the ED, were retrospectively analyzed. We defined high qSOFA or lactate concentrations as a qSOFA score ≥2 or a lactate concentration >2 mmol/L upon admission at the ED. The primary outcome was all-cause in-hospital mortality.

Results

Among the 443 patients, 44 (9.9%) died. Based on the receiver operating characteristic (ROC) analysis, the areas under the curves for the prediction of mortality were 0.720, 0.652, and 0.686 for qSOFA, CURB-65 (confusion, urea, respiratory rate, blood pressure, and age), and Pneumonia Severity Index, respectively. The area under the ROC curve of qSOFA was lower than that of SOFA (0.720 vs. 0.845, P=0.004). However, the area under the ROC curve of qSOFA with lactate concentration was not significantly different from that of SOFA (0.828 vs. 0.845, P=0.509). The sensitivity and specificity of qSOFA with lactate concentration were 71.4% and 83.2%, respectively.

Conclusion

qSOFA with lactate concentration is a useful and practical tool for the early prediction of in-hospital mortality among patients with CAP in the ED.

The qSOFA Score: A Simple and Accurate Predictor of Outcome in Patients with Glyphosate Herbicide Poisoning

This study aimed to investigate whether the quick Sequential Organ Failure Assessment (qSOFA) score at emergency department (ED) presentation can help improve the risk assessment of glyphosate-surfactant herbicide (GlySH) poisoning complications. A total of 150 patients presenting with acute glyphosate herbicide ingestion were enrolled in this retrospective observational study. The qSOFA scores at presentation, ΔqSOFA (calculated by subtracting the worst qSOFA score from 1 hr after admission from the qSOFA score at presentation), baseline characteristics, clinical courses and outcome were collected and analysed. A total of 41 patients had life-threatening complications (27.3%), and 14 patients died (9.3%). Patients with a qSOFA score of 0 at presentation had a 1.5% incidence rate of complications. As the qSOFA score at presentation increased from 1 to 3, the rate of life-threatening complications significantly increased from 29.6% to 100%. Patients with a ΔqSOFA of 1 had a higher frequency of complications than did patients with a ΔqSOFA of 0. The qSOFA score (OR: 8.39, 95% CI: 3.51-26.67) and ΔqSOFA (OR: 27.60, 95% CI: 3.87-575.67) were associated with the development of life-threatening complications in the multivariate analysis. The qSOFA score showed high sensitivity (97.56%), and the ΔqSOFA score showed high specificity (99.08%). The values of area under the curve were significantly higher in the models using the qSOFA and ΔqSOFA than they were in the models using previously known prognostic factors (p < 0.01). The clinician should pay more attention to patients with high qSOFA scores at presentation or an increase in the qSOFA score 1 hr after admission.

Prediction of 28-days mortality with sequential organ failure assessment (SOFA), quick SOFA (qSOFA) and systemic inflammatory response syndrome (SIRS) - A retrospective study of medical patients with acute infectious disease

AIMS

Evaluating the use of sequential organ failure assessment (SOFA) ≥ 2 compared to quick SOFA (qSOFA) and to systemic inflammatory response syndrome (SIRS) in assessing 28-days mortality in medical patients with acute infection.

METHODS

In total, 323 patients with verified infection were stratified in accordance to Sepsis-3. SOFA, qSOFA and SIRS were calculated using registered variables. Adverse outcome was death within 28-days of admission.

RESULTS

In total, 190 (59%) patients had a SOFA score≥2 and the overall in-hospital mortality was 21 (6%). Scores of SOFA and qSOFA were both significantly elevated in non-survivors. SOFA showed good accuracy (Area under the receiver operating characteristic (AUROC)=0.83, 95% CI, 0.76 - 0.90) for 28-days mortality compared with qSOFA (AUROC=0.67, 95% CI, 0.54 - 0.80) and SIRS (AUROC=0.62, 95% Cl 0.49 - 0.74). SOFA was≥2 in all patients who died, while qSOFA and SIRS was≥2 in 8 (38%) and 17 (81%) of the patients who died, respectively.

CONCLUSION

SOFA score≥2 was better than SIRS and qSOFA to predict mortality within 28-days of admission among patients with acute infectious disease.

Pre-hospital qSOFA as a predictor of sepsis and mortality

BACKGROUND

The quick sequential organ failure assessment score (qSOFA) has been proposed as a simple tool to identify patients with sepsis who are at risk for poor outcomes. Its utility in the pre-hospital setting has not been fully elucidated.

METHODS

This is a retrospective observational study of adult patients arriving by ambulance in September 2016 to an academic emergency department in Fresno, California. The qSOFA score was calculated from pre-hospital vital signs. We investigated its association with sepsis, ED diagnosis of infection, and mortality.

RESULTS

Of 2292 adult medical patients transported by ambulance during the study period, the sensitivity of qSOFA for sepsis and in-hospital mortality were 42.9% and 40.6%, respectively. Specificity of qSOFA for sepsis and mortality were 93.8% and 91.9%, respectively. Of those with an ED diagnosis of infection compared to all patients, qSOFA was more specific but less sensitive for sepsis. Increasing qSOFA score was associated with a discharge diagnosis of sepsis (OR 4.21, 95% CI 3.41-5.21, p < 0.001), in-hospital mortality (OR 3.30, 95% CI 2.28-4.78, p < 0.001), and ED diagnosis of infection (OR 1.37, 95% CI 1.18-1.58, p < 0.001). Higher qSOFA score was associated with triage to a higher acuity zone and longer hospital and ICU length of stay, but not up-triage during ED stay.

CONCLUSIONS

Pre-hospital qSOFA is specific, but poorly sensitive, for sepsis and sepsis outcomes, especially among patients with an ED diagnosis of infection. Higher qSOFA score was associated with worse outcomes.

Comparison of qSOFA and SOFA score for predicting mortality in severe sepsis and septic shock patients in the emergency department of a low middle income country

Objective

We aimed to determine a comparison between the Quick Sequential Organ Failure Assessment (qSOFA) score and existing Sequential Organ Failure Assessment (SOFA) score when applied to severe sepsis & septic shock patients in the Emergency Department (ED) for prediction of in-hospital mortality in the setting of a tertiary care hospital ED in a low-middle income country.

Method

We conducted a prospective observational cohort study on 760 subjects. The qSOFA, SOFA score and in-hospital mortality were assessed by area under the receiver operating curve (AUROC). We calculated sensitivity and specificity for each score for outcomes at cut-offs of 0.92 and 0.63 for qSOFA and SOFA in Severe Sepsis respectively and 0.89 and 0.63 for qSOFA and SOFA in Septic shock respectively.

Results

In patients with severe sepsis, the AUROC of qSOFA for predicting mortality in subjects was 0.92 (95% CI; 0.89–0.94) with 96% sensitivity and 87% specificity in comparison to the AUROC of SOFA score which was 0.63 (95% CI; 0.55–0.70 with 71% sensitivity and 57% specificity. In patients with septic shock, the AUROC of qSOFA for predicting mortality in subjects was 0.89 (95% CI; 0.85–0.92) with 92% sensitivity and 85% specificity in comparison to the AUROC of SOFA score which was 0.63 (95% CI; 0.55–0.70 with 70% sensitivity and 59% specificity.

Conclusion

Our study concludes that qSOFA score is an effective tool at predicting in hospital mortality in comparison to SOFA score when applied to severe sepsis and septic shock patients in the setting of a tertiary care hospital ED of a low-middle income country however, further studies are needed before application for this purpose.

Lactate ≥2 mmol/L plus qSOFA improves utility over qSOFA alone in emergency department patients presenting with suspected sepsis

OBJECTIVE

The Sepsis-3 task force recommends the use of the quick Sequential Organ Failure Assessment (qSOFA) score to identify risk for adverse outcomes in patients presenting with suspected infection. Lactate has been shown to predict adverse outcomes in patients with suspected infection. The aim of the study is to investigate the utility of a post hoc lactate threshold (≥2 mmol/L) added qSOFA score (LqSOFA₍₂₎ score) to predict primary composite adverse outcomes (mortality and/or ICU stay ≥72 h) in patients presenting to ED with suspected sepsis.

METHODS

Retrospective cohort study was conducted on a merged dataset of suspected or proven sepsis patients presenting to ED across multiple sites in Australia and The Netherlands. Patients are identified as candidates for quality improvement initiatives or research studies at respective sites based on local screening procedures. Data-sharing was performed across sites of demographics, qSOFA, SOFA, lactate thresholds and outcome data for included patients. LqSOFA₍₂₎ scores were calculated by adding an extra point to qSOFA score in patients who met lactate thresholds of ≥2 mmol/L.

RESULTS

In a merged dataset of 12 555 patients where a full qSOFA score and outcome data were available, LqSOFA₍₂₎ ≥2 identified more patients with an adverse outcome (sensitivity 65.5%, 95% confidence interval 62.6-68.4) than qSOFA ≥2 (sensitivity 47.6%, 95% confidence interval 44.6- 50.6). The post hoc addition of lactate threshold identified higher proportion of patients at risk of adverse outcomes.

CONCLUSIONS

The lactate ≥2 mmol/L threshold-based LqSOFA₍₂₎ score performs better than qSOFA alone in identifying risk of adverse outcomes in ED patients with suspected sepsis.

[Sepsis detection in emergency medicine : Results of an interprofessional survey on sepsis detection in prehospital emergency medicine and emergency departments]

BACKGROUND

Sepsis is associated with a high mortality, which can be reduced by starting screening, diagnostics and treatment as early as possible. Due to multiple educational programs and increased awareness, a decreased sepsis mortality on intensive care units has been achieved. Many patients with sepsis are admitted by the prehospital emergency service to hospital emergency departments. Thus, prehospital emergency services and emergency departments provide an opportunity to start screening, diagnosis and treatment earlier.

OBJECTIVES

To detect sepsis it is paramount that emergency personnel are aware of the disease and have a profound knowledge regarding symptoms, screening and diagnostics. The objective of this survey was to examine the state of knowledge regarding sepsis among staff working in emergency medicine.

MATERIAL AND METHODS

To assess the awareness and knowledge, a paper-based, anonymous survey was conducted among prehospital and emergency department personnel from May to August 2017 in northeastern Germany. Testing of significance was carried out using the χ²-testand Fisher's exact test.

RESULTS

Out of 411 persons polled 212 answered (response rate 51.6%) and 24 questionnaires were incomplete and thus excluded. A total of 188 questionnaires were included covering 55 emergency physicians, 23 nurses, 82 paramedics and 19 emergency dispatchers. On a 4-point Likert scale 100% of emergency doctors, 96% of nurses, 84% of paramedics and 84% of emergency dispatchers considered early initiation of sepsis treatment to be important. Additionally, 92% of emergency physicians and 65% of nurses had attended educational programs on sepsis within the last year, which is significantly higher than among paramedics (19%, p < 0.01) and emergency dispatchers (21%, p = 0.025). In addition, 38% of paramedics and 47% of emergency dispatchers had never attended lectures on sepsis. The quick sequential (sepsis-related) organ failure assessment (qSOFA) was known by 80% of emergency doctors, thus, significantly more often than by nurses (26%), paramedics (29%) and emergency dispatchers (29%, p < 0.01). The emergency personnel were asked to tick all symptoms they associated with sepsis from a display of 14 symptoms. Among all occupation groups the majority selected "increased body temperature", "drop in blood pressure" and "altered breathing". In relation to "increased body temperature" the symptom "altered mental status" was selected significantly more frequently by emergency doctors than by nurses and paramedics (p = 0.02 and p < 0.01, respectively). The combination of at least all 3 qSOFA parameters was selected significantly more often by emergency doctors (62%) than by nurses (13%) and paramedics (10%, p = 0.017 and p < 0.01, respectively).

CONCLUSION

Although emergency personnel rated an early initiation of sepsis treatment as important, sepsis knowledge was limited. While the majority of emergency doctors and many nurses had attended educational programs on sepsis within the last year, an alarmingly high percentage of paramedics and emergency dispatchers had never received sepsis education. Emergency personnel are mostly unfamiliar with the qSOFA score and did not associate an altered mental status with sepsis. In light of the high sepsis morbidity and mortality, further achievements might be made by initiating sepsis screening and diagnostics in the prehospital setting. Analogous to advancements in intensive care units, increased educational programs for emergency personnel might lead to an earlier detection and improved prognosis of sepsis.

A novel early risk assessment tool for detecting clinical outcomes in patients with heat-related illness (J-ERATO score): Development and validation in independent cohorts in Japan

BACKGROUND

We sought to develop a novel risk assessment tool to predict the clinical outcomes after heat-related illness.

METHODS

Prospective, multicenter observational study. Patients who transferred to emergency hospitals in Japan with heat-related illness were registered. The sample was divided into two parts: 60% to construct the score and 40% to validate it. A binary logistic regression model was used to predict hospital admission as a primary outcome. The resulting model was transformed into a scoring system.

RESULTS

A total of 3,001 eligible patients were analyzed. There was no difference in variables between development and validation cohorts. Based on the result of a logistic regression model in the development phase (n = 1,805), the J-ERATO score was defined as the sum of the six binary components in the prehospital setting (respiratory rate≥22 /min, Glasgow coma scale<15, systolic blood pressure≤100 mmHg, heart rate≥100 bpm, body temperature≥38°C, and age≥65 y), for a total score ranging from 0 to 6. In the validation phase (n = 1,196), the score had excellent discrimination (C-statistic 0.84; 95% CI 0.79-0.89, p<0.0001) and calibration (P>0.2 by Hosmer-Lemeshow test). The observed proportion of hospital admission increased with increasing J-ERATO score (score = 0, 5.0%; score = 1, 15.0%; score = 2, 24.6%; score = 3, 38.6%; score = 4, 68.0%; score = 5, 85.2%; score = 6, 96.4%). Multivariate analyses showed that the J-ERATO score was an independent positive predictor of hospital admission (adjusted OR, 2.43; 95% CI, 2.06-2.87; P<0.001), intensive care unit (ICU) admission (3.73; 2.95-4.72; P<0.001) and in-hospital mortality (1.65; 1.18-2.32; P = 0.004).

CONCLUSIONS

The J-ERATO score is simply assessed and can facilitate the identification of patients with higher risk of heat-related hospitalization. This scoring system is also significantly associated with the higher likelihood of ICU admission and in-hospital mortality after heat-related hospitalization.

Accuracy of quick Sequential Organ Failure Assessment (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria for predicting mortality in hospitalized patients with suspected infection: a meta-analysis of observational studies

OBJECTIVE

To identify sensitivity, specificity and predictive accuracy of quick sequential organ failure assessment (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria to predict in-hospital mortality in hospitalized patients with suspected infection.

METHODS

This meta-analysis followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) group consensus statement for conducting and reporting the results of systematic review. PubMed and EMBASE were searched for the observational studies which reported predictive utility of qSOFA score for predicting mortality in patients with suspected or proven infection with the following search words: 'qSOFA', 'q-SOFA', 'quick-SOFA', 'Quick Sequential Organ Failure Assessment', 'quick SOFA'. Sensitivity, specificity, area under receiver operating characteristic (ROC) curves with 95% confidence interval (CI) of qSOFA and SIRS criteria for predicting in-hospital mortality was collected for each study and a 2 × 2 table was created for each study.

RESULTS

Data of 406 802 patients from 45 observational studies were included in this meta-analysis. Pooled sensitivity (95% CI) and specificity (95% CI) of qSOFA ≥2 for predicting mortality in patients who were not in an intensive care unit (ICU) was 0.48 (0.41-0.55) and 0.83 (0.78-0.87), respectively. Pooled sensitivity (95% CI) of qSOFA ≥2 for predicting mortality in patients (both ICU and non-ICU settings) with suspected infection was 0.56 (0.47-0.65) and pooled specificity (95% CI) was 0.78 (0.71-0.83).

CONCLUSION

qSOFA has been found to be a poorly sensitive predictive marker for in-hospital mortality in hospitalized patients with suspected infection. It is reasonable to recommend developing another scoring system with higher sensitivity to identify high-risk patients with infection.

Can Sepsis Be Detected in the Nursing Home Prior to the Need for Hospital Transfer?

OBJECTIVES

To determine whether and to what extent simple screening tools might identify nursing home (NH) residents who are at high risk of becoming septic.

DESIGN

Retrospective chart audit of all residents who had been hospitalized and returned to participating NHs during the study period.

SETTING AND PARTICIPANTS

A total of 236 NH residents, 59 of whom returned from hospitals with a diagnosis of sepsis and 177 who had nonsepsis discharge diagnoses, from 31 community NHs that are typical of US nursing homes overall.

MEASURES

NH documentation of vital signs, mental status change, and medical provider visits 0-12 and 13-72 hours prior to the hospitalization. The specificity and sensitivity of 5 screening tools were evaluated for their ability to detect residents with incipient sepsis during 0-12 and 13-72 hours prior to hospitalization: The Systemic Inflammatory Response Syndrome criteria, the quick Sequential Organ Failure Assessment (SOFA), the 100-100-100 Early Detection Tool, and temperature thresholds of 99.0°F and 100.2°F. In addition, to validate the hospital diagnosis of sepsis, hospital discharge records in the NHs were audited to calculate SOFA scores.

RESULTS

Documentation of 1 or more vital signs was absent in 26%-34% of cases. Among persons with complete vital sign documentation, during the 12 hours prior to hospitalization, the most sensitive screening tools were the 100-100-100 Criteria (79%) and an oral temperature >99.0°F (51%); and the most specific tools being a temperature >100.2°F (93%), the quick SOFA (88%), the Systemic Inflammatory Response Syndrome criteria (86%), and a temperature >99.0°F (85%). Many SOFA data points were missing from the record; in spite of this, 65% of cases met criteria for sepsis.

CONCLUSIONS

NHs need better systems to monitor NH residents whose status is changing, and to present that information to medical providers in real time, either through rapid medical response programs or telemetry.

Addition of lactic acid levels improves the accuracy of quick sequential organ failure assessment in predicting mortality in surgical patients with complicated intra-abdominal infections: a retrospective study

Background

The quick sequential organ failure assessment (qSOFA) alone has a poor sensitivity for predicting mortality in patients with complicated intra-abdominal infections, and plasma lactate levels have been shown to have a strong association with mortality in critically ill patients. Therefore, this study aimed to compare the performance of qSOFA with a score derived from a combination of qSOFA and serum lactate levels for predicting mortality in surgical patients with complicated intra-abdominal infections.

Methods

This retrospective study was performed at a university hospital. The medical records of 457 patients who presented to the emergency department (ED) between January 2008 and December 2016 and required emergency gastrointestinal surgery for a complicated intra-abdominal infection were reviewed retrospectively. qSOFA criteria, sequential organ failure assessment (SOFA) scores, and plasma lactate levels during their ED stay were collected. We performed area under receiver operating characteristic (AUROC) curve and sensitivity analysis to compare the performance of qSOFA alone with that of a score derived from the use of a combination of the qSOFA and lactate levels for predicting patient mortality.

Results

Fifty patients (10.9%) died during hospitalization. The combined qSOFA and lactate level score was superior to qSOFA alone (AUROC = 0.754 vs. 0.717, p = 0.039, respectively) and comparable to the full SOFA score (AUROC = 0.754 vs. 0.795, p = 0.127, respectively) in predicting mortality. Sensitivity and specificity of qSOFA alone were 46 and 86%, respectively, and those of the combined score were 72 and 73%, respectively (p < 0.001).

Conclusion

A score derived from the qSOFA and serum lactate levels had better predictive performance with higher sensitivity than the qSOFA alone in predicting mortality in patients with complicated intra-abdominal infections and had a comparable predictive performance to that of the full SOFA score.

Performance of the quick Sequential (sepsis-related) Organ Failure Assessment score as a prognostic tool in infected patients outside the intensive care unit: a systematic review and meta-analysis

Background

The usefulness of the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) score in providing bedside criteria for early prediction of poor outcomes in patients with suspected infection remains controversial. We investigated the prognostic performance of a positive qSOFA score outside the intensive care unit (ICU) compared with positive systemic inflammatory response syndrome (SIRS) criteria.

Methods

A systematic literature search was performed using MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. Data were pooled on the basis of sensitivity, specificity, and diagnostic OR. Overall test performance was summarized using a hierarchical summary ROC and the AUC. Meta-regression analysis was used to identify potential sources of bias.

Results

We identified 23 studies with a total of 146,551 patients. When predicting in-hospital mortality in our meta-analysis, we identified pooled sensitivities of 0.51 for a positive qSOFA score and 0.86 for positive SIRS criteria, as well as pooled specificities of 0.83 for a positive qSOFA score and 0.29 for positive SIRS criteria. Discrimination for in-hospital mortality had similar AUCs between the two tools (0.74 vs. 0.71; P = 0.816). Using meta-regression analysis, an overall mortality rate ≥ 10% and timing of qSOFA score measurement could be significant sources of heterogeneity. For predicting acute organ dysfunction, although the AUC for a positive qSOFA score was higher than that for positive SIRS criteria (0.87 vs. 0.76; P < 0.001), the pooled sensitivity of positive qSOFA score was very low (0.47). In addition, a positive qSOFA score tended to be inferior to positive SIRS criteria in predicting ICU admission (0.63 vs. 0.78; P = 0.121).

Conclusions

A positive qSOFA score had high specificity outside the ICU in early detection of in-hospital mortality, acute organ dysfunction, and ICU admission, but low sensitivity may have limitations as a predictive tool for adverse outcomes. Because between-study heterogeneity was highly represented among the studies, our results should be interpreted with caution.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-1952-x) contains supplementary material, which is available to authorized users.

Low sensitivity of qSOFA, SIRS criteria and sepsis definition to identify infected patients at risk of complication in the prehospital setting and at the emergency department triage

Background

Sepsis is defined as life-threatening organ dysfunction caused by a host response to infection. The quick SOFA (qSOFA) score has been recently proposed as a new bedside clinical score to identify patients with suspected infection at risk of complication (intensive care unit (ICU) admission, in-hospital mortality). The aim of this study was to measure the sensitivity of the qSOFA score, SIRS criteria and sepsis definitions to identify the most serious sepsis cases in the prehospital setting and at the emergency department (ED) triage.

Methods

We performed a retrospective study of all patients transported by emergency medical services (EMS) to the Lausanne University Hospital (CHUV) over twelve months. All patients with a suspected or proven infection after the ED workup were included. We retrospectively analysed the sensitivity of the qSOFA score (≥2 criteria), SIRS criteria (≥2 clinical criteria) and sepsis definition (SIRS criteria + one sign of organ dysfunction or hypoperfusion) in the pre-hospital setting and at the ED triage as predictors of ICU admission, ICU stay of ≥3 days and early (i.e. 48 h) mortality. No direct comparison between the three tools was attempted.

Results

Among 11,411 patients transported to the University hospital, 886 (7.8%) were included. In the pre-hospital setting, the sensitivity of qSOFA reached 36.3% for ICU admission, 17.4% for ICU stay of three days or more and 68.0% for 48 h mortality. The sensitivity of SIRS criteria reached 68.8% for ICU admission, 74.6% for ICU stay of three days or more and 64.0% for 48 h mortality. The sensitivity of sepsis definition did not reach 60% for any outcome. At ED triage, the sensitivity of qSOFA reached 31.2% for ICU admission, 30.5% for ICU stay of ≥3 days and 60.0% for mortality at 48 h. The sensitivity of SIRS criteria reached 58.8% for ICU admission, 57.6% for ICU stay of ≥3 days 80.0% for mortality at 48 h. The sensitivity of sepsis definition reached 60.0% for 48 h mortality.

Discussion

Incidence of sepsis in the ED among patients transported by ambulance was 3.8 percent. This rate, associated to the mortality of sepsis, confirms the necessity to dispose of a test to early identify those patients.

Conclusion

The sensitivity performance of all three tools was suboptimal. The qSOFA score, SIRS criteria and sepsis definition have low identification sensitivity in selecting septic patients in the pre-hospital setting or upon arrival in the ED at risk of complication.

Low Accuracy of Positive qSOFA Criteria for Predicting 28-Day Mortality in Critically Ill Septic Patients During the Early Period After Emergency Department Presentation

STUDY OBJECTIVE

We determine the diagnostic performance of positive Quick Sequential Organ Failure Assessment (qSOFA) scores for predicting 28-day mortality among critically ill septic patients during the early period after emergency department (ED) presentation.

METHODS

This was a retrospective cohort study at a tertiary care academic center. We reviewed a registry of adult (≥18 years) patients who received a diagnosis of severe sepsis or septic shock during an ED stay from August 2008 through September 2014. We identified the point at which patients met 2 or more of the 3 qSOFA criteria (indicating a positive qSOFA score) simultaneously during the initial 24 hours. The diagnostic performance of positive qSOFA score for predicting 28-day mortality was assessed (on ED arrival and within 3, 6, and 24 hours after ED presentation).

RESULTS

A total of 1,395 patients were included, and the overall 28-day mortality was 15%. For patients with positive qSOFA score, 28-day mortality was 23% (95% confidence interval [CI] 19% to 28%) on ED arrival, 20% (95% CI 17% to 23%) at 3 hours, 20% (95% CI 17% to 22%) at 6 hours, and 17% (95% CI 15% to 20%) at 24 hours. Positive qSOFA score for predicting 28-day mortality had a sensitivity, specificity, and area under the receiver operating curve, respectively, of 39% (95% CI 32% to 46%), 77% (95% CI 75% to 80%), and 0.58 (95% CI 0.55 to 0.62) on ED arrival; 68% (95% CI 62% to 75%), 52% (95% CI 49% to 55%), and 0.60 (95% CI 0.57 to 0.63) within 3 hours; 82% (95% CI 76% to 87%), 41% (95% CI 38% to 44%), and 0.61 (95% CI 0.58 to 0.64) within 6 hours; and 91% (95% CI 86% to 94%), 23% (95% CI 21% to 25%), and 0.57 (95% CI 0.54 to 0.59) within 24 hours.

CONCLUSION

The diagnostic performance of positive qSOFA score for predicting 28-day mortality was low in critically ill septic patients, particularly during the early period after ED presentation. The study requires further prospective validation because of limitations with its retrospective design and use of single-center data.

Poor performance of quick-SOFA (qSOFA) score in predicting severe sepsis and mortality - a prospective study of patients admitted with infection to the emergency department

Background

We aimed to evaluate the clinical usefulness of qSOFA as a risk stratification tool for patients admitted with infection compared to traditional SIRS criteria or our triage system; the Rapid Emergency Triage and Treatment System (RETTS).

Methods

The study was an observational cohort study performed at one Emergency Department (ED) in an urban university teaching hospital in Norway, with approximately 20,000 visits per year. All patients >16 years presenting with symptoms or clinical signs suggesting an infection (n = 1535) were prospectively included in the study from January 1 to December 31, 2012. At arrival in the ED, vital signs were recorded and all patients were triaged according to RETTS vital signs, presenting infection, and sepsis symptoms. These admission data were also used to calculate qSOFA and SIRS. Treatment outcome was later retrieved from the patients’ electronic records (EPR) and mortality data from the Norwegian population registry.

Results

Of the 1535 admitted patients, 108 (7.0%) fulfilled the Sepsis2 criteria for severe sepsis. The qSOFA score ≥2 identified only 33 (sensitivity 0.32, specificity 0.98) of the patients with severe sepsis, whilst the RETTS-alert ≥ orange identified 92 patients (sensitivity 0.85, specificity 0.55). Twenty-six patients died within 7 days of admission; four (15.4%) of them had a qSOFA ≥2, and 16 (61.5%) had RETTS ≥ orange alert. Of the 68 patients that died within 30 days, only eight (11.9%) scored ≥2 on the qSOFA, and 45 (66.1%) had a RETTS ≥ orange alert.

Discussion

In order to achieve timely treatment for sepsis, a sensitive screening tool is more important than a specific one. Our study is the fourth study were qSOFA finds few of the sepsis cases in prehospital or at arrival to the ED. We add information on the RETTS triage system, the two highest acuity levels together had a high sensitivity (85%) for identifying sepsis at arrival to the ED - and thus, RETTS should not be replaced by qSOFA as a screening and trigger tool for sepsis at arrival.

Conclusion

In this observational cohort study, qSOFA failed to identify two thirds of the patients admitted to an ED with severe sepsis. Further, qSOFA failed to be a risk stratification tool as the sensitivity to predict 7-day and 30-day mortality was low. The sensitivity was poorer than the other warning scores already in use at the study site, RETTS-triage and the SIRS criteria.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-017-0399-4) contains supplementary material, which is available to authorized users.