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Zhang TY, Du YJ, Hou YZ, Du Q, Dou HR, Gao XM. Heart/breathing rate ratio (HBR) as a predictor of mortality in critically ill patients. Heliyon 2024; 10:e31187. [PMID: 38803872 PMCID: PMC11128922 DOI: 10.1016/j.heliyon.2024.e31187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 05/08/2024] [Accepted: 05/12/2024] [Indexed: 05/29/2024] Open
Abstract
Objectives The early prediction of death is a challenge for medical staff. We evaluated the ability of the heart/breathing rate ratio (HBR) to predict mortality. Methods This was a single-center retrospective observational study of adult patients who had fever with or without respiratory symptoms, who survived at least 2 h after visiting the hospital, and whose lactate levels and vital signs were tested. We evaluated the distribution of mortality at different HBR levels and compared HBR with lactate. Results A total of 18,872 fever clinic visits were screened, and 183 patients whose lactate levels were tested were recruited. Patients who had HBR values lower than 4·5 or higher than 5·5 had greater mortality than patients who had HBR values between 4·5 and 5·5 (21·3 % vs. 3·4 %, p = 0·003; 28·9 % vs. 3·4 %, p < 0·001, respectively). In patients whose HBR was <5, the AUROC for HBR for mortality was 0·762 (95 % CI: 0.643-0·880), and that for lactate was 0·701 (95 % CI: 0·564-0·837). In patients whose HBR was ≥5, the AUROC for HBR for mortality was 0·721 (95 % CI: 0·584-0·857), and that for lactate was 0·742 (95 % CI: 0·607-0·848). Conclusions HBR is helpful for stratifying mortality risk among critically ill patients in acute care clinics for infectious diseases.
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Affiliation(s)
- Tong Yan Zhang
- Infectious Diseases Department, Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Ya Jun Du
- TEDA International Cardiovascular Hospital, Tianjin, China
| | - Ya Zhu Hou
- Department of Cardiology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Qian Du
- Department of Pharmacy, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hai Rong Dou
- Infectious Diseases Department, Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xiu Mei Gao
- Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
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Baylis SR, Fletcher LR, Brown AJW, Hensman T, Serpa Neto A, Jones DA. Frequency of and associations with alterations of medical emergency team calling criteria in a teaching hospital emergency department. Aust Crit Care 2024; 37:301-308. [PMID: 37716882 DOI: 10.1016/j.aucc.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 07/09/2023] [Accepted: 07/13/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND Medical emergency team (METs), activated by vital sign-based calling criteria respond to deteriorating patients in the hospital setting. Calling criteria may be altered where clinicians feel this is appropriate. Altered calling criteria (ACC) has not previously been evaluated in the emergency department (ED) setting. OBJECTIVES The objectives of this study were to (i) describe the frequency of ACC in a teaching hospital ED and the number and type of vital signs that were modified and (ii) associations between ACC in the ED and differences in the baseline patient characteristics and adverse outcomes including subsequent MET activations, unplanned intensive care unit (ICU) admissions and death within 72 h of admission. METHODS Retrospective observational study of patients presenting to an academic, tertiary hospital ED in Melbourne, Australia between January 1st, 2019 and December 31st, 2019. The primary outcome was frequency and nature of ACC in the ED. Secondary outcomes included differences in baseline patient characteristics, frequency of MET activation, unplanned ICU admission, and mortality in the first 72 h of admission between those with and without ACC in the ED. RESULTS Amongst 14 159 ED admissions, 725 (5.1%) had ACC, most frequently for increased heart or respiratory rate. ACC was associated with older age and increased comorbidity. Such patients had a higher adjusted risk of MET activation (odds ratio [OR]: 3.14, 95% confidence interval [CI]: 2.50-3.91, p = <0.001), unplanned ICU admission (OR: 1.97, 95% CI: 1.17-3.14, p = 0.016), and death (OR: 3.87, 95% CI: 2.08-6.70, p = 0.020) within 72 h. CONCLUSIONS ACC occurs commonly in the ED, most frequently for elevated heart and respiratory rates and is associated with worse patient outcomes. In some cases, ACC requires consultant involvement, more frequent vital sign monitoring, expeditious inpatient team review, or ICU referral.
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Affiliation(s)
- Simon R Baylis
- Department of Intensive Care, Austin Health, Melbourne, Australia; Department of Emergency Medicine, Austin Health, Melbourne, Australia; Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia.
| | - Luke R Fletcher
- Department of Anaesthesia, Austin Health, Heidelberg Victoria, Australia; Data Analytics Research and Evaluation Centre (DARE), Austin Health and The University of Melbourne, Heidelberg, Victoria, Australia; Department of Critical Care, University of Melbourne, Australia
| | - Alastair J W Brown
- Department of Intensive Care, Austin Health, Melbourne, Australia; Department of Intensive Care, Alfred Health, Melbourne, Australia; Department of Intensive Care, St. Vincent's Hospital, Melbourne, Australia
| | - Tamishta Hensman
- Department of Intensive Care, Austin Health, Melbourne, Australia; Department of Intensive Care, Royal Children's Hospital, Melbourne, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Daryl A Jones
- Department of Intensive Care, Austin Health, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
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Kattinanon N, Liengswangwong W, Yuksen C, Phontabtim M, Damdin S, Jermsiri K. A Clinical Score for Predicting Successful Weaning from Noninvasive Positive Pressure Ventilation in Emergency Department; a Retrospective Cohort Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2023; 12:e15. [PMID: 38371444 PMCID: PMC10871050 DOI: 10.22037/aaem.v12i1.2173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Introduction Noninvasive positive pressure ventilation (NIPPV) is recognized as an efficient treatment for patients with acute respiratory failure (ARF) in emergency department (ED). This study aimed to develop a scoring system for predicting successful weaning from NIPPV in patients with ARF. Methods In this retrospective cohort study patients with ARF who received NIPPV in the ED of Ramathibodi Hospital, Thailand, between January 2020 and March 2022 were evaluated. Factors associated with weaning from NIPPV were recorded and compared between cases with and without successful weaning from NIPPV. Multivariable logistic regression analysis was used to develop a predictive model for weaning from NIPPV in ED. Results A total of 494 eligible patients were treated with NIPPV of whom 203(41.1%) were successfully weaned during the study period. Based on the multivariate analysis the successful NIPPV weaning (SNOW) score was designed with six factors before discontinuation: respiratory rate, heart rate ≤ 100 bpm, systolic blood pressure ≥ 100 mmHg, arterial pH≥ 7.35, arterial PaCO2, and arterial lactate. The scores were classified into three groups: low, moderate, and high. A score of >14.5 points suggested a high probability of successful weaning from NIPPV with a positive likelihood ratio of 3.58 (95%CI: 2.56-4.99; p < 0.001). The area under the receiver operating characteristic (ROC) curve of the model in predicting successful weaning was 0.79 (95% confidence interval (CI): 0.75-0.83). Conclusion It seems that the SNOW score could be considered as a helpful tool for predicting successful weaning from NIPPV in ED patients with ARF. A high predictive score, particularly one that exceeds 14.5, strongly suggests a high likelihood of successful weaning from NIPPV.
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Affiliation(s)
- Natthapat Kattinanon
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Thailand
| | - Wijittra Liengswangwong
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Thailand
| | - Chaiyaporn Yuksen
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Thailand
| | - Malivan Phontabtim
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Thailand
| | - Siriporn Damdin
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Thailand
| | - Khunpol Jermsiri
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Thailand
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Kaur H, Chandran VP, Rashid M, Kunhikatta V, Poojari PG, Bakkannavar SM, Balakrishnan JM, Thunga G. The significance of APACHE II as a predictor of mortality in paraquat poisoning: A systematic review and meta-analysis. J Forensic Leg Med 2023; 97:102548. [PMID: 37327568 DOI: 10.1016/j.jflm.2023.102548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 05/19/2023] [Accepted: 05/29/2023] [Indexed: 06/18/2023]
Abstract
The Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system is utilised as a prognostic method in paraquat poisoning; however, current evidence shows ambiguity. Although some studies have shown APACHE II to be a superior tool, others have reported it inferior to other prognostic markers, such as lactate, severity index of paraquat poisoning and urine paraquat concentration. Hence, to address this ambiguity, we conducted a systematic review and meta-analysis to analyse prognostic accuracy of APACHE II score in predicting mortality in paraquat poisoning. We included twenty studies with 2524 paraquat poisoned patients in the systematic review, after a comprehensive literature search in databases PubMed, Embase, Web of Science, Scopus and Cochrane Library, from which 16 studies were included in the meta-analysis. The survivors of paraquat poisoning were found to have significantly lower APACHE II scores (Mean Difference (MD): -5.76; 95% CI: -7.93 to -3.60 p < 0.0001; n = 16 studies) compared to non-survivors. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR) and diagnostic odds ratio (DOR) for APACHE II score <9 was found to be 74%, 68%, 2.58, 0.38 and 7.10, respectively (n = 5 studies). The area under the curve (AUC) of the bivariate summary receiver operating characteristic (SROC) curve was found to be 0.80. The pooled sensitivity, specificity, PLR, NLR and DOR for APACHE II score ≥9 was found to be 73%, 86%, 4.69, 0.33 and 16.42, respectively (n = 9 studies). The AUC of the SROC curve was found to be 0.89. Pairwise AUC comparison of APACHE II with other prognostic markers showed serum presepsin to have a significantly better discriminatory ability than APACHE II. Through the findings of this study, we conclude that APACHE II was found to be a good indicator of death in paraquat poisoning patients. However, higher APACHE II scores (≥9) depicted greater specificity in predicting mortality in paraquat poisoning. Thus, APACHE II can be used as a practical tool in the hand of physicians to prognose patients with paraquat poisoning to aid clinical decisions.
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Affiliation(s)
- Harsimran Kaur
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
| | - Viji Pulikkel Chandran
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
| | - Muhammed Rashid
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
| | - Vijayanarayana Kunhikatta
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
| | - Pooja Gopal Poojari
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
| | - Shankar M Bakkannavar
- Department of Forensic Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
| | - Jayaraj Mymbilly Balakrishnan
- Department of Emergency Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
| | - Girish Thunga
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
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Kang MW, Tangri N, Kwon S, Li L, Lee H, Han SS, An JN, Lee J, Kim DK, Lim CS, Kim YS, Kim S, Lee JP. Development of New Equations Predicting the Mortality Risk of Patients on Continuous RRT. KIDNEY360 2022; 3:1494-1501. [PMID: 36245653 PMCID: PMC9528377 DOI: 10.34067/kid.0000862022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 05/02/2022] [Indexed: 11/27/2022]
Abstract
BackgroundPredicting the risk of death in patients admitted to the critical care unit facilitates appropriate management. In particular, among patients who are critically ill, patients with continuous RRT (CRRT) have high mortality, and predicting the mortality risk of these patients is difficult. The purpose of this study was to develop models for predicting the mortality risk of patients on CRRT and to validate the models externally.MethodsA total of 699 adult patients with CRRT who participated in the VolumE maNagement Under body composition monitoring in critically ill patientS on CRRT (VENUS) trial and 1515 adult patients with CRRT in Seoul National University Hospital were selected as the development and validation cohorts, respectively. Using 11 predictor variables selected by the Cox proportional hazards model and clinical importance, equations predicting mortality within 7, 14, and 28 days were developed with development cohort data.ResultsThe equation using 11 variables had area under the time-dependent receiver operating characteristic curve (AUROC) values of 0.75, 0.74, and 0.73 for predicting 7-, 14-, and 28-day mortality, respectively. All equations had significantly higher AUROCs than the Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores. The 11-variable equation was superior to the SOFA and APACHE II scores in the integrated discrimination index and net reclassification improvement analyses.ConclusionsThe newly developed equations for predicting CRRT patient mortality showed superior performance to the previous scoring systems, and they can help physicians manage patients.
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Nagamine T. How to facilitate respiratory rate measurement in the emergency room. Jpn J Nurs Sci 2022; 19:e12493. [PMID: 35545839 DOI: 10.1111/jjns.12493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 04/17/2022] [Accepted: 04/19/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Takahiko Nagamine
- Sunlight Brain Research Center, Yamaguchi, Japan.,Graduate School of Medical and Dental sciences, Tokyo Medical and Dental University, Tokyo, Japan.,Department of Emergency Medicine, Matsumoto Surgical Hospital, Yamaguchi, Japan
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Simbawa JH, Jawhari AA, Almutairi F, Almahmoudi A, Alshammrani B, Qashqari R, Alattas I. The Association Between Abnormal Vital Signs and Mortality in the Emergency Department. Cureus 2021; 13:e20454. [PMID: 35047287 PMCID: PMC8760028 DOI: 10.7759/cureus.20454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 11/14/2022] Open
Abstract
Background The emergency department (ED) receives patients from all over the world every day. Hence, using various triage scales to detect sick patients and the need for early admission are essential. Triage is a process used in the ED to prioritize patients requiring the most urgent care over those with minor injuries based on medical urgency and medical needs. These decisions may be based on patients’ chief complaints at the time of their ED visit and their vital signs. Vital signs, including blood pressure (BP), respiratory rate (RR), heart rate (HR), and body temperature, are necessary tools that are traditionally used in the ED during procedures such as triage and recognizing high-risk hospital inpatients. This study aimed to determine the relationship between abnormal vital signs and mortality in the ED. Method and Material This retrospective record review study was performed at the ED of King Abdulaziz University Hospital (KAUH). Altogether, 641 patients fulfilled our inclusion criteria. Data including patients’ demographics, vital signs, in-hospital mortality, triage level, and precipitating factors were collected. Results The mean age of the patients was 45.66 ± 18.43 years (69.3% females), and the majority of them had Canadian Triage and Acuity Scale (CTAS) level 3 (71.1%). The total number of in-hospital mortalities was 32 (5%). Lower systolic blood pressure (SBP) and diastolic blood pressure (DBP), high respiratory rates, and low oxygen saturation (O2SAT) were significantly associated with high mortality rates. Conclusion Abnormal vital signs play a major role in determining patient prognosis and outcomes. Triage score systems should be adjusted and carefully studied in each center according to its population.
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Brekke IJ, Puntervoll LH, Pedersen PB, Kellett J, Brabrand M. The value of vital sign trends in predicting and monitoring clinical deterioration: A systematic review. PLoS One 2019; 14:e0210875. [PMID: 30645637 PMCID: PMC6333367 DOI: 10.1371/journal.pone.0210875] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 01/03/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Vital signs, i.e. respiratory rate, oxygen saturation, pulse, blood pressure and temperature, are regarded as an essential part of monitoring hospitalized patients. Changes in vital signs prior to clinical deterioration are well documented and early detection of preventable outcomes is key to timely intervention. Despite their role in clinical practice, how to best monitor and interpret them is still unclear. OBJECTIVE To evaluate the ability of vital sign trends to predict clinical deterioration in patients hospitalized with acute illness. DATA SOURCES PubMed, Embase, Cochrane Library and CINAHL were searched in December 2017. STUDY SELECTION Studies examining intermittently monitored vital sign trends in acutely ill adult patients on hospital wards and in emergency departments. Outcomes representing clinical deterioration were of interest. DATA EXTRACTION Performed separately by two authors using a preformed extraction sheet. RESULTS Of 7,366 references screened, only two were eligible for inclusion. Both were retrospective cohort studies without controls. One examined the accuracy of different vital sign trend models using discrete-time survival analysis in 269,999 admissions. One included 44,531 medical admissions examining trend in Vitalpac Early Warning Score weighted vital signs. They stated that vital sign trends increased detection of clinical deterioration. Critical appraisal was performed using evaluation tools. The studies had moderate risk of bias, and a low certainty of evidence. Additionally, four studies examining trends in early warning scores, otherwise eligible for inclusion, were evaluated. CONCLUSIONS This review illustrates a lack of research in intermittently monitored vital sign trends. The included studies, although heterogeneous and imprecise, indicates an added value of trend analysis. This highlights the need for well-controlled trials to thoroughly assess the research question.
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Affiliation(s)
- Idar Johan Brekke
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Peter Bank Pedersen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - John Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Guirgis FW, Puskarich MA, Smotherman C, Sterling SA, Gautam S, Moore FA, Jones AE. Development of a Simple Sequential Organ Failure Assessment Score for Risk Assessment of Emergency Department Patients With Sepsis. J Intensive Care Med 2017; 35:270-278. [PMID: 29141524 DOI: 10.1177/0885066617741284] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Sepsis-3 recommends using the quick Sequential Organ Failure Assessment (qSOFA) score followed by SOFA score for sepsis evaluation. The SOFA is complex and unfamiliar to most emergency physicians, while qSOFA is insensitive for sepsis screening and may result in missed cases of sepsis. The objective of this study was to devise an easy-to-use simple SOFA score for use in the emergency department (ED). METHODS Retrospective study of ED patients with sepsis with in-hospital mortality as the primary outcome. A simple SOFA score was derived and validated and compared with SOFA and qSOFA. RESULTS A total of 3297 patients with sepsis were included, and in-hospital mortality was 10.1%. Simple SOFA had a sensitivity and specificity of 88% and 44% in the derivation set and 93% and 44% in the validation set for in-hospital mortality, respectively. The sensitivity and specificity of qSOFA was 38% and 86% and for SOFA was 90% and 50%, respectively. There were 2760 (84%) of 3297 qSOFA-negative (<2) patients. In this group, simple SOFA had a sensitivity and specificity of 86% and 48% in the derivation set and 91% and 48% in the validation set, respectively. Sequential Organ Failure Assessment was 86% sensitive and 57% specific in qSOFA-negative patients. For all encounters, the areas under the receiver-operator characteristic curves (AUROC) were 0.82 for SOFA, 0.78 (derivation) and 0.82 (validation) for simple SOFA, and 0.68 for qSOFA. In qSOFA-negative patients, the AUROCs were 0.80 for SOFA and 0.76 (derivation) and 0.82 (validation) for simple SOFA. CONCLUSIONS Simple SOFA demonstrates similar predictive ability for in-hospital mortality from sepsis compared to SOFA. External validation of these findings is indicated.
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Affiliation(s)
- Faheem W Guirgis
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Michael A Puskarich
- Department of Emergency Medicine, University of Mississippi, Jackson, MS, USA
| | - Carmen Smotherman
- Center for Health Equity and Quality Research, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Sarah A Sterling
- Department of Emergency Medicine, University of Mississippi, Jackson, MS, USA
| | - Shiva Gautam
- Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Frederick A Moore
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Alan E Jones
- Department of Emergency Medicine, University of Mississippi, Jackson, MS, USA
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