Rationale: The 2016 definitions of sepsis included the quick Sepsisrelated Organ Failure Assessment (qSOFA) score to identify highrisk patients outside the intensive care unit (ICU).Objectives: We sought to compare qSOFA with other commonly used early warning scores. . Using the highest non-ICU score of patients, >2 SIRS had a sensitivity of 91% and specificity of 13% for the composite outcome compared with 54% and 67% for qSOFA >2, 59% and 70% for MEWS >5, and 67% and 66% for NEWS >8, respectively. Most patients met >2 SIRS criteria 17 hours before the combined outcome compared with 5 hours for >2 and 17 hours for >1 qSOFA criteria.Conclusions: Commonly used early warning scores are more accurate than the qSOFA score for predicting death and ICU transfer in non-ICU patients. These results suggest that the qSOFA score should not replace general early warning scores when risk-stratifying patients with suspected infection.

OBJECTIVE Studies in sepsis are limited by heterogeneity regarding what constitutes suspicion of infection. We sought to compare potential suspicion criteria using antibiotic and culture order combinations in terms of patient characteristics and outcomes. We further sought to determine the impact of differing criteria on the accuracy of sepsis screening tools and early warning scores. DESIGN Observational cohort study SETTING Academic center from November 2008 until January 2016 PATIENTS Hospitalized patients outside the intensive care unit (ICU) INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS Six criteria were investigated: 1) any culture; 2) blood culture; 3) any culture plus intravenous (IV) antibiotics; 4) blood culture plus IV antibiotics; 5) any culture plus IV antibiotics for at least four of seven days; and 6) blood culture plus IV antibiotics for at least four of seven days. Accuracy of the quick Sepsis-related Organ Failure Assessment (qSOFA) score, SOFA score, systemic inflammatory response system (SIRS) criteria, the National and Modified Early Earning Score (NEWS and MEWS), and the electronic Cardiac Arrest Risk Triage (eCART) score were calculated for predicting ICU transfer or death within 48 hours of meeting suspicion criteria. A total of 53,849 patients met at least one infection criteria. Mortality increased from 3% for group 1 to 9% for group 6 and percentage meeting Angus sepsis criteria increased from 20% to 40%. Across all criteria, score discrimination was lowest for SIRS (median AUC 0.60) and SOFA score (median AUC 0.62), intermediate for qSOFA (median AUC 0.65) and MEWS (median AUC 0.67), and highest for NEWS (median AUC 0.71) and eCART (median AUC 0.73). CONCLUSIONS The choice of criteria to define a potentially infected population significantly impacts on prevalence of mortality but has little impact on accuracy. SIRS was the least predictive and eCART the most predictive regardless of how infection was defined.

Medical ICU patients who developed new-onset AF experienced a 2-fold increase in the odds of in-hospital mortality and death at 60 days. Further research investigating contributing factors to new-onset AF and potential treatments is warranted.

Objective Prior research indicates off-label use is common in the intensive care unit (ICU); however the safety of off-label use has not been assessed. The study objective was to determine the incidence of adverse drug reactions (ADRs) associated with off-label use and evaluate off-label use as a risk factor for the development of ADRs in an adult ICU population. Setting Medical ICUs at three academic medical centers Patients Adult patients (age ≥ 18 years old) receiving medication therapy Interventions All administered medications were evaluated for Food and Drug Administration (FDA) approved or off-label use. Patients were assessed daily for the development of an ADR through active surveillance. Three ADR assessment instruments were used to determine the probability of an ADR resulting from drug therapy. Severity and harm of the ADR were also assessed. Cox proportional hazard regression was used to identify a set of covariates that influenced the rate of ADRs. Measurements and Main Results Overall, 1654 patient days (327 patients) and 16,391 medications were evaluated, with 43% of medications being used off-label. One hundred and sixteen ADRs were categorized dichotomously (FDA or off-label), with 56% and 44% being associated with FDA approved and off-label use, respectively. The number of ADRs for medications administered and number of harmful and severe ADRs did not differ for medications used for FDA approved or off-label use (0.74% vs 0.67%, p = 0.336; 33 vs. 31 events, p=0.567; 24 vs. 24 events, p = 0.276). Age, sex, number of high-risk medications, number of off-label medications, and severity of illness score were included in the Cox proportional hazard regression. It was found that the rate of ADRs increases by 8% for every one additional off-label medication (HR = 1.08; 95 % CI: 1.018–1.154). Conclusion While ADRs do not occur more frequently with off-label use, ADR risk increases with each additional off-label medication used.

Delays in lactate measurement are associated with delayed antibiotics and increased mortality in patients with initial intermediate or elevated lactate levels. Systematic early lactate measurement for all patients with sepsis will lead to a significant increase in lactate draws that may prompt more rapid physician intervention for patients with abnormal initial values.