Accuracy of a Modified qSOFA Score for Predicting Critical Care Admission in Febrile Children

Abstract

BACKGROUND AND OBJECTIVES: The identification of life-threatening infection in febrile children presenting to the emergency department (ED) remains difficult. The quick Sequential Organ Failure Assessment (qSOFA) was only derived for adult populations, implying an urgent need for pediatric scores. We developed and validated a novel, adapted qSOFA score (Liverpool quick Sequential Organ Failure Assessment [LqSOFA]) and compared its performance with qSOFA, Pediatric Early Warning Score (PEWS), and National Institute for Health and Care Excellence (NICE) high-risk criteria in predicting critical care (CC) admission in febrile children presenting to the ED. METHODS: The LqSOFA (range, 0-4) incorporates age-adjusted heart rate, respiratory rate, capillary refill, and consciousness level on the Alert, Voice, Pain, Unresponsive scale. The primary outcome was CC admission within 48 hours of ED presentation, and the secondary outcome was sepsisrelated mortality. LqSOFA, qSOFA, PEWS, and NICE high-risk criteria scores were calculated, and performance characteristics, including area under the receiver operating characteristic curve, were calculated for each score. RESULTS: In the initial (n = 1121) cohort, 47 CC admissions (4.2%) occurred, and in the validation (n = 12 241) cohort, 135 CC admissions (1.1%) occurred, and there were 5 sepsis-related deaths. In the validation cohort, LqSOFA predicted CC admission with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval [CI], 0.76 to 0.86), versus qSOFA (0.66; 95% CI, 0.60 to 0.71), PEWS (0.93; 95% CI, 0.90 to 0.95), and NICE high-risk criteria (0.81; 95% CI, 0.78 to 0.85). For predicting CC admission, the LqSOFA outperformed the qSOFA, with a net reclassification index of 10.4% (95% CI, 1.0% to 19.9%). CONCLUSIONS: In this large study, we demonstrate improved performance of the LqSOFA over qSOFA in identifying febrile children at risk for CC admission and sepsis-related mortality. Further validation is required in other settings. WHAT'S KNOWN ON THIS SUBJECT: The quick Sequential Organ Failure Assessment has been shown to more accurately predict mortality or ICU transfer than systemic inflammatory response syndrome or the quick Pediatric Logistic Organ Dysfunction-2 in an emergency department population, but with only moderate prognostic accuracy. WHAT THIS STUDY ADDS: In this retrospective study of .12 000 febrile children, the Liverpool quick Sequential Organ Failure Assessment outperforms the quick Sequential Organ Failure Assessment in predicting critical care admission. Liverpool quick Sequential Organ Failure Assessment is a rapid bedside tool that should undergo implementation testing.

Performance of seven different paediatric early warning scores to predict critical care admission in febrile children presenting to the emergency department: a retrospective cohort study

“…We have previously developed such a score, the Liverpool quick Sequential Organ Failure Assessment (LqSOFA) and demonstrated its ability to identify those children at risk of poorer outcomes within a febrile ED cohort. 27 Compared with the AH PEWS, the LqSOFA was less discriminative (AUC 0.93 vs 0.81). 27 However, the LqSOFA has the advantage of using fewer parameters (four vs eight), which are measured easily and consistently, while still achieving good discrimination.…”

“… 27 Compared with the AH PEWS, the LqSOFA was less discriminative (AUC 0.93 vs 0.81). 27 However, the LqSOFA has the advantage of using fewer parameters (four vs eight), which are measured easily and consistently, while still achieving good discrimination. This means it may be ideally suited for settings where BP measurement is inconsistent or impossible, such as prehospital, and resource-poor settings, but the LqSOFA requires further validation in these settings.…”

“…Details of the cohort have been previously published. 27 Patients were identified retrospectively from the electronic patient record (EPR) by reviewing eligible ED attendances and critical care (CC) admissions across this 2-year period. Cases were excluded if there was missing observation data, age ≥16 years, no history of fever or patients transferred from another hospital.…”

Shock Index in the early assessment of febrile children at the emergency department: a prospective multicentre study

“…Physiologically based scores have been developed for the early recognition of disease severity in children including scores as quick Sequential Organ Failure Assessment (qSOFA), quick Paediatric Logistic Organ Dysfunction-2 (qPELOD-2) and Liverpool qSOFA (LqSOFA). [34][35][36][37] In previous ED studies, these scores showed high specificity but low sensitivity for serious illness. 36 37 LqSOFA is based on heart rate and capillary refill time as haemodynamic parameters, whereas qSOFA and qPELOD-2 both require BP measurement.…”

Laboratory Markers in the Management of Pediatric Polytrauma: Current Role and Areas of Future Research

“…Besides the prognostic value of CRP after trauma, increased CRP levels in febrile children in the emergency department should also initiate further infection diagnostics such as blood culture and smear tests. Furthermore, the Pediatric Early Warning Score (PEWS) and National Institute for Health and Care Excellence (NICE) or the Liverpool quick Sequential Organ Failure Assessment (LqSOFA) (25) are applied in children with acute febrile illness in the pediatric emergency department in order to identify life-threatening infection.…”