Comparing Mortality Prediction by Quick Sequential Organ Failure Assessment with Emergency Physician Judgment

Abstract

Study Objective: The quick sequential organ failure assessment (qSOFA) was proposed to identify infected patients at risk for mortality, an indication of sepsis, in nonintensive care unit settings. This study tests whether qSOFA improves physician prediction of mortality among infected Emergency Department (ED) patients. Methods: We performed a secondary analysis of a prospective, observational study of potentially septic ED patients, conducted between two urban, academic medical centers, from July 2016 to December 2017. We enrolled ED patients with two or more systemic inflammatory response syndrome criteria and severe sepsis qualifying organ dysfunction, systolic blood pressure <90 mm Hg, or lactate ≥ 4.0 mmol/L. Infectious etiology was adjudicated retrospectively by paired physician review. We excluded noninfected patients. Treating ED physicians submitted judgment for in-hospital mortality (0%–100%) at hospital admission, and qSOFA was calculated retrospectively using ED data. The primary outcome was in-hospital mortality within 28 days. We used logistic regression to predict mortality using physician judgment, qSOFA, and combined physician judgment and qSOFA. To assess differences between models, 95% confidence intervals for area under the curve (AUC) were derived by bootstrapping with 1,000 iterations. Results: Of 405 patients meeting inclusion criteria, 195 (48.1%) were determined to have infection and analyzed. Of analyzed patients, 16 (8.2%) suffered in-hospital mortality within 28 days. Analyzed patients had a mean age of 58.3 (SD 16.5) years and 78 (40%) were female. qSOFA alone (AUC 0.63; 95% CI: 0.53–0.73) was not superior to unstructured physician judgment (AUC 0.80; 0.70–0.89) when predicting 28-day in-hospital mortality with mean AUC difference 0.17 (0.07–0.28) across bootstrapped datasets. Combining qSOFA with physician judgment (AUC 0.79; 0.69–0.89) did not improve performance compared with physician judgment alone. Conclusion: When predicting 28-day in-hospital mortality among infected ED patients, qSOFA did not outperform or improve physician judgment.

Predicting intensive care unit admission and death for COVID-19 patients in the emergency department using early warning scores

“…19 However, the accuracy of qSOFA was low in our study, confirming results from previous studies conducted in non-COVID potentially septic patients. 24,33,34 Notably, most patients in our cohort did not have any of the three qSOFA criteria, and none of them had a qSOFA score of 2 or higher. Among the three qSOFA criteria, the prevalence of hypotension and altered mental status on ED admission in our patient population was particularly low (6.6% and 3.3%; data not shown).…”

Quick sequential organ failure assessment score combined with other sepsis-related risk factors to predict in-hospital mortality: Post-hoc analysis of prospective multicenter study data

“…The present study findings are consistent with those of previous studies, demonstrating poor prognostic value of the qSOFA score for sepsis-related mortality despite model augmentation with other risk factors. Although, our results were not in favor of complicating qSOFA with any additional values, a prospective observational trial from the United States [20] successfully improved the qSOFA by adding the clinician's "gut feeling" for the 28-day mortality. Despite being subjective, such a prediction based on the ED physician's experience may be one of the most important surrogate markers for the patients' risk of death.…”

Mortality Prediction in Hip Fracture Patients: Physician Assessment Versus Prognostic Models

“…Multiple studies on ED patients have demonstrated an association between physician judgment and increased hospitalization, morbidity, and mortality. [41][42][43] To our knowledge, this is the first study comparing physician assessment with prognostic models for mortality in hip fracture patients. Strengths of this study include the prospective collection of data and long-term follow-up.…”

“…Multiple studies on ED patients have demonstrated an association between physician judgment and increased hospitalization, morbidity, and mortality. 41 – 43 …”