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

Abstract

BackgroundWe 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).MethodsThe 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.ResultsOf 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.DiscussionIn 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.ConclusionIn 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 materialThe online version of this article (doi:10.1186/s13049-017-0399-4) contains supplementary material, which is available to authorized users.

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

“…On a merged dataset of 12 555 patients from multiple EDs in Australia and The Netherlands, post hoc addition of lactate ≥2 mmol/L cut‐off to the qSOFA score resulted in improved sensitivity for identifying patients at risk for mortality or prolonged ICU stay. Our study found poor sensitivity for the qSOFA score, which is in keeping with recent prospective evaluations …”

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SOFA criteria predict infection-related in-hospital mortality in ICU patients better than SIRS criteria and the qSOFA score

“…The qSOFA score should provide a simple bedside score to identify adult patients outside the ICU with suspected infection who are likely to have poor outcomes, and an increased qSOFA should prompt clinicians to further investigate for organ dysfunction, to initiate or escalate therapy as appropriate, and to consider referral to critical care or increase the frequency of monitoring. However, we and others have shown that qSOFA does not perform well in identifying and prognosticating critical illness and sepsis in the emergency room (ER) 4. It is therefore an urgent need of prospective studies on the usefulness of qSOFA in clinical settings outside the ICU (ie, in prehospital setting, ER and at the ward).…”