Predictive performance of quick Sepsis-related Organ Failure Assessment for mortality and ICU admission in patients with infection at the ED

doi:10.1016/j.ajem.2016.06.015

The American Journal of Emergency Medicine

Volume 34, Issue 9, September 2016, Pages 1788-1793

https://doi.org/10.1016/j.ajem.2016.06.015 Get rights and content

Abstract

Objective

The objectives of this study are to investigate the performance of the quick Sepsis-related Organ Failure Assessment (qSOFA) in predicting mortality and intensive care unit (ICU) admission in patients with clinically diagnosed infection and to compare its performance with that of Mortality in Emergency Department Sepsis (MEDS), Acute Physiology and Chronic Health Evaluation (APACHE) II, and Sepsis-related Organ Failure Assessment (SOFA).

Methods

From July to December 2015, we retrospectively analyzed 477 patients clinically diagnosed with infection in the emergency department. We compared the performance of SOFA, MEDS, APACHE II, and qSOFA in predicting ICU admission and 28-day mortality.

Results

All scores were higher in nonsurvivors and ICU patients than in survivors and non-ICU patients (P< .001). The area under the receiver operating characteristic curve of qSOFA was lower than that of MEDS (0.666 vs 0.751; P< .05) and similar to that of SOFA (0.729) and APACHE II (0.732) in predicting 28-day mortality. The areas under the receiver operating characteristic curve of qSOFA, SOFA, MEDS, and APACHE II in predicting ICU admission were 0.636, 0.682, 0.661, and 0.640, respectively. There were no significant differences among the score systems. In patients with qSOFA scores less than 2 and greater than or equal to 2, 28-day mortality rates were 17.4% and 42.9% (P< .001), and ICU admission rates were 16.0% and 33.3% (P< .001).

Conclusions

Quick SOFA predicted ICU admission with similar performance to that of SOFA, MEDS, and APACHE II. Its prognostic ability was similar to that of SOFA and APACHE II but slightly inferior to that of MEDS.

Introduction

The definitions of sepsis and septic shock were recently modified in The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) [1]. A new screening tool, the quick Sepsis-related Organ Failure Assessment (qSOFA), has been recommended to evaluate sepsis in accordance with its new definition. qSOFA criteria for sepsis include a Glasgow Coma Scale score of less than or equal to 13, systolic blood pressure less than or equal to 100 mm Hg, and respiratory rate greater than or equal to 22 per minute (1 point each to yield a score value between 0 and 3) [2]. In the original retrospective qSOFA study, the area under the receiver operating characteristic (ROC) curve (AUC) for qSOFA was 0.81. This scoring system was found to perform better than full Sepsis-related Organ Failure Assessment (SOFA) (AUC, 0.79; P< .01) in predicting inhospital mortality in settings other than the intensive care unit (ICU). According to the recommendations in Sepsis-3, patients outside the ICU with a qSOFA score of greater than or equal to 2 who are suspected of having an infection should be closely monitored for sepsis and further assessed using the SOFA score.

Simplicity in calculation and close accordance with complex systems used for non-ICU settings are the main advantages of qSOFA. Furthermore, its independence from laboratory test results means that qSOFA can be calculated within a few minutes at the patient's bedside. The original qSOFA study enrolled a broad-spectrum cohort, including prehospital patients, those treated at the emergency department (ED), hospitalized patients, and those admitted to ICU. In that study, the inhospital mortality (4%-11%) was relatively low in non-ICU patients, who comprised 89% of the entire cohort, and was increased in patients admitted to the ICU (18%). The prognostic ability of qSOFA was found to be lower for ICU patients; thus, its predictive performance remains unclear in high-risk patients in the ED. In the same study, qSOFA was compared with SOFA and Logistic Organ Dysfunction Score, which were derived from critically ill ICU patients and were rarely used in non-ICU settings. Compared with SOFA and Logistic Organ Dysfunction Score, the Mortality in Emergency Department Sepsis (MEDS) is more widely used at the ED than the ICU. The MEDS score was derived from patients at the ED suspected of having an infection, and its high prognostic performance was demonstrated in predicting short- and long-term mortality [3], [4]. However, the performances of qSOFA and MEDS have not yet been compared.

The present study aimed to investigate the performance of qSOFA for predicting mortality and ICU admission in patients with clinically diagnosed infection at the ED and to compare its performance with that of MEDS, Acute Physiology and Chronic Health Evaluation (APACHE) II, and SOFA [5], [6].

Section snippets

Setting and design

The present study was a single-center, retrospective analysis of a prospective observational research database in patients with clinically diagnosed infection at the ED of Beijing Chao-Yang Hospital from July to December 2015. Our hospital is a 2000-bed teaching hospital with approximately 20 000 ED visitors per year. This study was approved by the Ethics Committee of our institution (13-ke-02/2015.01.12). All the patients gave written informed consent.

Patients

Adult patients (age, ≥ 18 years) with

Baseline information

A total of 516 patients with clinically diagnosed infection were enrolled in this study from July to December 2015. Thirty-nine patients were excluded because of incomplete data, and 477 patients were finally included. Most patients (61.8%) were male, with a median age of 73 years (60-79). The 28-day mortality and ICU admission rate of the entire cohort were 27.5% and 22.9%, respectively. Vasopressors and mechanical ventilation were used in 9.9% and 6.9% of all enrolled patients, respectively.

Study cohorts

In the present study, the 28-day mortality of the entire cohort was 27.5%, which was higher than that reported in the original qSOFA study [2]. The possible reason for the higher mortality in the present study may be the higher numbers of older patients and patients with more comorbidities and greater illness severity. The SOFA score (4 [3-7]) of the present study was also higher than the mean SOFA (1 [0-3]) of the original study. The APACHE II score (17 ± 8) and MEDS score (11 [8-16]) were

Conclusion

The performance of qSOFA in predicting ICU admission was similar to that of SOFA, MEDS, and APACHE II. The prognostic ability of qSOFA was similar to that of SOFA and APACHE II but slightly inferior to that of MEDS.

Author contributions

Conception and design: all authors. Acquisition of data: J-Y Wang, Y-X Chen, P Yang, and X Mei. Analysis and interpretation of data: J-Y Wang and Y-X Chen. Drafting the article: J-Y Wang and Y-X Chen. Critically revising the article: S-B Guo. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: S-B Guo. Study supervision: S-B Guo and X Mei.

Acknowledgments

The authors would like to thank Si-Si Ren, Xiu-Yun Weng, Jian-Yuan Tian, and Jun-Hui Wang for their help in collecting data.

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Citation Excerpt :
qSOFA has also been used to predict poor outcomes in pneumonia patients, including the need for mechanical ventilation, and has been shown to either match or outperform other outcome predictors such as SOFA, CRB, CRB-65 and the pneumonia severity index (PSI) [30,31]. Among more generally used mortality prediction scores, qSOFA has been shown to have similar predictive performance to that of Acute Physiology, Age, Chronic Health Evaluation (APACHE) II or SOFA, as evidenced by a lack of statistical difference between AUROC [32]. The MEWS and CURB-65 scores have also been validated for mortality prediction in general patient populations [33,34] and those with community-acquired pneumonia [35] or COVID-19 [36], respectively.
Prediction of patients at risk for mortality can help triage patients and assist in resource allocation.
Develop and evaluate a machine learning-based algorithm which accurately predicts mortality in COVID-19, pneumonia, and mechanically ventilated patients.
Retrospective study of 53,001 total ICU patients, including 9166 patients with pneumonia and 25,895 mechanically ventilated patients, performed on the MIMIC dataset. An additional retrospective analysis was performed on a community hospital dataset containing 114 patients positive for SARS-COV-2 by PCR test. The outcome of interest was in-hospital patient mortality.
When trained and tested on the MIMIC dataset, the XGBoost predictor obtained area under the receiver operating characteristic (AUROC) values of 0.82, 0.81, 0.77, and 0.75 for mortality prediction on mechanically ventilated patients at 12-, 24-, 48-, and 72- hour windows, respectively, and AUROCs of 0.87, 0.78, 0.77, and 0.734 for mortality prediction on pneumonia patients at 12-, 24-, 48-, and 72- hour windows, respectively. The predictor outperformed the qSOFA, MEWS and CURB-65 risk scores at all prediction windows. When tested on the community hospital dataset, the predictor obtained AUROCs of 0.91, 0.90, 0.86, and 0.87 for mortality prediction on COVID-19 patients at 12-, 24-, 48-, and 72- hour windows, respectively, outperforming the qSOFA, MEWS and CURB-65 risk scores at all prediction windows.
This machine learning-based algorithm is a useful predictive tool for anticipating patient mortality at clinically useful timepoints, and is capable of accurate mortality prediction for mechanically ventilated patients as well as those diagnosed with pneumonia and COVID-19.

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^☆: Conflicts of interest and source of funding: None.

¹: These authors contributed to the work equally and should be regarded as cofirst authors.

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Original ContributionPredictive performance of quick Sepsis-related Organ Failure Assessment for mortality and ICU admission in patients with infection at the ED☆

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Setting and design

Patients

Baseline information

Study cohorts

Conclusion

Author contributions

Acknowledgments

J Crit Care

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

JAMA

Assessment of clinical criteria for sepsis: for the Third International Consensus Definitions for Sepsis And Septic Shock (Sepsis-3)

JAMA

Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule

Crit Care Med

Mortality in Emergency Department Sepsis (MEDS) score predicts 1-year mortality

Crit Care Med

APACHE II: a severity of disease classification system

Crit Care Med

Original Contribution
Predictive performance of quick Sepsis-related Organ Failure Assessment for mortality and ICU admission in patients with infection at the ED☆