Original ContributionPredictive performance of quick Sepsis-related Organ Failure Assessment for mortality and ICU admission in patients with infection at the ED☆
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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2020, Annals of Medicine and SurgeryCitation 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.
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Conflicts of interest and source of funding: None.
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These authors contributed to the work equally and should be regarded as cofirst authors.