Quick Sequential Organ Failure Assessment and Systemic Inflammatory Response Syndrome Criteria as Predictors of Critical Care Intervention Among Patients With Suspected Infection*

Abstract

Objective The Sepsis III clinical criteria for the diagnosis of sepsis rely on scores derived to predict in-hospital mortality. In this study, we introduce the novel outcome of ‘received critical care intervention (CCI)’ and investigate the related predictive performance of both the quick-Sequential Organ Failure Assessment (qSOFA) and the Systemic Inflammatory Response Syndrome (SIRS) criteria. Design This was a single center, retrospective analysis of electronic health records. Setting Tertiary care hospital in the United States. Patients Patients with suspected infection who presented to the Emergency Department (ED) and were admitted to the hospital between January 2010 and December 2014. Interventions SIRS and qSOFA scores were calculated and their relationships to the receipt of CCI and in-hospital mortality were determined. Measurement and Main Results 24,164 patients were included of whom 6,693 (27.7%) were admitted to an ICU within 48-hours. 4,453 (66.5%) patients admitted to the ICU received a CCI. Among those with qSOFA <2, 13.4% received a CCI and 3.5% died compared to 48.2% and 13.4% respectively for qSOFA ≥2. The area under the receiver operating characteristic (AUROC) was similar whether qSOFA was used to predict receipt of CCI or in-hospital mortality (0.74 [95%CI 0.73, 0.74] vs. 0.71 [0.69, 0.72]). The AUROC of SIRS for CCI (0.69) and mortality (0.66) were lower than that for qSOFA (p<0.001 for both outcomes). The sensitivity of qSOFA for predicting CCI was 38%. Conclusions ED patients with suspected infection and low qSOFA scores frequently require CCIs. The misclassification of these patients as ‘low risk,’ in combination with the low sensitivity of qSOFA ≥2, may diminish the clinical utility of the qSOFA score for patients with suspected infection in the ED.

Accuracy of the qSOFA Score and RED Sign in Predicting Critical Care Requirements in Patients with Suspected Infection in the Emergency Department: A Retrospective Observational Study

“…Several studies investigated the role of qSOFA as a screening tool in the ED. Moskowitz et al [13] compared qSOFA and systemic inflammatory response syndrome criteria in predicting the need for critical care intervention (vasopressor use, assisted ventilation, continuous insulin infusion, ≥4000 mL intravenous fluid within 12 h of ICU admission, placement of invasive catheters, or RRT) in patients with suspected infection who presented to the ED. They showed that the sensitivity of qSOFA+ was only 13% in predicting the need for critical care intervention.…”

“…Finally, qSOFA focused on the in-hospital mortality and ICU length of stay as outcomes. For initial evaluation in ED, however, screening patients requiring early critical interventions such as vasopressor use, mechanical ventilator use (MV), renal replacement therapy (RRT), or ICU admission may be more appropriate than predicting in-hospital mortality or ICU stay [13].…”

Identifying adults with sepsis, bedside tools versus administrative data: a cohort study

“…Other studies have also noted GCS as being frequently missing. 22 We considered replacing GCS with AVPU (Alert, Verbal, Pain, Unresponsive), however, although AVPU was more complete, only 6 out of 17 patients identified as having a GCS ≤ 13 had an abnormal AVPU. The limitations of AVPU in identifying people with altered mentation is reflected in its amendment within NEWS2 to ACVPU to include 'new confusion or delirium'.…”

Quick Sequential Organ Failure Assessment: Illness Severity Indicator, Clinical Decision Support Tool, or Both?*

“…In this issue of Critical Care Medicine , Moskowitz and colleagues [13] address a different concern about qSOFA—the decision to use mortality and prolonged ICU stay as the outcome. They argue that this end-point makes qSOFA purely a severity-of-illness score and, therefore, inappropriate for clinician decision-support [13, 14].…”

“…They argue that this end-point makes qSOFA purely a severity-of-illness score and, therefore, inappropriate for clinician decision-support [13, 14]. A patient’s risk for death may be low, but only because he or she received critical care intervention.…”