Comparison of SIRS,qSOFA, and NEWS for the early identification of sepsis in the Emergency Department

ObjectivesThe increasing use of sepsis screening in the Emergency Department (ED) and the Sepsis-3 recommendation to use the quick Sepsis-related Organ Failure Assessment (qSOFA) necessitates validation. We compared Systemic Inflammatory Response Syndrome (SIRS), qSOFA, and the National Early Warning Score (NEWS) for the identification of severe sepsis and septic shock (SS/SS) during ED triage.MethodsThis was a retrospective analysis from an urban, tertiary-care academic center that included 130,595 adult visits to the ED, excluding dispositions lacking adequate clinical evaluation (n = 14,861, 11.4%). The SS/SS group (n = 930) was selected using discharge diagnoses and chart review. We measured sensitivity, specificity, and area under the receiver-operating characteristic (AUROC) for the detection of sepsis endpoints.ResultsNEWS was most accurate for triage detection of SS/SS (AUROC = 0.91, 0.88, 0.81), septic shock (AUROC = 0.93, 0.88, 0.84), and sepsis-related mortality (AUROC = 0.95, 0.89, 0.87) for NEWS, SIRS, and qSOFA, respectively (p < 0.01 for NEWS versus SIRS and qSOFA). For the detection of SS/SS (95% CI), sensitivities were 84.2% (81.5–86.5%), 86.1% (83.6–88.2%), and 28.5% (25.6–31.7%) and specificities were 85.0% (84.8–85.3%), 79.1% (78.9–79.3%), and 98.9% (98.8–99.0%) for NEWS ≥ 4, SIRS ≥ 2, and qSOFA ≥ 2, respectively.ConclusionsNEWS was the most accurate scoring system for the detection of all sepsis endpoints. Furthermore, NEWS was more specific with similar sensitivity relative to SIRS, improves with disease severity, and is immediately available as it does not require laboratories. However, scoring NEWS is more involved and may be better suited for automated computation. QSOFA had the lowest sensitivity and is a poor tool for ED sepsis screening.     

qSOFA Has Poor Sensitivity for Prehospital Identification of Severe Sepsis and Septic Shock

Objectives: Sepsis is a common and deadly disease process for which early recognition and intervention can significantly improve clinical outcomes. Despite this, sepsis remains underrecognized and therefore undertreated in the prehospital setting. Recent recommendations by the Society of Critical Care and European Society of Intensive Care Medicine advocate use of the qSOFA (quick Sequential [Sepsis-related] Organ Failure Assessment) score in non-ICU settings to screen for septic patients at greater risk for poor outcomes. Methods: We retrospectively evaluated the sensitivity and specificity of a prehospital qSOFA score ≥ 2 for prehospital identification of patients with severe sepsis or septic shock. Emergency Department (ED) patients with confirmed or suspected infection were classified as having infection without sepsis (n = 71), sepsis (n = 38), or severe sepsis/septic shock (n = 43), where designation of severe sepsis/septic shock required evidence of end-organ dysfunction, hypoperfusion (lactate > 2), or vasopressor requirement. Results: We found that a prehospital qSOFA score ≥ 2 was 16.3% sensitive (95% CI 6.8–30.7%) and 97.3% specific (95% CI 92.1–99.4%) for patients ultimately confirmed to have severe sepsis/septic shock in the ED. Adding an additional point to the prehospital qSOFA score for a pulse > 100, nursing home residence, age > 50, or reported fever increased the sensitivity to 58.1% (95% CI 42.1–73.0%) and decreased the specificity to 78.0% (95% CI 69.0–85.4%). During their ED stay, approximately two-thirds of patients meeting severe sepsis/septic shock criteria eventually met qSOFA criteria with a sensitivity of 67.4% (95% CI 51.5–80.9) and specificity of 86.2% (95% CI 78.3–92). Failure to meet qSOFA criteria prehospital was predominantly due to a systolic blood pressure and respiratory rate that did not yet meet predetermined thresholds. Conclusions: These findings suggest that the dynamic nature of sepsis can make sensitive detection difficult in the prehospital setting, although combining qSOFA with other clinical information (age, nursing home status, fever, and tachycardia) can identify more patients with sepsis who may benefit from time critical interventions.     

qSOFA is a useful prognostic factor for 30-day mortality in infected patients fulfilling the SIRS criteria for sepsis

IntroductionThe “quick Sequential Organ Failure Assessment” (qSOFA) score is a bedside risk-stratification tool to predict the likelihood of organ dysfunction. This study evaluated the qSOFA score as a prognostic factor for 30-day mortality in emergency department (ED) patients with sepsis identified by the Systemic Inflammatory Response Syndrome (SIRS) criteria.MethodsA historical cohort study was conducted reviewing patients admitted to a single-center ED from November 1, 2013, to October 31, 2014. All patients with suspected or proven infections who fulfilled two or more SIRS criteria were included. Data of SIRS, qSOFA and baseline clinical data were obtained from triage forms and patient records.ResultsA total of 434 patients with sepsis of any severity were included. A total of 73 (16.8%) had a qSOFA score of ≥2 and were more frequently transferred to the intensive care unit (ICU) (26.0 vs. 6.7%; 95% confidence interval (CI) of the difference 8.9–29.7%) and had increased 30-day mortality (32.9 vs. 9.1%, 95% CI of the difference 12.6–35.0%) compared to patients with a qSOFA score of <2. In an adjusted logistic regression model, a qSOFA score of ≥2 was independently associated with 30-day mortality (odds ratio 4.83; 95% CI 2.11–11.02).ConclusionAlmost one third of the patients with a qSOFA score of ≥2 had died within 30 days and a qSOFA score of ≥2 was independently associated with mortality. This study indicated that qSOFA score of at least two could provide useful prognostic information for septic patients defined by the SIRS criteria.     

Sepsis Clinical Criteria in Emergency Department Patients Admitted to an Intensive Care Unit: An External Validation Study of Quick Sequential Organ Failure Assessment

Background

Quick Sequential Organ Failure Assessment (qSOFA) is a prognostic score for patients with sepsis.

National Early Warning Score Is Modestly Predictive of Care Escalation after Emergency Department-to-Floor Admission

BackgroundDecompensation on the medical floor is associated with increased in-hospital mortality.ObjectiveOur aim was to determine the accuracy of the National Early Warning Score (NEWS) in predicting early, unplanned escalation of care in patients admitted to the hospital from the emergency department (ED) compared to the Shock Index (SI) and the quick Sepsis-Related Organ Failure Assessment (qSOFA) score.MethodsWe conducted a retrospective cohort study of patients admitted directly from the ED to monitored or unmonitored beds (November 9, 2015 to April 30, 2018) in 3 hospitals. Interhospital transfers were excluded. Patient data, vital status, and bed assignment were extracted from the electronic medical record. Scores were calculated using the last set of vital signs prior to leaving the ED. Primary endpoint was in-hospital death or placement in an intermediate or intensive care unit within 24 h of admission from the ED. Scores were compared using the area under the receiver operating curve (AUROC).ResultsOf 46,018 ED admissions during the study window, 39,491 (85.8%) had complete data, of which 3.7% underwent escalation in level of care within 24 h of admission. NEWS outperformed (AUROC 0.69; 95% confidence interval [CI] 0.68–0.69) qSOFA (AUROC 0.63; 95% CI 0.62–0.63; p < 0.001) and SI (AUROC 0.60; 95% CI 0.60–0.61; p < 0.001) at predicting unplanned escalations or death at 24 h.ConclusionsThis multicenter study found NEWS was superior to the qSOFA score and SI in predicting early, unplanned escalation of care for ED patients admitted to a general medical-surgical floor.     

Comparison the accuracy of early warning scores with qSOFA and SIRS for predicting sepsis in the emergency department

IntroductionThe aims of this study were to evaluate the accuracy of early warnings scores including National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), Mortality in Emergency Department Sepsis score (MEDS), Search Out Severity score (SOS) and compare them with quick Sequential Organ Failure Assessment (qSOFA) and Systemic Inflammatory Response Syndrome (SIRS) for detecting sepsis among infected patients at the emergency department (ED).MethodsA retrospective study was conducted at ED of a university hospital. Primary outcome was sepsis defined by sepsis-2 definition. Secondary outcomes were sepsis defined by sepsis-3 definition, hospital admission and in-hospital mortality.ResultsA total of 652 (83.9%) from 777 infected patients were classified as sepsis by sepsis-2. MEWS and SOS outperformed other scores in predicting sepsis with the area under receiver operating characteristic curve (AUC) (95%CI) 0.845 (0.805–0.885) and 0.839 (0.799–0.879), followed by NEWS 0.800 (0.753–0.846), MEDS 0.608 (0.551–0.665) and qSOFA 0.657 (0.609–0.706) (p < .001 for all). MEWS ≥3 had a sensitivity of 87.7%, specificity of 69.6%, positive and negative likelihood ratio of 2.88 and 0.18 for predicting sepsis by sepsis-2. Whereas, MEDS and NEWS presented the highest AUC for predicting sepsis according to sepsis-3 (AUC 0.738 and 0.722). NEWS ≥7 predicted sepsis by sepsis-3 with 53.3% sensitivity, 80.9% specificity, 2.75 positive likelihood ratio (LR+) and 0.59 negative likelihood ratio. qSOFA had the highest LR+ of 3.69 for predicting hospital mortality.ConclusionThe early warning scores, qSOFA and SIRS had limited decision making for predicting sepsis and adverse outcomes among infected patients.     

Emergency Severity Index as a predictor of in-hospital mortality in suspected sepsis patients in the emergency department

ObjectivesTo demonstrate the accuracy, sensitivity, and specificity of the Emergency Severity Index (ESI), quick Sepsis-related Organ Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome (SIRS) criteria, and National Early Warning Score (NEWS) for predicting in-hospital mortality and intensive care unit (ICU) admission in suspected sepsis patients.MethodsA retrospective cohort study conducted at a tertiary care hospital, Thailand. Suspected sepsis was defined by a combination of (1) hemoculture collection and (2) the initiation of intravenous antibiotics therapy during the emergency department (ED) visit. The accuracy of each scoring system for predicting in-hospital mortality and ICU admission was analyzed.ResultsA total of 8177 patients (median age: 62 years, 52.3% men) were enrolled in the study, 509 (6.2%) of whom died and 1810 (22.1%) of whom were admitted to the ICU. The ESI and NEWS had comparable accuracy for predicting in-hospital mortality (AUC of 0.70, 95% confidence interval [CI] 0.68 to 0.73 and AUC of 0.73, 95% CI 0.70 to 0.75) and ICU admission (AUC of 0.75, 95% CI 0.74 to 0.76 and AUC of 0.74, 95% CI 0.72 to 0.75). The ESI level 1–2 had the highest sensitivity for predicting in-hospital mortality (96.7%), and qSOFA ≥2 had the highest specificity (86.6%).ConclusionThe ESI was accurate and had the highest sensitivity for predicting in-hospital mortality and ICU admission in suspected sepsis patients in the ED. This confirms that the ESI is useful in both ED triage and predicting adverse outcomes in these patients.     

Impact of a qSOFA-based triage procedure on antibiotic timing in ED patients with sepsis: A prospective interventional study

BackgroundIt has not been investigated whether the quick sepsis-related organ failure assessment score (qSOFA), a new bedside tool for early sepsis detection, may help accelerating antibiotic initiation in ED patients with sepsis.MethodsIn this prospective pre/post quasi-experimental single-ED study, patients admitted with a suspected bacterial infection were managed using standard triage procedures only (baseline) or in association with qSOFA (intervention, with prioritization of patients with a qSOFA ≥ 2).ResultsA total of 151/328 (46.0%) and 185/350 (52.8%) patients with definite bacterial infection met the criteria for sepsis in the baseline and intervention periods, respectively. The sensitivity and specificity of a qSOFA ≥ 2 for sepsis prediction were 17.3% (95% confidence interval [CI], 13.6%–21.7%) and 98.8% (95% CI, 97.0%–99.5%). Eleven (7.3%) and 28 (13.5%) patients with sepsis in the baseline and intervention periods received a first antibiotic dose within one hour following triage (primary endpoint, absolute difference 6.2%, 95% CI [−0.5%, 12.7%], P = 0.08). The proportions of patients with sepsis receiving a first antibiotic dose within three hours following triage (39.7% [50/151] versus 36.8% [68/185], absolute difference − 2.9%, 95% CI [−13.3%, 7.3%], P = 0.65), requiring ICU admission, or dying in the hospital were similar in both periods. The median ED occupation rate at triage was 104.3% (interquartile range [IQR], 80.4%–128.3%), with a median number of 157 ED visits per day (IQR, 147–169).ConclusionsA qSOFA-based triage procedure does not improve antibiotic timing and outcomes in patients with sepsis admitted to a high-volume ED. The qSOFA value at triage was poorly sensitive for early sepsis detection.Trial registration (ClinicalTrials.gov): NCT03299894.     

Comparison of QSOFA score and SIRS criteria as screening mechanisms for emergency department sepsis

Objectives

The Quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) score has been shown to accurately predict mortality in septic patients and is part of recently proposed diagnostic criteria for sepsis. We sought to ascertain the sensitive of the score in diagnosing sepsis, as well as the diagnostic timeliness of the score when compared to traditional systemic inflammatory response syndrome (SIRS) criteria in a population of emergency department (ED) patients treated in the ED, admitted, and subsequently discharged with a diagnosis of sepsis.

Performance of a quick sofa-65 score as a rapid sepsis screening tool during initial emergency department assessment: A propensity score matching study

PurposeWe sought to elucidate the performance of a Quick Sequential Organ Function Assessment-65 (qSOFA-65) score in recognizing sepsis and to compare the qSOFA-65 score to systemic inflammatory response syndrome (SIRS) and qSOFA scores.MethodsWe performed a matched case-control study using propensity score matching. The number of patients meeting qSOFA-65, qSOFA, and SIRS positive criteria were calculated between the sepsis and non-sepsis groups. We compared the diagnostic performance of the three scoring systems in predicting sepsis.ResultsA total of 2441 patients were included in the study. In propensity matched cohorts, the percentage of patients who met qSOFA-65, qSOFA, and SIRS positive criteria were 46.7%, 14.3%, and 55.6%, respectively. The sensitivity and specificity scores for the qSOFA-65, qSOFA, and SIRS positive criteria for sepsis were 0.66 and 0.73, 0.28 and 0.97, and 0.66 and 0.55, respectively. The AUC value of qSOFA-65 positive criteria in predicting sepsis was significantly higher than that of qSOFA and SIRS positive criteria (adjusted AUC 0.688 vs. 0.630 vs. 0.596, respectively).ConclusionsWe found that qSOFA-65 was more likely to identify patients with sepsis on the initial ED visit relative to qSOFA or SIRS. This may have quality improvement implications in predicting sepsis.     

Comparison of qSOFA,SIRS, and NEWS scoring systems for diagnosis,mortality, and morbidity of sepsis in emergency department

PurposeThis study was aimed to compare the quick Sequential Organ Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome (SIRS), and National Early Warning Score (NEWS) scoring systems for diagnosing sepsis and predicting mortality and morbidity.Patients and methodsA prospective study was designed. qSOFA, SIRS, and NEWS scores were calculated at the admission. The diagnosis of sepsis was made with SOFA scoring initially. The morbidity and mortality of the patients were identified during follow-up. Also, the sensitivity, specificity, negative predictive value, and positive predictive value of three scoring systems were calculated. The scoring systems were compared with ROC analysis.ResultsA total of 463 patients were evaluated. There were 287 (62.0%) patients diagnosed with sepsis, and septic shock occurred in 64 (13.8%) of patients. Seven-day mortality rate was 8.4% (n = 39), 30-day mortality rate was 18.1% (n = 84). The sensitivity for qSOFA, SIRS, and NEWS for diagnosis of sepsis was 23%, 77%, 58%, and specificity was 99%, 35%, 81% respectively. The sensitivity of the qSOFA, SIRS and NEWS scoring systems for mortality was 39%, 82%, 77% and specificity 91%, 29%, and 64%, respectively. AUROC values for mortality detected as NEWS = 0.772, qSOFA = 0.758, SIRS = 0.542. According to the ROC analysis, the SIRS system was significantly less useful than the qSOFA and NEWS system in the diagnosis of sepsis and mortality (p < 0.0001).ConclusionNEWS and qSOFA scoring systems have similar prognosis in both diagnosing sepsis and predicting mortality and both are superior to SIRS.     

Pre-hospital qSOFA as a predictor of sepsis and mortality

BackgroundThe quick sequential organ failure assessment score (qSOFA) has been proposed as a simple tool to identify patients with sepsis who are at risk for poor outcomes. Its utility in the pre-hospital setting has not been fully elucidated.MethodsThis is a retrospective observational study of adult patients arriving by ambulance in September 2016 to an academic emergency department in Fresno, California. The qSOFA score was calculated from pre-hospital vital signs. We investigated its association with sepsis, ED diagnosis of infection, and mortality.ResultsOf 2292 adult medical patients transported by ambulance during the study period, the sensitivity of qSOFA for sepsis and in-hospital mortality were 42.9% and 40.6%, respectively. Specificity of qSOFA for sepsis and mortality were 93.8% and 91.9%, respectively. Of those with an ED diagnosis of infection compared to all patients, qSOFA was more specific but less sensitive for sepsis. Increasing qSOFA score was associated with a discharge diagnosis of sepsis (OR 4.21, 95% CI 3.41–5.21, p < 0.001), in-hospital mortality (OR 3.30, 95% CI 2.28–4.78, p < 0.001), and ED diagnosis of infection (OR 1.37, 95% CI 1.18–1.58, p < 0.001). Higher qSOFA score was associated with triage to a higher acuity zone and longer hospital and ICU length of stay, but not up-triage during ED stay.ConclusionsPre-hospital qSOFA is specific, but poorly sensitive, for sepsis and sepsis outcomes, especially among patients with an ED diagnosis of infection. Higher qSOFA score was associated with worse outcomes.     

Prognostic accuracy of qSOFA at triage in patients with suspected infection in a Brazilian emergency department

ObjectiveTo evaluate the prognostic accuracy of qSOFA for predicting in-hospital mortality among patients with suspected infection presenting to the ED of a public tertiary hospital in Brazil.MethodsWe performed a retrospective cohort study of consecutive adult patients (age ≥ 18 years) with suspected infection who presented to an academic tertiary ED in Porto Alegre (Southern Brazil) during an 18-month period. The qSOFA was calculated by using information collected at triage and patients were followed throughout hospitalization for the primary outcome of in-hospital mortality. Sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratios with corresponding 95% CIs were calculated for the qSOFA and qSOFA65.ResultsA total of 7523 ED visits of patients with suspected infection in which an intravenous antibiotic was administered within 24 h were included, which resulted in 908 in-hospital deaths (12.1%). There were 690 (9.2%) patients whose triage qSOFA was ≥2 points. When such cutoff was used, the sensitivity for in-hospital death was 24.6% (95% CI 21.8 to 27.4%) and the specificity was 92.9% (95% CI 92.3% to 93.5%). The sensitivity increased to 67.4% (95% CI 64.2% to 70.3%) when a cutoff of ≥1 was tested, but the specificity decreased to 55.3% (95% CI 54.1% to 56.5%). Using a cutoff of ≥2, the qSOFA65 had a sensitivity of 51.0% (95% CI 47.7% to 54.3%) and a specificity of 75.7% (95% CI 74.6% to 76.7%).ConclusionsThe qSOFA score yielded very low sensitivity in predicting in-hospital mortality. Emergency physicians or ED triage nurses in low-to-middle income countries should not be using qSOFA or qSOFA65 as “rule-out” screening tools in the initial evaluation of patients with suspected infection.     

The role of the quick sequential organ failure assessment score (qSOFA) and modified early warning score (MEWS) in the pre-hospitalization prediction of sepsis prognosis

ObjectiveMany biomarkers and scoring systems to make clinical predictions about the prognosis of sepsis have been investigated. In this study, we aimed to assess the use of the quick sequential organ failure assessment score (qSOFA) and modified early warning score (MEWS) scoring systems in emergency health care services for sepsis to predict intensive care hospitalization and 28-day mortality.MethodPatients who arrived by ambulance at the Emergency Department (ED) of Dışkapı YıldırımBeyazıt Training and Research Hospital between January 2017 and December 2019, and who were diagnosed with sepsis and admitted to the hospital were included in the study. Demographic data and physiological parameters from 112 ambulance case delivery forms were recorded.QSOFA and MEWS scores were calculated from vital parameters.ResultsOf the 266 patients diagnosed with sepsis, 50% (n = 133) were female, and the mean age was 74.8 ± 13. The difference between the rate of intensive care (ICU) hospitalization and mortality for patients with a high MEWS and qSOFA score and patients whose MEWS and qSOFA score were lower was found to be statistically significant (p < 0.05). Thus, the criteria for MEWS and qSOFA could determine ICU hospitalization and early mortality. Those with a high MEWS value had a mortality rate approximately 1.24 times higher than those with a low MEWS value (p < 0.001, 95% CI: 1.110–1.385), while those with a high qSOFA score had a mortality rate approximately 2.0 times higher than those with a low qSOFA score (p < 0.001, 95% CI: 1.446–2.693). Those with a high MEWS were 1.34 times more likely than hose with a lower MEWS to require ICU hospitalization (p < 0.001, 95% CI: 1.1773–1.5131), while patients with a high qSOFA score were 3.21 times more likely than those with a lower qSOFA score to require ICU care (p < 0.001, 95% CI: 2.2289–4.6093).ConclusionAlthough qSOFA and MEWS are clinical scores used to identify septic patients outside the critical care unit, we believe that patients already diagnosed with sepsis can be assessed with qSOFA and MEWS prior to hospitalization to predict intensive care hospitalization and mortality. qSOFA was found be more valuable than MEWS in determining the prognosis of pre-hospitalization sepsis.     

Combining qSOFA criteria with initial lactate levels: Improved screening of septic patients for critical illness

ObjectiveTo determine if the addition of lactate to Quick Sequential Organ Failure Assessment (qSOFA) scoring improves emergency department (ED) screening of septic patients for critical illness.MethodsThis was a multicenter retrospective cohort study of consecutive adult patients admitted to the hospital from the ED with infectious disease-related illnesses. We recorded qSOFA criteria and initial lactate levels in the first 6 h of ED stay. Our primary outcome was a composite of hospital death, vasopressor use, and intensive care unit stay ≤72 h of presentation. Diagnostic test characteristics were determined for: 1) lactate levels ≥2 and ≥4; 2) qSOFA scores ≥1, ≥2, and =3; and 3) combinations of these.ResultsOf 3743 patients, 2584 had a lactate drawn ≤6 h of ED stay and 18% met the primary outcome. The qSOFA scores were ≥1, ≥2, and =3 in 59.2%, 22.0%, and 5.3% of patients, respectively, and 34.4% had a lactate level ≥2 and 7.9% had a lactate level ≥4. The combination of qSOFA ≥1 OR Lactate ≥2 had the highest sensitivity, 94.0% (95% CI: 91.3–95.9).ConclusionsThe combination of qSOFA ≥1 OR Lactate ≥2 provides substantially improved sensitivity for the screening of critical illness compared to isolated lactate and qSOFA thresholds.     

The quick sequential organ failure assessment (qSOFA) identifies septic patients in the out-of-hospital setting

Background

Recently a multispecialty, multinational task force convened to redefine the criteria for organ dysfunction, sepsis, severe sepsis, and septic shock. The study recommended the quick sequential organ failure assessment (qSOFA) score to identify sepsis patients. The qSOFA is felt to be the initial screen to prompt a more in-depth sepsis workup. This may be particularly true in resource-limited environments such as the prehospital arena.

Triage of Septic Patients Using qSOFA Criteria at the SAMU Regulation: A Retrospective Analysis

Purpose: One of the major prognostic factors in the management of sepsis is the early initiation of appropriate treatment. To serve this purpose, early identification and triage of patients are crucial steps, which are still not optimal. The objective of this study was to determine whether the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) score is an accurate method for prehospital triaging of septic patients. We evaluated whether the use of qSOFA criteria collected by the Service Mobile d'Urgence et de Réanimation 15 (SAMU 15) regulation call center during prehospital care would facilitate appropriate intensive care unit (ICU) admission of patients with septic syndromes. Methods: We conducted a retrospective observational register-based study using data collected between April 01 and May 31 2011. These data are based on call registry reports of calls received by the Paris Emergency regulation call centre during prehospital management of patients. All patients with suspected infection were included in the study and evaluated using qSOFA and systemic inflammatory response syndrome (SIRS) criteria. The primary outcome was Intensive Care Unit (ICU) admission. Results: Among the 30 642 reports received, 141 patients with presumed sepsis were included. Twenty-two patients were admitted to an ICU. The qSOFA and SIRS scores were the same in predicting admission to an ICU (p = 0.26). The qSOFA had a sensitivity of 75% and a specificity of 68% for ICU admission whereas the SIRS had a sensitivity of 87% and a specificity of 43%. At day 28, 12 patients (9%) had died, 5 of them in the ICU. The negative predictive value reached 93% and 94% for pre-hospital qSOFA and SIRS respectively. Pre-hospital systolic blood pressure (SBP) ≤100 mmHg was significantly associated with ICU admission (OR = 4.19 [1.89–9.84]), while all other criteria were not. Conclusion: The current study reports no difference between the SIRS and the qSOFA scores for prehospital triage of septic patients to predict ICU admission. Both scores have comparable, pertinent, negative predictive value for ICU admission. Nevertheless, an improved score for pre-hospital triaging is needed to predict ICU admission of septic patients.     

Clinical prediction rule is more useful than qSOFA and the Sepsis-3 definition of sepsis for screening bacteremia

BackgroundClinical guidelines recommend blood cultures for patients suspected with sepsis and bacteremia. Sepsis-3 task force introduced the new definition of sepsis in 2016; however, the relationship between the Sepsis-3 definition of sepsis and bacteremia remains unclear. This study aimed to investigate how to detect patients who need blood cultures.MethodsConsecutive patients who visited the emergency department in our hospital with suspected symptoms of bacterial infection and with collected blood culture were retrospectively examined between April and September 2019. The relationship between bacteremia and Sepsis-3 definition of sepsis, and the relationship between bacteremia and clinical scores (quick-Sequential Organ Failure Assessment [qSOFA], systematic inflammatory response syndrome [SIRS], and Shapiro's clinical prediction rule) were investigated. In any scores used, ≥2 points were considered positive.ResultsAmong the 986 patients who met the inclusion criteria, 171 (17%) were complicated with bacteremia and 270 (27%) were patients with sepsis. Sepsis was more frequent (61% vs. 20%, P < 0.001) and all clinical scores were more frequently positive in patients with bacteremia than in those without (qSOFA, 23% vs. 9%; SIRS, 72% vs. 58%; Shapiro's clinical prediction rule, 88% vs. 49%; P < 0.001). Specificity to predict bacteremia was high in sepsis and positive qSOFA (0.80 and 0.91, respectively), whereas sensitivity was high in positive SIRS and Shapiro's clinical prediction rule (0.72 and 0.88, respectively); however, no clinical definitions and scores had both high sensitivity and specificity. The area under the receiver operating characteristic curves were 0.59 (95% confidence interval, 0.55–0.64), 0.60 (0.56–0.65), and 0.78 (0.74–0.82) in qSOFA, SIRS, and Shapiro's clinical prediction rule, respectively.ConclusionBlood cultures should be obtained for patients with sepsis and positive qSOFA because of its high specificities to predict bacteremia; however, because of low sensitivities, Shapiro's clinical prediction rule can be more efficiently used for screening bacteremia.     

Association of ischemia modified albumin with mortality in qSOFA positive sepsis patients by sepsis-3 in the emergency department

BackgroundThe early detection and treatment of sepsis and septic shock patients in emergency departments are critical. Ischemia modified albumin (IMA) is a biomarker produced by ischemia and oxygen free radicals which are related to the pathogenesis of sepsis-induced organ dysfunction. This study aimed to investigate whether IMA was associated with short-term mortality in quick sequential organ failure assessment (qSOFA)-positive sepsis or septic shock patients screened by the sepsis management program.MethodFrom September 2019 to April 2020, patients who arrived at the emergency departments with qSOFA-positive sepsis or septic shock were included in this retrospective observational study.ResultsAmong 124 patients analyzed, IMA was higher in the non-surviving group than in the surviving group (92.6 ± 8.1 vs. 86.8 ± 6.2 U/mL, p < 0.001). The area under the receiver operating characteristics curve was 0.703 (95% CI: 0.572–0.833, p < 0.001). The optimal IMA cutoff was 90.45 (sensitivity 60.9%, specificity 79.2%). IMA values were independently associated with 28-day mortality in the multivariate Cox proportional hazard model (adjusted hazard ratio (aHR) = 1.16, 95% CI: 1.06–1.27, p < 0.01).ConclusionsIn this study, we showed that IMA in the emergency departments was associated with 28-day mortality in qSOFA-positive sepsis and septic shock patients. Further studies are needed to evaluate the clinical value of IMA as a useful biomarker in large populations and multicenter institutions.     

Can corticosteroids reduce the mortality of patients with severe sepsis? A systematic review and meta-analysis

BackgroundThe effects of corticosteroids on clinical outcomes of patients with sepsis remains controversial. We aimed to further determine the effectiveness of corticosteroids in reducing mortality in adult patients with severe sepsis by comparison with placebo.MethodsPubmed, Embase, Medline, Cochrane Central Register of Controlled Trials (CENTRAL) as well as the Information Sciences Institute (ISI) Web of Science were searched for all controlled studies that compared corticosteroids and placebo in adult patients with severe sepsis. The primary outcome was the mortality 28-day mortality and the secondary outcomes were mortality at longest follow up, occurrence, and reoccurrence of septic shock.ResultsA total of 19 trials involving 7035 patients were pooled in our final analyses. No significant heterogeneity was found in any of the outcome measures. Compared with placebo, corticosteroids were associated with a lower 28-day mortality (RR 0.91, 95% CI 0.85–0.98, Z = 2.57, P = 0.01) both in patients having sepsis and in those who developed septic shock (RR 0.92, 95% CI 0.85–0.99, Z = 2.19, P = 0.03), while no significant difference was found in mortality with the longest follow up in patients either having sepsis (RR 0.94, 95% CI 0.89–1.00, Z = 1.93, P = 0.05), or occurrence (RR 0.83, 95% CI 0.56–1.24, Z = 0.90, P = 0.37) or reoccurrence of septic shock (RR 1.08, 95% CI 1.00–1.16, Z = 1.89, P = 0.06).ConclusionsCorticosteroids were effective in reducing the 28-day mortality in patients with severe sepsis and in those with septic shock.