Study objective
The Quick Sequential Organ Failure Assessment (qSOFA) score (composed of respiratory rate ≥22 breaths/min, systolic blood pressure ≤100 mm Hg, and altered mental status) may identify patients with infection who are at risk of complications. We determined the association between qSOFA scores and outcomes in adult emergency department (ED) patients with and without suspected infection.
Methods
We performed a single-site, retrospective review of adult ED patients between January 2014 and March 2015. Patients triaged to fast-track, dentistry, psychiatry, and labor and delivery were excluded. qSOFA scores were calculated with simultaneous vital signs and Modified Early Warning System scores. Patients receiving intravenous antibiotics were presumed to have suspected infection. Univariate and multivariate analyses were performed to explore the association between qSOFA scores and inpatient mortality, admission, and length of stay. Receiver operating characteristics curve analysis and c statistics were also calculated for ICU admission and mortality.
Results
We included 22,530 patients. Mean age was 54 years (SD 21 years), 53% were women, 45% were admitted, and mortality rate was 1.6%. qSOFA scores were associated with mortality (0 [0.6%], 1 [2.8%], 2 [12.8%], and 3 [25.0%]), ICU admission (0 [5.1%], 1 [10.5%], 2 [20.8%], and 3 [27.4%]), and hospital length of stay (0 [123 hours], 1 [163 hours], 2 [225 hours], and 3 [237 hours]). Adjusted rates were also associated with qSOFA. The c statistics for mortality in patients with and without suspected infection were similarly high (0.75 [95% confidence interval 0.71 to 0.78) and 0.70 (95% confidence interval 0.65 to 0.74), respectively.
Conclusion
qSOFA scores were associated with inpatient mortality, admission, ICU admission, and hospital length of stay in adult ED patients likely to be admitted both with and without suspected infection and may be useful in predicting outcomes.
Introduction
Recently, a panel of experts derived and validated a novel scoring system for patients with suspected sepsis: the Quick Sequential Organ Failure Assessment (qSOFA) score. This score was calculated by assigning 1 point each for a respiratory rate greater than or equal to 22 breaths/min, systolic blood pressure less than or equal to 100 mm Hg, and any alteration in mental status. The total score was then calculated by adding the individual scores for the 3 elements. In their cohort, the ability of the qSOFA score to predict mortality was even greater than that of the more detailed SOFA score. To the best of our knowledge, this novel score has not been assessed as a generic predictive score in the overall emergency department (ED) patient population.
What is already known on this topic
The Quick Sequential Organ Failure Assessment (qSOFA) was recently introduced as an easy tool to identify infected patients with high risk of deterioration.
What question this study addressed
The association between qSOFA scores and subsequent outcome in emergency department (ED) patients both with and without infection.
What this study adds to our knowledge
In this retrospective study of 22,530 (of 67,475 eligible patients) who had sufficient data to permit analysis, increasing qSOFA scores were associated with death, ICU admission, and hospital length of stay in both infected and noninfected patients admitted to the hospital from the ED.
How this is relevant to clinical practice
This informs clinical practice by suggesting that qSOFA may be an easy and quick tool to help identify patients at risk of deterioration. However, further validation of qSOFA is important before widespread use.
The availability of a simple, generic tool that can be rapidly calculated in all ED patients, without the need for any laboratory or advanced testing, would be of great benefit to ED practitioners. We determined whether the qSOFA was predictive of poor outcomes in all ED patients both with and without suspected infection.
Materials and Methods
Study Design, Setting, and Selection of Participants
We searched the electronic ED database at a suburban academic medical center (January 2014 to March 2015) for adult (>18 years) patients for whom a qSOFA score could be calculated according to simultaneous (within 2 minutes or less) reporting of vital signs (systolic blood pressure, respiratory rate, pulse rate, temperature, and oximetry) and a Modified Early Warning System score. We excluded fast-track, dental, psychiatric, and labor and delivery patients because they are generally at low risk or managed by nonemergency practitioners. The Modified Early Warning System is a tool for nurses to help monitor their patients, allowing early detection of a sudden decline in their condition, which, in our institution, is supposed to be documented for all ED patients. The Modified Early Warning System version we used included respiratory rate, pulse rate, temperature, pulse oximetry, systolic blood pressure, and level of consciousness. The study was approved by our institutional review board and exempt from informed consent.
Maximal Modified Early Warning System scores were obtained for each patient, and vital signs (systolic blood pressure, respiratory rate, pulse rate, oximetry, and temperature) entered within 2 minutes of when the Modified Early Warning System scores were entered into the computer were identified. A “calculated” Modified Early Warning System score was determined from the vital signs, and a patient was assumed to have an altered mental status if the calculated score was less than the actual one.
Outcome Measures
The primary outcome was inhospital mortality. Secondary outcomes were hospital admission, ICU admission, and total hospital length of stay from ED triage to discharge from the hospital.
Primary Data Analysis
Descriptive statistics were used for baseline characteristics and outcomes. Univariate χ 2 tests were used to compare categorical variables, and t tests and ANOVA were used to compare continuous variables. Multivariate analyses were used to adjust for age, sex, and presence of suspected infection. Multivariate analyses included logistic regression for dichotomous outcomes (death or admission) and linear regression for continuous outcomes (length of stay). Receiver operating characteristics analysis was used to assess the predictive ability of qSOFA scores. Sensitivities, specificities, and negative predictive values were calculated for ICU admission and inhospital mortality with a cutoff of greater than 2 or greater than 1, respectively, on qSOFA scores. Planned subgroup analyses were performed separately for patients with and without suspected infection. We assigned patients to the group with suspected infection if intravenous antibiotics were administered in the ED. All analyses were performed with SPSS (version 23.0; IBM, Armonk, NY).
Materials and Methods
Study Design, Setting, and Selection of Participants
We searched the electronic ED database at a suburban academic medical center (January 2014 to March 2015) for adult (>18 years) patients for whom a qSOFA score could be calculated according to simultaneous (within 2 minutes or less) reporting of vital signs (systolic blood pressure, respiratory rate, pulse rate, temperature, and oximetry) and a Modified Early Warning System score. We excluded fast-track, dental, psychiatric, and labor and delivery patients because they are generally at low risk or managed by nonemergency practitioners. The Modified Early Warning System is a tool for nurses to help monitor their patients, allowing early detection of a sudden decline in their condition, which, in our institution, is supposed to be documented for all ED patients. The Modified Early Warning System version we used included respiratory rate, pulse rate, temperature, pulse oximetry, systolic blood pressure, and level of consciousness. The study was approved by our institutional review board and exempt from informed consent.
Maximal Modified Early Warning System scores were obtained for each patient, and vital signs (systolic blood pressure, respiratory rate, pulse rate, oximetry, and temperature) entered within 2 minutes of when the Modified Early Warning System scores were entered into the computer were identified. A “calculated” Modified Early Warning System score was determined from the vital signs, and a patient was assumed to have an altered mental status if the calculated score was less than the actual one.
Outcome Measures
The primary outcome was inhospital mortality. Secondary outcomes were hospital admission, ICU admission, and total hospital length of stay from ED triage to discharge from the hospital.
Primary Data Analysis
Descriptive statistics were used for baseline characteristics and outcomes. Univariate χ 2 tests were used to compare categorical variables, and t tests and ANOVA were used to compare continuous variables. Multivariate analyses were used to adjust for age, sex, and presence of suspected infection. Multivariate analyses included logistic regression for dichotomous outcomes (death or admission) and linear regression for continuous outcomes (length of stay). Receiver operating characteristics analysis was used to assess the predictive ability of qSOFA scores. Sensitivities, specificities, and negative predictive values were calculated for ICU admission and inhospital mortality with a cutoff of greater than 2 or greater than 1, respectively, on qSOFA scores. Planned subgroup analyses were performed separately for patients with and without suspected infection. We assigned patients to the group with suspected infection if intravenous antibiotics were administered in the ED. All analyses were performed with SPSS (version 23.0; IBM, Armonk, NY).
Results
Characteristics of Study Subjects
There were 67,475 ED adult visits meeting study criteria during the study period; 3,569 patients (5.3%) were without any Modified Early Warning System score and 41,376 (61.3%) were without independently documented vital signs within 2 minutes of entering the Modified Early Warning System, leaving 22,530 study patients, of whom 10,048 were admitted. Excluded patients were younger (50 versus 54 years) and they appeared to be less severely ill, as indicated by lower rates of hospital admission (27% versus 47%), ICU admission (3% versus 7%), and inhospital death (0.6% versus 1.6%). The mean age of the included study patients was 54 years (SD 21 years), 53% were women, 45% were admitted, 7% were admitted to an ICU, and the inhospital mortality rate was 1.6%. Intravenous antibiotics were administered in the ED to 4,149 patients (18%) who were classified as having a suspected infection. Intravenous antibiotics were not administered to the remaining 18,381 patients classified as being without a suspected infection.
Of the 22,530 study patients, 16,507 (73%) had a qSOFA score of 0, 5,290 (23%) had a score of 1, 649 (3%) had a score of 2, and 84 (0.4%) had a score of 3. The percentage of men increased with qSOFA scores (47%, 42%, 54%, and 64% for qSOFA scores 0, 1, 2, and 3, respectively), as did age (53, 56, 63, and 69 years for qSOFA scores 0, 1, 2, and 3, respectively).
Main Results
The mortality rates for the entire group of patients (both with and without suspected infection) according to qSOFA scores were 0.6% (95% confidence interval [CI] 0.5% to 0.8%), 2.8% (95% CI 2.4% to 3.3%), 12.8% (95% CI 10.4% to 15.7%), and 25.0% (95% CI 16.5% to 35.9%) for scores of 0, 1, 2, and 3, respectively ( Table ). Age (odds ratio 1.042 [95% CI 1.035 to 1.049] per year), female sex (odds ratio 0.78 [95% CI 0.63 to 0.97]), suspected infection (odds ratio 2.14 [95% CI 1.69 to 2.71]), and qSOFA (odds ratio 3.05 [95% CI 2.66 to 3.49]) were associated with mortality after adjusting for covariates ( Table ). The sensitivity and specificity of a qSOFA score greater than or equal to 2 for predicting mortality were 29% (95% CI 25% to 34%) and 97% (95% CI 97% to 97%), respectively, with a negative predictive value of 99% (95% CI 99% to 99%). A qSOFA score greater than or equal to 1 had 71% sensitivity (95% CI 66% to 76%), 74% specificity (95% CI 73% to 75%), and 99% negative predictive value (95% CI 99% to 99%).
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