Comparison of different versions of the quick sequential organ failure assessment for predicting in-hospital mortality of sepsis patients: A retrospective observational study

doi:10.5847/wjem.j.1920-8642.2022.027

Abstract

Abstract:

BACKGROUND: The quick sequential organ failure assessment (qSOFA) is recommended to identify sepsis and predict sepsis mortality. However, some studies have recently shown its poor performance in sepsis mortality prediction. To enhance its effectiveness, researchers have developed various revised versions of the qSOFA by adding other parameters, such as the lactate-enhanced qSOFA (LqSOFA), the procalcitonin-enhanced qSOFA (PqSOFA), and the modified qSOFA (MqSOFA). This study aimed to compare the performance of these versions of the qSOFA in predicting sepsis mortality in the emergency department (ED).
METHODS: This retrospective study analyzed data obtained from an electronic register system of adult patients with sepsis between January 1 and December 31, 2019. Receiver operating characteristic (ROC) curve analyses were performed to determine the area under the curve (AUC), with sensitivity, specificity, and positive and negative predictive values calculated for the various scores.
RESULTS: Among the 936 enrolled cases, there were 835 survivors and 101 deaths. The AUCs of the LqSOFA, MqSOFA, PqSOFA, and qSOFA were 0.740, 0.731, 0.712, and 0.705, respectively. The sensitivity of the LqSOFA, MqSOFA, PqSOFA, and qSOFA were 64.36%, 51.40%, 71.29%, and 39.60%, respectively. The specificity of the four scores were 70.78%, 80.96%, 61.68%, and 91.62%, respectively. The LqSOFA and MqSOFA were superior to the qSOFA in predicting in-hospital mortality.
CONCLUSIONS: Among patients with sepsis in the ED, the performance of the PqSOFA was similar to that of the qSOFA and the values of the LqSOFA and MqSOFA in predicting in-hospital mortality were greater compared to qSOFA. As the added parameter of the MqSOFA was more convenient compared to the LqSOFA, the MqSOFA could be used as a candidate for the revised qSOFA to increase the performance of the early prediction of sepsis mortality.

Key words: Quick sequential organ failure assessment, In-hospital mortality, Sepsis, Lactate- enhanced qSOFA, Modified qSOFA

Hai Hu, Jing-yuan Jiang, Ni Yao. Comparison of different versions of the quick sequential organ failure assessment for predicting in-hospital mortality of sepsis patients: A retrospective observational study[J]. World Journal of Emergency Medicine, 2022, 13(2): 114-119.

Figures/Tables 5

Figure 1.

Table 1

Table 2

Figure 2.

Table 3

References 35

1	Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016; 315(8):801-10. doi: 10.1001/jama.2016.0287
2	Vincent JL, Marshall JC, Namendys-Silva SA, François B, Martin-Loeches I, Lipman J, et al. Assessment of the worldwide burden of critical illness: the intensive care over nations (ICON) audit. Lancet Respir Med. 2014; 2(5):380-6. doi: 10.1016/S2213-2600(14)70061-X
3	Fleischmann C, Scherag A, Adhikari NK, Hartog CS, Tsaganos T, Schlattmann P, et al. Assessment of global incidence and mortality of hospital-treated sepsis. Current estimates and limitations. Am J Respir Crit Care Med. 2016; 193(3):259-72. doi: 10.1164/rccm.201504-0781OC
4	Iwashyna TJ, Ely EW, Smith DM, Langa KM. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA. 2010; 304(16):1787-94. doi: 10.1001/jama.2010.1553
5	Shu E, Ives Tallman C, Frye W, Boyajian JG, Farshidpour L, Young M, et al. Pre-hospital qSOFA as a predictor of sepsis and mortality. Am J Emerg Med. 2019; 37(7):1273-8. doi: 10.1016/j.ajem.2018.09.025
6	Song JU, Sin CK, Park HK, Shim SR, Lee J. Performance of the quick sequential (sepsis-related) organ failure assessment score as a prognostic tool in infected patients outside the intensive care unit: a systematic review and meta-analysis. Crit Care. 2018; 22(1):28. doi: 10.1186/s13054-018-1952-x
7	Maitra S, Som A, Bhattacharjee S. Accuracy of quick sequential organ failure assessment (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria for predicting mortality in hospitalized patients with suspected infection: a meta-analysis of observational studies. Clin Microbiol Infect. 2018; 24(11):1123-9. doi: 10.1016/j.cmi.2018.03.032
8	Liu YC, Luo YY, Zhang X, Shou ST, Gao YL, Lu B, et al. Quick sequential organ failure assessment as a prognostic factor for infected patients outside the intensive care unit: a systematic review and meta-analysis. Intern Emerg Med. 2019; 14(4):603-15. doi: 10.1007/s11739-019-02036-0
9	Fernando SM, Tran A, Taljaard M, Cheng W, Rochwerg B, Seely AJE, et al. Prognostic accuracy of the quick sequential organ failure assessment for mortality in patients with suspected infection: a systematic review and meta-analysis. Ann Intern Med. 2018; 168(4):266-75. doi: 10.7326/M17-2820 pmid: 29404582
10	Liu SJ, He CQ, He W, Jiang T. Lactate-enhanced-qSOFA (LqSOFA) score is superior to the other four rapid scoring tools in predicting in-hospital mortality rate of the sepsis patients. Ann Transl Med. 2020; 8(16):1013. doi: 10.21037/atm
11	Xia YQ, Zou LQ, Li DZ, Qin Q, Hu H, Zhou YW, et al. The ability of an improved qSOFA score to predict acute sepsis severity and prognosis among adult patients. Medicine (Baltimore). 2020; 99(5):e18942. doi: 10.1097/MD.0000000000018942
12	Guarino M, Gambuti E, Alfano F, de Giorgi A, Maietti E, Strada A, et al. Predicting in-hospital mortality for sepsis: a comparison between qSOFA and modified qSOFA in a 2-year single-centre retrospective analysis. Eur J Clin Microbiol Infect Dis. 2021; 40(4):825-31. doi: 10.1007/s10096-020-04086-1
13	Hu H, Yao N, Qiu YR. Predictive value of 5 early warning scores for critical COVID-19 patients. Disaster Med Public Health Prep. 2020:1-8.
14	DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics. 1988; 44(3):837-45. pmid: 3203132
15	Waligora G, Gaddis G, Church A, Mills L. Rapid systematic review: the appropriate use of quick sequential organ failure assessment (qSOFA) in the emergency department. J Emerg Med. 2020; 59(6):977-83. doi: 10.1016/j.jemermed.2020.06.043
16	Perman SM, Mikkelsen ME, Goyal M, Ginde A, Bhardwaj A, Drumheller B, et al. The sensitivity of qSOFA calculated at triage and during emergency department treatment to rapidly identify sepsis patients. Sci Rep. 2020; 10(1):20395. doi: 10.1038/s41598-020-77438-8 pmid: 33230117
17	Hwang SY, Jo IJ, Lee SU, Lee TR, Yoon H, Cha WC, et al. Low accuracy of positive qSOFA criteria for predicting 28-day mortality in critically ill septic patients during the early period after emergency department presentation. Ann Emerg Med. 2018; 71(1):1-9.e2.
18	Moskowitz A, Patel PV, Grossestreuer AV, Chase M, Shapiro NI, Berg K, et al. Quick sequential organ failure assessment and systemic inflammatory response syndrome criteria as predictors of critical care intervention among patients with suspected infection. Crit Care Med. 2017; 45(11):1813-9. doi: 10.1097/CCM.0000000000002622 pmid: 28759474
19	Askim Å, Moser F, Gustad LT, Stene H, Gundersen M, Åsvold BO, et al. Poor performance of quick-SOFA (qSOFA) score in predicting severe sepsis and mortality - a prospective study of patients admitted with infection to the emergency department. Scand J Trauma Resusc Emerg Med. 2017; 25(1):56. doi: 10.1186/s13049-017-0399-4
20	Huson MA, Kalkman R, Grobusch MP, van der Poll T. Predictive value of the qSOFA score in patients with suspected infection in a resource limited setting in Gabon. Travel Med Infect Dis. 2017; 15:76-7. doi: 10.1016/j.tmaid.2016.10.014
21	Donnelly JP, Safford MM, Shapiro NI, Baddley JW, Wang HE. Application of the Third International Consensus Definitions for Sepsis (Sepsis-3) Classification: a retrospective population-based cohort study. Lancet Infect Dis. 2017; 17(6):661-70. doi: S1473-3099(17)30117-2 pmid: 28268067
22	Forward E, Konecny P, Burston J, Adhikari S, Doolan H, Jensen T. Predictive validity of the qSOFA criteria for sepsis in non-ICU inpatients. Intensive Care Med. 2017; 43(6):945-6. doi: 10.1007/s00134-017-4776-2 pmid: 28357459
23	Oduncu AF, Kıyan GS, Yalçınlı S. Comparison of qSOFA, SIRS, and NEWS scoring systems for diagnosis, mortality, and morbidity of sepsis in emergency department. Am J Emerg Med. 2021; 48:54-9. doi: 10.1016/j.ajem.2021.04.006 pmid: 33839632
24	Goulden R, Hoyle MC, Monis J, Railton D, Riley V, Martin P, et al. qSOFA, SIRS and NEWS for predicting inhospital mortality and ICU admission in emergency admissions treated as sepsis. Emerg Med J. 2018; 35(6):345-9. doi: 10.1136/emermed-2017-207120 pmid: 29467173
25	Cecconi M, Evans L, Levy M, Rhodes A. Sepsis and septic shock. Lancet. 2018; 392(10141):75-87. doi: 10.1016/S0140-6736(18)30696-2
26	Vincent JL, Quintairos E, Silva A, Couto L Jr, Taccone FS. The value of blood lactate kinetics in critically ill patients: a systematic review. Crit Care. 2016; 20(1):257. doi: 10.1186/s13054-016-1403-5
27	Khodashahi R, Sarjamee S. Early lactate area scores and serial blood lactate levels as prognostic markers for patients with septic shock: a systematic review. Infect Dis (Lond). 2020; 52(7):451-63.
28	Baumann BM, Greenwood JC, Lewis K, Nuckton TJ, Darger B, Shofer FS, et al. Combining qSOFA criteria with initial lactate levels: Improved screening of septic patients for critical illness. Am J Emerg Med. 2020; 38(5):883-9. doi: 10.1016/j.ajem.2019.07.003
29	Sinto R, Suwarto S, Lie KC, Harimurti K, Widodo D, Pohan HT. Prognostic accuracy of the quick Sequential Organ Failure Assessment (qSOFA)-lactate criteria for mortality in adults with suspected bacterial infection in the emergency department of a hospital with limited resources. Emerg Med J. 2020; 37(6):363-9. doi: 10.1136/emermed-2018-208361
30	Leopold SJ, Ghose A, Plewes KA, Mazumder S, Pisani L, Kingston HWF, et al. Point-of-care lung ultrasound for the detection of pulmonary manifestations of malaria and sepsis: an observational study. PLoS One. 2018; 13(12):e0204832. doi: 10.1371/journal.pone.0204832
31	Rice TW, Wheeler AP, Bernard GR, Hayden DL, Schoenfeld DA, Ware LB, et al. Comparison of the SpO₂/FiO₂ ratio and the PaO₂/FiO₂ ratio in patients with acute lung injury or ARDS. Chest. 2007; 132(2):410-7.
32	Pepper DJ, Sun JF, Rhee C, Welsh J, Powers JH 3rd, Danner RL, et al. Procalcitonin-guided antibiotic discontinuation and mortality in critically ill adults: a systematic review and meta-analysis. Chest. 2019; 155(6):1109-18. doi: 10.1016/j.chest.2018.12.029
33	Robati Anaraki M, Nouri-Vaskeh M, Abdoli Oskouie S. Effectiveness of procalcitonin-guided antibiotic therapy to shorten treatment duration in critically-ill patients with bloodstream infections: a systematic review and meta-analysis. Infez Med. 2020; 28(1):37-46.
34	Liu D, Su LX, Han GC, Yan P, Xie LX. Prognostic value of procalcitonin in adult patients with sepsis: a systematic review and meta-analysis. PLoS One. 2015; 10(6):e0129450. doi: 10.1371/journal.pone.0129450
35	AlRawahi AN, AlHinai FA, Doig CJ, Ball CG, Dixon E, Xiao ZW, et al. The prognostic value of serum procalcitonin measurements in critically injured patients: a systematic review. Crit Care. 2019; 23:390. doi: 10.1186/s13054-019-2669-1

Variables	Survivors (n=835)	Non-survivors (n=101)	P value
Male	509 (60.96)	68 (67.33)	0.234
Age (years)	50.13±18.32	58.91±20.92	<0.001
Temperature (°C)	36.10±5.58	36.95±0.88	0.121
Pulse (beats/min)	105.46±69.60	103.27±24.76	0.753
RR (breaths/min)	21.62±5.96	22.74±5.49	0.072
SBP (mmHg)	113.19±37.60	107.18±36.63	0.129
Mental status
Alert	835 (100.0)	51 (50.5)	<0.001
Altered mentation	0 (0.0)	50 (49.5)
SpO₂ (%)	95 (90-96)	93 (89-94)	<0.001
PCT (ng/mL)	0.98 (0.66-5.91)	1.23 (0.73-5.28)	0.215
Serum lactate (mmol/L)	2.1 (1.7-2.8)	2.5 (2.0-4.3)	<0.001
SOFA	4 (3-5)	6 (5-8)	<0.001
qSOFA	1 (0-1)	1 (1-2)	<0.001
LqSOFA	1 (0-2)	2 (1-3)	<0.001
PqSOFA	1 (1-2)	2 (1-3)	<0.001
MqSOFA	2 (1-2)	3 (2-4)	<0.001

Score	AUC	95%CI	P value	Cut-off	Sen (%)	Spe (%)	PPV (%)	NPV (%)	Youden’s index
qSOFA	0.705	0.645-0.764	<0.001	1	80.20	42.16	14.36	94.62	0.224
				2	39.60	91.62	36.36	92.62	0.312^*
				3	6.93	98.08	30.44	89.70	0.050
LqSOFA	0.740	0.686-0.794	<0.001	1	94.06	25.63	13.27	97.27	0.197
				2	64.36	70.78	21.04	94.26	0.351^*
				3	28.71	95.57	43.94	91.72	0.243
				4	3.96	98.08	20.00	89.41	0.020
PqSOFA	0.712	0.653-0.771	<0.001	1	91.09	17.13	11.74	94.08	0.082
				2	71.29	61.68	18.37	94.67	0.330^*
				3	31.68	93.89	38.55	91.91	0.256
				4	1.98	98.08	11.11	89.22	0.001
MqSOFA	0.731	0.675-0.787	<0.001	1	86.14	39.76	14.75	95.95	0.259
				2	51.49	80.96	24.65	93.24	0.324^*
				3	25.74	97.01	50.98	91.53	0.227
				4	5.94	98.08	27.27	89.61	0.040
				5	/	98.08	/	89.02	/

Pairs of scores	ΔAUC	S.E.	95%CI	P value
qSOFA vs. LqSOFA	0.0353	0.0162	0.0035 to 0.0671	0.0295^*
qSOFA vs. MqSOFA	0.0266	0.0134	0.0003 to 0.0529	0.0478^*
qSOFA vs. PqSOFA	0.0072	0.0143	-0.0208 to 0.0353	0.6129
LqSOFA vs. MqSOFA	0.0087	0.0178	-0.0262 to 0.0436	0.6243
LqSOFA vs. PqSOFA	0.0281	0.0230	-0.0170 to 0.0731	0.2218
MqSOFA vs. PqSOFA	0.0193	0.0201	-0.0201 to 0.0588	0.3369

[1]	Li-wei Duan, Jin-long Qu, Jian Wan, Yong-hua Xu, Yi Shan, Li-xue Wu, Jin-hao Zheng, Wei-wei Jiang, Qi-tong Chen, Yan Zhu, Jian Zhou, Wen-bo Yu, Lei Pei, Xi Song, Wen-fang Li, Zhao-fen Lin. Effects of viral infection and microbial diversity on patients with sepsis: A retrospective study based on metagenomic next-generation sequencing [J]. World Journal of Emergency Medicine, 2021, 12(1): 29-35.
[2]	Hai-jiang Zhou, Tian-fei Lan, Shu-bin Guo. Outcome prediction value of National Early Warning Score in septic patients with community-acquired pneumonia in emergency department: A single-center retrospective cohort study [J]. World Journal of Emergency Medicine, 2020, 11(4): 206-215.
[3]	Yu-ming Wang, Yan-jun Zheng, Ying Chen, Yun-chuan Huang, Wei-wei Chen, Ran Ji, Li-li Xu, Zhi-tao Yang, Hui-qiu Sheng, Hong-ping Qu, En-qiang Mao, Er-zhen Chen. Effects of fluid balance on prognosis of acute respiratory distress syndrome patients secondary to sepsis [J]. World Journal of Emergency Medicine, 2020, 11(4): 216-222.
[4]	Miao Yuan, Ding-yi Yan, Fang-shi Xu, Yi-di Zhao, Yang Zhou, Long-fei Pan. Effects of sepsis on hippocampal volume and memory function [J]. World Journal of Emergency Medicine, 2020, 11(4): 223-230.
[5]	Wen-peng Yin, Jia-bao Li, Xiao-fang Zheng, Le An, Huan Shao, Chun-sheng Li. Effect of neutrophil CD64 for diagnosing sepsis in emergency department [J]. World Journal of Emergency Medicine, 2020, 11(2): 79-86.
[6]	Shao-hua Liu, Huo-yan Liang, Hong-yi Li, Xian-fei Ding, Tong-wen Sun, Jing Wang. Effect of low high-density lipoprotein levels on mortality of septic patients: A systematic review and meta-analysis of cohort studies [J]. World Journal of Emergency Medicine, 2020, 11(2): 109-116.
[7]	Yi-wen Fan, Shao-wei Jiang, Jia-meng Chen, Hui-qi Wang, Dan Liu, Shu-ming Pan, Cheng-jin Gao. A pulmonary source of infection in patients with sepsis-associated acute kidney injury leads to a worse outcome and poor recovery of kidney function [J]. World Journal of Emergency Medicine, 2020, 11(1): 18-26.
[8]	Kimberly A. Chambers, Adam Y. Park, Rosa C. Banuelos, Bryan F. Darger, Bindu H. Akkanti, Annamaria Macaluso, Manoj Thangam, Pratik B. Doshi. Outcomes of severe sepsis and septic shock patients after stratification by initial lactate value [J]. World Journal of Emergency Medicine, 2018, 9(2): 113-117.
[9]	Muhammad Akbar Baig, Hira Shahzad, Erfan Hussain, Asad Mian. Validating a point of care lactate meter in adult patients with sepsis presenting to the emergency department of a tertiary care hospital of a low- to middle-income country [J]. World Journal of Emergency Medicine, 2017, 8(3): 184-189.
[10]	Chao Cao, Tao Ma, Yan-fen Chai, Song-tao Shou. The role of regulatory T cells in immune dysfunction during sepsis [J]. World Journal of Emergency Medicine, 2015, 6(1): 5-9.
[11]	Kun Chen, Qiu-xiang Zhou, Hong-wei Shan, Wen-fang Li, Zhao-fen Lin. Prognostic value of CD4⁺CD25⁺ Tregs as a valuable biomarker for patients with sepsis in ICU [J]. World Journal of Emergency Medicine, 2015, 6(1): 40-43.
[12]	Hui Fu, Qiao-sheng Wang, Qiong Luo, Si Tan, Hua Su, Shi-lin Tang, Zheng-liang Zhao, Li-ping Huang. Simvastatin inhibits apoptosis of endothelial cells induced by sepsis through upregulating the expression of Bcl-2 and downregulating Bax [J]. World Journal of Emergency Medicine, 2014, 5(4): 291-297.
[13]	Qi Zou, Wei Wen, Xin-chao Zhang. Presepsin as a novel sepsis biomarker [J]. World Journal of Emergency Medicine, 2014, 5(1): 16-19.
[14]	Nishant Raj Pandey, Yu-yao Bian, Song-tao Shou. Significance of blood pressure variability in patients with sepsis [J]. World Journal of Emergency Medicine, 2014, 5(1): 42-47.
[15]	Huan Ding, Xiang-yuan Cao, Xi-gang Ma, Wen-jie Zhou. Endothelial cell injury with inflammatory cytokine and coagulation in patients with sepsis [J]. World Journal of Emergency Medicine, 2013, 4(4): 285-289.