A qSOFA Trifecta

There’s a new sepsis in town – although, by “new” it’s not very anymore. We’re supposedly all-in on Sepsis-3, which in theory is superior to the old sepsis.

One of the most prominent and controversial aspects of the sepsis reimagining is the discarding of the flawed Systemic Inflammatory Response Syndrome criteria and its replacement with the Quick Sequential Organ Failure Assessment. In theory, qSOFA replaces the non-specific items from SIRS with physiologic variables more closely related to organ failure. However, qSOFA was never prospectively validated or compared prior to its introduction.

These three articles give us a little more insight – and, as many have voiced concern already, it appears we’ve just replaced one flawed agent with another.

The first article, from JAMA, describes the performance of qSOFA against SIRS and a 2-point increase in the full SOFA score in an ICU population. This retrospective analysis of 184,875 patients across 15 years of registry data from 182 ICUs in Australia and New Zealand showed very little difference between SIRS and qSOFA with regard to predicting in-hospital mortality. Both screening tools were also far inferior to the full SOFA score – although, in practical terms, the differences in adjusted AUC were only between ~0.69 for SIRS and qSOFA and 0.76 for SOFA. As prognostic tools, then, none of these are fantastic – and, unfortunately, qSOFA did not seem to offer any value over SIRS.

The second article, also from JAMA, is some of the first prospective data regarding qSOFA in the Emergency Department. This sample is 879 patients with suspected infection, followed for in-hospital mortality or ICU admission. The big news from this article is the AUC for qSOFA of 0.80 compared with the 0.65 for SIRS or “severe sepsis”, as defined by SIRS plus a lactate greater than 2mmol/L. However, at a cut-off of 2 or more for qSOFA, the advertised cut-off for “high risk”, the sensitivity and specificity were 70% and 79% respectively.

Finally, a third article, from Annals of Emergency Medicine, also evaluates the performance characteristics of qSOFA in an Emergency Department population. This retrospective evaluation describes the performance of qSOFA at predicting admission and mortality, but differs from the JAMA article by applying qSOFA to a cross-section of mostly high-acuity visits, both with and without suspected infection. Based on a sample of 22,350 ED visits, they found similar sensitivity and specificity of a qSOFA score of 2 or greater for predicting mortality, 71% and 74%, respectively. Performance was not meaningfully different between those with and without infection.

It seems pretty clear, then, this score doesn’t hold a lot of value. SIRS, obviously, has its well-documented flaws. qSOFA seems to have better discriminatory value with regards to the AUC, but its performance at the cut-off level of 2 puts it right in a no-man’s land of clinical utility. It is not sensitive enough to rely upon to capture all patients at high-risk for deterioration – but, then, its specificity is also poor enough using it to screen the general ED population will still result in a flood of false positives.

So, unfortunately, these criteria are probably a failed paradigm perpetuating all the same administrative headaches as the previous approach to sepsis – better than SIRS, but still not good enough. We should be pursuing more robust decision-support built-in to the EHR, not attempting to reinvent overly-simplified instruments without usable discriminatory value.

“Prognostic Accuracy of the SOFA Score, SIRS Criteria, and qSOFA Score for In-Hospital Mortality Among Adults With Suspected Infection Admitted to the Intensive Care Unit”

http://jamanetwork.com/journals/jama/article-abstract/2598267

“Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients With Suspected Infection Presenting to the Emergency Department”

http://jamanetwork.com/journals/jama/fullarticle/2598268

“Quick SOFA Scores Predict Mortality in Adult Emergency Department Patients With and Without Suspected Infection”

http://www.annemergmed.com/article/S0196-0644(16)31219-7/fulltext