A comparison of scoring systems for predicting mortality and sepsis in the emergency department patients with a suspected infection

Objective We aimed to compare the modified National Early Warning Score (mNEWS), quick Sequential Organ Failure Assessment (qSOFA) score, modified Systemic Inflammatory Response Syndrome (mSIRS) score, and modified Search Out Severity (mSOS) score in predicting mortality and sepsis among patients suspected of first observed infections in the emergency department. The modified scores were created by removing variables for simplicity.Methods This was a prospective cohort study that enrolled adult patients presenting at the emergency department with signs and symptoms suggesting infection. The mNEWS, qSOFA score, mSIRS score, and mSOS score were calculated using triage data. The SOFA score was a reference standard for sepsis diagnosis. All patients were monitored for up to 30 days after the initial visit to measure each scoring system’s ability to predict 30-day mortality and sepsis.Results There were 260 patients included in the study. The 30-day mortality prediction with mNEWS ≥5 had the highest sensitivity (91.18%). The highest area under the receiver operating characteristic curve (AUC) for the 30-day mortality prediction was mNEWS (0.607), followed by qSOFA (0.605), mSOS (0.550), and mSIRS (0.423). The sepsis prediction with mNEWS ≥5 had the highest sensitivity (96.48%). The highest AUC for the sepsis prediction was also mNEWS (0.685), followed by qSOFA (0.605), mSOS (0.480), and mSIRS (0.477).Conclusion mNEWS was an acceptable scoring system screening tool for predicting mortality and sepsis in patients with a suspected infection.

Profile of Sepsis Patients Treated in Intensive Care Unit of Sanglah Hospital Denpasar

BACKGROUND: Primary data regarding sepsis patients in Indonesia, especially in Denpasar, are still limited in number in reporting. The lack of information about sepsis made the authors interested in conducting this study. AIM: The aim of the study was to obtain more in-depth information about the profile of sepsis patients treated in Sanglah Hospital, Denpasar. MATERIALS AND METHODS: This was a cross-sectional descriptive research. Target population in this study are data on patient registers that are included in the inclusion criteria from June 1, 2019 to June 30, 2021, at intensive care unit Sanglah Hospital, Denpasar. The variables in this study included: Demographic conditions such as age, gender, and address, qSOFA score, comorbidities, ventilator, and patient’s outcome (survival or non-survival). RESULTS: A total samples were 173 patients. The average age of patients in this study was 54 years old with 56.6% male and 32.9% lived in Denpasar. Patients suspected of having early sepsis had a qSOFA 0 score of 35.3%, qSOFA 1 was 33.5%, qSOFA 2 was 23.7%, and qSOFA 3 was 7.5%. Patients with sepsis and suspected sepsis with comorbidities were 96% and 79.8% of patients were on a ventilator. The mortality rate in this study was 67.1%. CONCLUSION: These primary data hopefully become references for the future research.

Prognostic Accuracy of the qSOFA Score for In-Hospital Mortality in Elderly Patients with Obstructive Acute Pyelonephritis: A Multi-Institutional Study

Prognostic accuracy of the quick sequential organ failure assessment (qSOFA) score for mortality may be limited in elderly patients. Using our multi-institutional database, we classified obstructive acute pyelonephritis (OAPN) patients into young and elderly groups, and evaluated predictive performance of the qSOFA score for in-hospital mortality. qSOFA score ≥ 2 was an independent predictor for in-hospital mortality, as was higher age, and Charlson comorbidity index (CCI) ≥ 2. In young patients, the area under the curve (AUC) of the qSOFA score for in-hospital mortality was 0.85, whereas it was 0.61 in elderly patients. The sensitivity and specificity of qSOFA score ≥ 2 for in-hospital mortality was 80% and 80% in young patients, and 50% and 68% in elderly patients, respectively. For elderly patients, we developed the CCI-incorporated qSOFA score, which showed higher prognostic accuracy compared with the qSOFA score (AUC, 0.66 vs. 0.61, p < 0.001). Therefore, the prognostic accuracy of the qSOFA score for in-hospital mortality was high in young OAPN patients, but modest in elderly patients. Although it can work as a screening tool to determine therapeutic management in young patients, for elderly patients, the presence of comorbidities should be considered at the initial assessment.

Identification and validation of objective triggers for initiation of resuscitation management of acutely ill non-trauma patients: the INITIATE IRON MAN study

Background While there are clear national resuscitation room admission guidelines for major trauma patients, there are no comparable alarm criteria for critically ill nontrauma (CINT) patients in the emergency department (ED). The aim of this study was to define and validate specific trigger factor cut-offs for identification of CINT patients in need of a structured resuscitation management protocol. Methods All CINT patients at a German university hospital ED for whom structured resuscitation management would have been deemed desirable were prospectively enrolled over a 6-week period (derivation cohort, n = 108). The performance of different thresholds and/or combinations of trigger factors immediately available during triage were compared with the National Early Warning Score (NEWS) and Quick Sequential Organ Failure Assessment (qSOFA) score. Identified combinations were then tested in a retrospective sample of consecutive nontrauma patients presenting at the ED during a 4-week period (n = 996), and two large external datasets of CINT patients treated in two German university hospital EDs (validation cohorts 1 [n = 357] and 2 [n = 187]). Results The any-of-the-following trigger factor iteration with the best performance in the derivation cohort included: systolic blood pressure < 90 mmHg, oxygen saturation < 90%, and Glasgow Coma Scale score < 15 points. This set of triggers identified > 80% of patients in the derivation cohort and performed better than NEWS and qSOFA scores in the internal validation cohort (sensitivity = 98.5%, specificity = 98.6%). When applied to the external validation cohorts, need for advanced resuscitation measures and hospital mortality (6.7 vs. 28.6%, p < 0.0001 and 2.7 vs. 20.0%, p < 0.012) were significantly lower in trigger factor-negative patients. Conclusion Our simple, any-of-the-following decision rule can serve as an objective trigger for initiating resuscitation room management of CINT patients in the ED.

Exploring Associations with Severe Hypoxemic Respiratory Failure in COVID-19 Patients upon Admission: A Model for Severe Hypoxemic Respiratory Failure in 329 Unvaccinated, Hospitalized COVID-19 Patients.

Objective The severe acute respiratory syndrome-Coronavirus-2 (SARS-CoV-2) has caused a pandemic claiming more than 4 million lives worldwide. Overwhelming Coronavirus-Disease-2019 (COVID-19) respiratory failure placed tremendous demands on healthcare systems increasing the death toll. Cost-effective prognostic tools to characterize COVID-19 patients' likely to progress to severe hypoxemic respiratory failure are still needed. Design We conducted a retrospective cohort study to develop a model utilizing demographic and clinical data collected in the first 12-hours admission to explore associations with severe hypoxemic respiratory failure in unvaccinated and hospitalized COVID-19 patients. Setting University based healthcare system including 6 hospitals located in the Galveston, Brazoria and Harris counties of Texas. Participants Adult patients diagnosed with COVID-19 and admitted to one of six hospitals between March 19th and June 31st, 2020. Primary outcome The primary outcome was defined as reaching a WHO ordinal scale between 6-9 at any time during admission, which corresponded to severe hypoxemic respiratory failure requiring high-flow oxygen supplementation or mechanical ventilation. Results We included 329 participants in the model cohort and 62 (18.8%) met the primary outcome. Our multivariable regression model found that lactate dehydrogenase (OR 3.38 (95% CI 2.04-5.59)), qSOFA score (OR: 2.24 (95% CI 1.22-4.12)), neutrophil to lymphocyte ratio (OR:1.08 (95% CI 1.02-1.14)), age (OR: 1.04 (95% CI 1.02-1.07)), BMI (OR: 1.08 (95% CI1.03-1.13)), oxygen saturation or admission SpO2 (OR: 0.91 (95% CI 0.83-0.99)), and admission date (OR: 0.99 (95% CI 0.98-0.99)). The final model showed an area under curve (AUC) of 0.85. The sensitivity analysis and point of influence analysis did not reveal inconsistencies. Conclusions Our study demonstrated that a combination of accessible demographic and clinical information provide a powerful predictive tool to identify subjects with CoVID-19 likely to progress to severe hypoxemic respiratory failure.

Risk prediction of biomarkers for early multiple organ dysfunction in critically ill patients

Background Shock and organ damage occur in critically ill patients in the emergency department because of biological responses to invasion, and cytokines play an important role in their development. It is important to predict early multiple organ dysfunction (MOD) because it is useful in predicting patient outcomes and selecting treatment strategies. This study examined the accuracy of biomarkers, including interleukin (IL)-6, in predicting early MOD in critically ill patients compared with that of quick sequential organ failure assessment (qSOFA). Methods This was a multicenter observational sub-study. Five universities from 2016 to 2018. Data of adult patients with systemic inflammatory response syndrome who presented to the emergency department or were admitted to the intensive care unit were prospectively evaluated. qSOFA score and each biomarker (IL-6, IL-8, IL-10, tumor necrosis factor-α, C-reactive protein, and procalcitonin [PCT]) level were assessed on Days 0, 1, and 2. The primary outcome was set as MOD on Day 2, and the area under the curve (AUC) was analyzed to evaluate qSOFA scores and biomarker levels. Results Of 199 patients, 38 were excluded and 161 were included. Patients with MOD on Day 2 had significantly higher qSOFA, SOFA, and Acute Physiology and Chronic Health Evaluation II scores and a trend toward worse prognosis, including mortality. The AUC for qSOFA score (Day 0) that predicted MOD (Day 2) was 0.728 (95% confidence interval [CI]: 0.651–0.794). IL-6 (Day 1) showed the highest AUC among all biomarkers (0.790 [95% CI: 0.711–852]). The combination of qSOFA (Day 0) and IL-6 (Day 1) showed improved prediction accuracy (0.842 [95% CI: 0.771–0.893]). The combination model using qSOFA (Day 1) and IL-6 (Day 1) also showed a higher AUC (0.868 [95% CI: 0.799–0.915]). The combination model of IL-8 and PCT also showed a significant improvement in AUC. Conclusions The addition of IL-6, IL-8 and PCT to qSOFA scores improved the accuracy of early MOD prediction.

Sepsis Awareness at the University Hospital Level: A Survey-Based Cross-Sectional Study

Background: Sepsis is a leading cause of morbidity and mortality. Prompt recognition and management are critical to improved outcomes. In 2019, the Lausanne University Hospital (LUH) launched a quality of care project aiming to improve sepsis management. As part of this effort, we aimed to assess sepsis awareness among nurses and physicians of the LUH and among the local paramedics. Methods: We conducted a survey on nurses and physicians at our institution and local paramedics between January and October 2020 representing over 1,000 professionals distributed over all hospital departments. The survey assessed professionals’ knowledge of sepsis epidemiology, definition, recognition and initial evaluation (nurses and paramedics) or sepsis epidemiology, diagnosis, and management (physicians). Pediatrics and the neonatal unit were excluded. Results: A total of 1,116 of 1,216 contacted persons among the 4417 targeted population participated and completed the survey (participation rate 91.8%). This included 619 of 2,463 (25.1%) of hospital nurses, 348 of 1,664 (20.9 %) of physicians and 149 of 290 (51.4%) of canton paramedics. Our nurse and physician sample was slightly imbalanced for sex and age. Thirteen percent of participants (28.4% of physicians, 5.9% of nurses, 6.8% of paramedics) correctly identified the Sepsis-3 consensus definition. Similarly, 48.6% of physicians and 10.0% of nurses identified the SOFA (sequential organ failure assessment) score as a sepsis defining score for infected patients. Furthermore, 24% of participants identified the Quick Sepsis-related Organ Failure Assessment (qSOFA) score as a predictor of increased mortality; 6% identified correctly the components of the score. For a patient with suspected sepsis, 96.1%, 91.6% and 75.8% of physicians respectively identified blood cultures, broad-spectrum antibiotics and fluid resuscitation as required interventions; 76.4% and 18.2% of physicians requested these initial measures within 1 and 3 hours, respectively. For physicians, recent training correlated with awareness regarding definitions, SOFA score and qSOFA score use and components: ORs (95%CI) 2.2 (1.4-3.6), 4.3 (2.7-6.7), 3.4 (2.2-5.2), and 2.6 (1.5-4.6), respectively).Conclusions: We identify a deficit of awareness among physicians, nurses and paramedics at LUH correlating with a lack of sepsis-specific training. Enhanced sepsis-specific educational efforts could significantly improve early identification and treatment of affected patients.

Prognostic Accuracy of QSOFA Score Compared to SOFA Score among Patients with Sepsis

BACKGROUND Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. According to sepsis - 3 criteria, sepsis is diagnosed by Sequential organ failure assessment (SOFA) score of more than two. Surviving sepsis campaign introduced a newer scoring system, quick SOFA (QSOFA) score which uses only clinical parameters to prognosticate sepsis bed side and at the earliest. The purpose of this study was to evaluate the QSOFA score and then compare it to SOFA score in prognostication of sepsis. METHODS This study was a prospective observational study conducted in R. L. Jalappa Hospital among 150 individuals. Assessment of SOFA and QSOFA score was done and its significance in predicting mortality and morbidity was compared. RESULTS There were 87 males and 63 females. Mortality rate was 38.7 %. The initial QSOFA score of 1, 2 and 3 had mortality rate of 5.2 %, 24.1 % and 70.7 % respectively. Initial SOFA score of < 4, 4 - 8 and > 8 had mortality rate of 5.2 %, 37.9 % and 56.9 % respectively. Interpretation - The SOFA score had statistically significant correlation in assessing need for ventilator support, QSOFA score had a significant relation assessing need for ventilator support, vasopressor support. CONCLUSIONS Both scores demonstrated good accuracy for predicting in-hospital mortality. The QSOFA scoring system can aid where the resources are limited. KEY WORDS Sepsis, SOFA Score, QSOFA Score, Septic Shock