Automated Calculator for the Pediatric Sequential Organ Failure Assessment Score: Development and External Validation in a Single-Center 7-Year Cohort, 2015-2021.

OBJECTIVES: The pediatric Sequential Organ Failure Assessment (pSOFA) score summarizes severity of organ dysfunction and can be used to predict in-hospital mortality. Manual calculation of the pSOFA score is time-consuming and prone to human error. An automated method that is open-source, flexible, and scalable for calculating the pSOFA score directly from electronic health record data is desirable. DESIGN: Single-center, retrospective cohort study. SETTING: Quaternary 40-bed PICU. PATIENTS: All patients admitted to the PICU between 2015 and 2021 with ICU stay of at least 24 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used 77 records to evaluate the automated score. The automated algorithm had an overall accuracy of 97%. The algorithm calculated the respiratory component of two cases incorrectly. An expert human annotator had an initial accuracy of 75% at the patient level and 95% at the component level. An untrained human annotator with general clinical research experience had an overall accuracy of 16% and component-wise accuracy of 67%. Weighted kappa for agreement between the automated method and the expert annotator's initial score was 0.92 (95% CI, 0.88-0.95), and between the untrained human annotator and the automated score was 0.50 (95% CI, 0.36-0.61). Data from 9146 patients (in-hospital mortality 3.6%) were included to validate externally the discriminability of the automated pSOFA score. The admission-day pSOFA score had an area under the receiver operating characteristic curve of 0.79 (95% CI, 0.77-0.82). CONCLUSIONS: The developed automated algorithm calculates pSOFA score with high accuracy and is more accurate than a trained expert rater and nontrained data abstracter. pSOFA's performance for predicting in-hospital mortality was lower in our cohort than it was for the originally derived score.

Biomarkers Improve Diagnostics of Sepsis in Adult Patients With Suspected Organ Dysfunction Based on the Quick Sepsis-Related Organ Failure Assessment (qSOFA) Score in the Emergency Department.

OBJECTIVES: Consensus regarding biomarkers for detection of infection-related organ dysfunction in the emergency department is lacking. We aimed to identify and validate biomarkers that could improve risk prediction for overt or incipient organ dysfunction when added to quick Sepsis-related Organ Failure Assessment (qSOFA) as a screening tool. DESIGN: In a large prospective multicenter cohort of adult patients presenting to the emergency department with a qSOFA score greater than or equal to 1, admission plasma levels of C-reactive protein, procalcitonin, adrenomedullin (either bioavailable adrenomedullin or midregional fragment of proadrenomedullin), proenkephalin, and dipeptidyl peptidase 3 were assessed. Least absolute shrinkage and selection operator regression was applied to assess the impact of these biomarkers alone or in combination to detect the primary endpoint of prediction of sepsis within 96 hours of admission. SETTING: Three tertiary emergency departments at German University Hospitals (Jena University Hospital and two sites of the Charité University Hospital, Berlin). PATIENTS: One thousand four hundred seventy-seven adult patients presenting with suspected organ dysfunction based on qSOFA score greater than or equal to 1. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The cohort was of moderate severity with 81% presenting with qSOFA = 1; 29.2% of these patients developed sepsis. Procalcitonin outperformed all other biomarkers regarding the primary endpoint (area under the curve for receiver operating characteristic [AUC-ROC], 0.86 [0.79-0.93]). Adding other biomarkers failed to further improve the AUC-ROC for the primary endpoint; however, they improved the model regarding several secondary endpoints, such as mortality, need for vasopressors, or dialysis. Addition of procalcitonin with a cutoff level of 0.25 ng/mL improved net (re)classification by 35.2% compared with qSOFA alone, with positive and negative predictive values of 60.7% and 88.7%, respectively. CONCLUSIONS: Biomarkers of infection and organ dysfunction, most notably procalcitonin, substantially improve early prediction of sepsis with added value to qSOFA alone as a simple screening tool on emergency department admission.

Biomarker Assessment of a High-Risk, Data-Driven Pediatric Sepsis Phenotype Characterized by Persistent Hypoxemia, Encephalopathy, and Shock.

OBJECTIVES: Identification of children with sepsis-associated multiple organ dysfunction syndrome (MODS) at risk for poor outcomes remains a challenge. We sought to the determine reproducibility of the data-driven "persistent hypoxemia, encephalopathy, and shock" (PHES) phenotype and determine its association with inflammatory and endothelial biomarkers, as well as biomarker-based pediatric risk strata. DESIGN: We retrained and validated a random forest classifier using organ dysfunction subscores in the 2012-2018 electronic health record (EHR) dataset used to derive the PHES phenotype. We used this classifier to assign phenotype membership in a test set consisting of prospectively (2003-2023) enrolled pediatric septic shock patients. We compared profiles of the PERSEVERE family of biomarkers among those with and without the PHES phenotype and determined the association with established biomarker-based mortality and MODS risk strata. SETTING: Twenty-five PICUs across the United States. PATIENTS: EHR data from 15,246 critically ill patients with sepsis-associated MODS split into derivation and validation sets and 1,270 pediatric septic shock patients in the test set of whom 615 had complete biomarker data. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The area under the receiver operator characteristic curve of the modified classifier to predict PHES phenotype membership was 0.91 (95% CI, 0.90-0.92) in the EHR validation set. In the test set, PHES phenotype membership was associated with both increased adjusted odds of complicated course (adjusted odds ratio [aOR] 4.1; 95% CI, 3.2-5.4) and 28-day mortality (aOR of 4.8; 95% CI, 3.11-7.25) after controlling for age, severity of illness, and immunocompromised status. Patients belonging to the PHES phenotype were characterized by greater degree of systemic inflammation and endothelial activation, and were more likely to be stratified as high risk based on PERSEVERE biomarkers predictive of death and persistent MODS. CONCLUSIONS: The PHES trajectory-based phenotype is reproducible, independently associated with poor clinical outcomes, and overlapped with higher risk strata based on prospectively validated biomarker approaches.

The Sequential Organ Failure Assessment (SOFA) Score: has the time come for an update?

The Sequential Organ Failure Assessment (SOFA) score was developed more than 25 years ago to provide a simple method of assessing and monitoring organ dysfunction in critically ill patients. Changes in clinical practice over the last few decades, with new interventions and a greater focus on non-invasive monitoring systems, mean it is time to update the SOFA score. As a first step in this process, we propose some possible new variables that could be included in a SOFA 2.0. By so doing, we hope to stimulate debate and discussion to move toward a new, properly validated score that will be fit for modern practice.

Sequential organ failure assessment scores to predict outcomes: from adults to neonates.

PURPOSE OF REVIEW: Organ dysfunction severity scores (sequential organ failure assessment or SOFA) are commonly used in the adult and pediatric populations when assessing risk of mortality and adverse outcomes from sepsis. In contrast to sepsis definition in adults and children, clinical and laboratory criteria for defining neonatal sepsis have been inconclusive. More recently, studies have attempted to better understand the clinical progression of neonatal sepsis and associated mortality. This data has guided the development of a neonatal SOFA (nSOFA) score, based on common patterns of organ dysfunction observed in this population. RECENT FINDINGS: Although SOFA scores in the adult and pediatric populations have their limitations with moderate sensitivities and specificities depending on the clinical setting, the nSOFA score has been validated in predicting sepsis attributable mortality in very low birth weight (VLBW) infants across several patient cohorts. Furthermore, the nSOFA score has been adapted for use in neonatal disease states, other than sepsis, with similar prognostic utility. SUMMARY: Utilizing an nSOFA scoring system for prediction of sepsis attributable mortality in preterm infants allows for targeted interventions based on risk stratification, as well as better delineation of neonatal sepsis with subsequent improvements in research and patient safety outcomes.

Application of organ dysfunction assessment scores following pediatric lung transplantation.

OBJECTIVE: Organ dysfunction (OD) after lung transplantation can reflect preoperative organ failure, intraoperative acute organ damage and post-operative complications. We assessed two OD scoring systems, both the PEdiatric Logistic Organ Dysfunction (PELOD) and the pediatric Sequential Organ Failure Assessment (pSOFA) scores, in recognizing risk factors for morbidity as well as recipients with prolonged post-transplant morbidity. DESIGN: Medical records of recipients from January 2009 to March 2016 were reviewed. PELOD and pSOFA scores were calculated on post-transplant days 1-3. Risk factors assessed included cystic fibrosis (CF), prolonged surgical time and worst primary graft dysfunction (PGD) score amongst others. Patients were classified into three groups based on their initial scores (group A) and subsequent trends either uptrending (group B) or downtrending (group C). Morbidity outcomes were compared between these groups. RESULTS: Total 98 patients were enrolled aged 0-20 years. Risk factors for higher pSOFA scores ≥ 5 on day 1 included non-CF diagnosis and worst PGD scores (p = .0006 and p = .03, respectively). Kruskal Wallis analysis comparing pSOFA group A versus B versus C scores showed significantly prolonged ventilatory days (median 1 vs. 4 vs. 2, p = .0028) and ICU days (median 4 vs. 10 vs. 6, p = .007). Similarly, PELOD group A versus B versus C scores showed significantly prolonged ventilatory days (1 vs. 5 vs. 2, p = < .0001). CONCLUSION: Implementing pSOFA scores bedside is a more effective tool compared to PELOD in identifying risk factors for worsened OD post-lung transplant and can be valuable in providing direction on morbidity outcomes in the ICU.

Validation of the Pediatric Sequential Organ Failure Assessment Score and Evaluation of Third International Consensus Definitions for Sepsis and Septic Shock Definitions in the Pediatric Emergency Department.

Importance: Pediatric sepsis definitions have evolved, and some have proposed using the measure used in adults to quantify organ dysfunction, a Sequential Organ Failure Assessment (SOFA) score of 2 or more in the setting of suspected infection. A pediatric adaptation of SOFA (pSOFA) showed excellent discrimination for mortality in critically ill children but has not been evaluated in an emergency department (ED) population. Objective: To delineate test characteristics of the pSOFA score for predicting in-hospital mortality among (1) all patients and (2) patients with suspected infection treated in pediatric EDs. Design, Setting, and Participants: This retrospective cohort study took place from January 1, 2012, to January 31, 2020 in 9 US children's hospitals included in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. The data was analyzed from February 1, 2020, to April 18, 2022. All ED visits for patients younger than 18 years were included. Exposures: ED pSOFA score was assigned by summing maximum pSOFA organ dysfunction components during ED stay (each 0-4 points). In the subset with suspected infection, visit meeting criteria for sepsis (suspected infection with a pSOFA score of 2 or more) and septic shock (suspected infection with vasoactive infusion and serum lactate level >18.0 mg/dL) were identified. Main Outcomes and Measures: Test characteristics of pSOFA scores of 2 or more during the ED stay for hospital mortality. Results: A total of 3 999 528 (female, 47.3%) ED visits were included. pSOFA scores ranged from 0 to 16, with 126 250 visits (3.2%) having a pSOFA score of 2 or more. pSOFA scores of 2 or more had sensitivity of 0.65 (95% CI, 0.62-0.67) and specificity of 0.97 (95% CI, 0.97-0.97), with negative predictive value of 1.0 (95% CI, 1.00-1.00) in predicting hospital mortality. Of 642 868 patients with suspected infection (16.1%), 42 992 (6.7%) met criteria for sepsis, and 374 (0.1%) met criteria for septic shock. Hospital mortality rates for suspected infection (599 502), sepsis (42 992), and septic shock (374) were 0.0%, 0.9%, and 8.0%, respectively. The pSOFA score had similar discrimination for hospital mortality in all ED visits (area under receiver operating characteristic curve, 0.81; 95% CI, 0.79-0.82) and the subset with suspected infection (area under receiver operating characteristic curve, 0.82; 95% CI, 0.80-0.84). Conclusions and Relevance: In a large, multicenter study of pediatric ED visits, a pSOFA score of 2 or more was uncommon and associated with increased hospital mortality yet had poor sensitivity as a screening tool for hospital mortality. Conversely, children with a pSOFA score of 2 or less were at very low risk of death, with high specificity and negative predictive value. Among patients with suspected infection, patients with pSOFA-defined septic shock demonstrated the highest mortality.

The pathophysiology of sepsis - 2021 update: Part 2, organ dysfunction and assessment.

PURPOSE: This is the second article in a 2-part series discussing the pathophysiology of sepsis. Part 1 of the series reviewed the immunologic response and overlapping pathways of inflammation and coagulation that contribute to the widespread organ dysfunction. In this article (part 2), major organ systems and their dysfunction in sepsis are reviewed, with discussion of scoring systems used to identify patterns and abnormal vital signs and laboratory values associated with sepsis. SUMMARY: Sepsis is a dysregulated host response to infection that produces significant morbidity, and patients with shock due to sepsis have circulatory and cellular and metabolic abnormalities that lead to a higher mortality. Cardiovascular dysfunction produces vasodilation, reduced cardiac output and hypotension/shock requiring fluids, vasopressors, and advanced hemodynamic monitoring. Respiratory dysfunction may require mechanical ventilation and attention to volume status. Renal dysfunction is a frequent manifestation of sepsis. Hematologic dysfunction produces low platelets and either elevation or reduction of leukocytes, so consideration of the neutrophil:lymphocyte ratio may be useful. Procoagulant and antifibrinolytic activity leads to coagulation that is stimulated by inflammation. Hepatic dysfunction manifest as elevated bilirubin is often a late finding in sepsis and may cause reductions in production of essential proteins. Neurologic dysfunction may result from local endothelial injury and systemic inflammation through activity of the vagus nerve. CONCLUSION: Timely recognition and team response with efficient use of therapies can improve patient outcome, and pharmacists with a complete understanding of the pathophysiologic mechanisms and treatments are valuable members of that team.

Evaluation of the sequential organ failure assessment score and newly introduced criteria - Traumasis - in traffic collision patients.

BACKGROUND: The aim of this study was to evaluate the performance of the Sequential Organ Failure Assessment (SOFA) score and the newly introduced criteria, traumasis, defined as a SOFA score 2 or more among trauma patients. METHODS: Consecutive adult traffic collision patients who were admitted to the study hospital emergency department (ED) from January 2017 to December 2018 were enrolled retrospectively in the study. The primary outcome was in-hospital death. The SOFA score was calculated using relevant initial ED data. Traditional risk scores for trauma patients, such as the injury severity score (ISS), the revised trauma score (RTS), and the trauma injury severity score (TRISS), were also calculated. RESULTS: A total of 927 patients were available for analysis, of whom 46 died (5.0%). The median SOFA score was 1.0 (interquartile range [IQR], 0.0-3.0). A total of 417 patients (45.0%) were identified as having traumasis (SOFA score ≥ 2), of whom 44 died (10.6%). The area under the receiver operating characteristic (AUROC) curve of the SOFA score (0.91; 95% confidence interval [CI] 0.87-0.95) was comparable with that of the TRISS (0.88; 95% CI, 0.84-0.93) and better than that of the ISS(0.81; 95% CI 0.75-0.86) and the RTS (0.82; 95% CI 0.75-0.90). The sensitivity, specificity, positive predictive value and negative predictive value of the traumasis criteria for the primary outcome were 95.7%, 63.0%, 11.9%, and 99.6%, respectively. The net reclassification improvement for the comparison between the traumasis criteria and major trauma criteria (ISS ≥ 15) was 0.69 (95% CI, 0.55-0.82; p < 0.001). The multivariate Cox regression model showed that the SOFA score (adjusted hazard ratio [aHR] 1.52; 95% CI 1.37-1.67) and traumasis (aHR 11.40; 95% CI 2.70-48.13), respectively, was independently associated with higher in-hospital mortality. CONCLUSION: The SOFA score can be used as a reliable tool for predicting in-hospital death among traffic collision patients. The newly introduced criteria, traumasis, may be used as a risk-stratification and quality-control criteria among patients with trauma, similar to the sepsis criteria among patients with infectious disease.

Assessment of severity of acute pancreatitis in a Sars-CoV-2 pandemia.

HUMAN AND ANIMAL RIGHTS: Every patient has given permission for publication of information from the medical history as long as it is used for medical research purposes. INFORMED CONSENT: Informed consent was obtained from all the individual participants of the study.

Plasma lactate can improve the accuracy of the Pediatric Sequential Organ Failure Assessment Score for prediction of mortality in critically ill children: A pilot study.

BACKGROUND: Plasma lactate has been used to predict the prognosis of critically ill children, but mortality risk scores appear to be more appealing, particularly in resource-limited countries. OBJECTIVE: To assess the prognostic utility of lactate compared with the pediatric Sequential Organ Failure Assessment (pSOFA) score among the general pediatric intensive care unit (PICU) population. METHODS: This was a prospective observational study including 78 children admitted to a tertiary-level PICU. Plasma lactate was measured upon admission and repeated 24h later. pSOFA score, Pediatric Risk of Mortality, and Pediatric Index of Mortality-2 (PIM2) were calculated. The primary outcome was 30-day mortality. RESULTS: In total, 47.4% of patients had hyperlactatemia at admission. Among these, 20.5% had persistent hyperlactatemia. No significant difference in admission lactate level was found between survivors and nonsurvivors. The 24-h, peak, and average lactate levels were higher among nonsurvivors (P=0.005, 0.035, and 0.019, respectively). The 24-h lactate level and pSOFA score were independent predictors of mortality (adjusted odds ratio and 95% confidence interval=1.12 [1.02-1.23] and 1.80 [1.23-2.64], respectively]. The 24-h lactate level showed positive correlations with pSOFA, PRISM, and PIM2 (Spearman correlation coefficient=0.31, 0.23, 0.43; P=0.006, P=0.047, P<0.001, respectively). The 24-h lactate level had an area under the receiver operating characteristic curve (AUC) of 0.77 (P=0.013) for mortality prediction, while admission, peak, and average lactate level had an AUC of 0.69, 0.69, 0.71 (P=0.086, P=0.035, P=0.019), respectively. PIM2, PRISM, and pSOFA score had an AUC of 0.80, 0.78, 0.82 (P=0.001, P=0.001, and P<0.001), respectively. Combining 24-h lactate level with pSOFA demonstrated superior performance (AUC=0.88). CONCLUSION: Both 24-h lactate level and pSOAF are useful for prediction of mortality. Incorporating the 24-h lactate level into the pSOFA Score achieved superior prognostic utility.

Sequential organ failure assessment score on admission predicts long-term mortality in acute heart failure patients.

AIMS: The sequential organ failure assessment (SOFA) score has been a widely used predictor of outcomes in the intensive care unit, whereas short-term and long-term survivals of heart failure (HF) patients are predicted by the American Heart Association Get With the Guidelines-Heart Failure (GWTG-HF) risk score. The purpose of present study was to examine whether the SOFA score on admission is more useful for predicting long-term mortality in acute HF patients than the GWTG-HF risk score. METHODS AND RESULTS: A total of 269 patients (mean age, 78.5 ± 10.9 years; all-cause mortality, 53.9%) seen in a single facility from January 2007 to December 2016 were enrolled retrospectively. They were followed up for a mean of 32.1 ± 22.3 months. All-cause death was associated with higher SOFA and GWTG-HF risk scores. However, no significant difference was observed in the area under the curve value between the scores. Kaplan-Meier survival analysis indicated that higher SOFA scores (P < 0.001) and GWTG-HF risk scores (P < 0.001) were related to increased probabilities of all-cause death. On multivariate Cox proportional hazard model analysis, the SOFA score (P < 0.001) and GWTG-HF (P < 0.001) score were independent predictors of all-cause death. Incorporating the SOFA score into the GWTG-HF risk score yielded a significant net reclassification improvement and integrated discrimination improvement. On decision curve analysis, the net benefit of the SOFA score model when compared with the reference model was greater across the range of threshold probabilities. CONCLUSIONS: In acute HF patients, long-term all-cause mortality can be predicted by the SOFA score. Discriminative performance metrics, such as net reclassification improvement, integrated discrimination improvement, and decision curve analysis, for predicting mortality were improved when the SOFA score was incorporated.

[Paediatric sequential organ failure assessment (pSOFA) score: A new mortality prediction score in the paediatric intensive care unit]. / La escala pediátrica de evaluación del fallo multiorgánico secuencial (pSOFA): una nueva escala de predicción de la mortalidad en la unidad de cuidados intensivos pediátricos.

OBJECTIVES: To assess performance of the age-adapted SOFA score in children admitted into Paediatric Intensive Care Units (PICUs) and whether the SOFA score can compete with the systemic inflammatory response syndrome (SIRS) in diagnosing sepsis, as recommended in the Sepsis-3 consensus definitions. METHODS: Two-centre prospective observational study in 281 children admitted to the PICU. We calculated the SOFA, Pediatric Risk of Mortality (PRISM), and Pediatric Index of Mortality-2 (PIM2) scores and assessed for the presence of SIRS at admission. The primary outcome was 30-day mortality. RESULTS: The SOFA score was higher in nonsurvivors (P<.001) and mortality increased progressively across patient subgroups from lower to higher SOFA scores. The receiver operating characteristic (ROC) curve analysis revealed that the area under the curve (AUC) of the SOFA score for predicting 30-day mortality was 0.89, compared to AUCs of 0.84 and 0.79 for the PRISM and PIM2 scores, respectively. The AUC of the SOFA score for predicting a prolonged stay in the PICU was 0.67. The SOFA score was correlated to the PRISM score (rs=0.59) and the PIM2 score (rs=0.51). In children with infection, the AUC of the SOFA score for predicting mortality was 0.87 compared to an AUC of 0.60 using SIRS. The diagnosis of sepsis applying a SOFA cutoff of 3 points predicted mortality better than both the SIRS and the SOFA cutoff of 2 points recommended by the Sepsis-3 consensus. CONCLUSIONS: The SOFA score at admission is useful for predicting outcomes in the general PICU population and is more accurate than SIRS for definition of paediatric sepsis.

Quick Sequential (Sepsis Related) Organ Failure Assessment: A high performance rapid prognostication tool in patients having acute pyelonephritis with upper urinary tract calculi.

Purpose: To analyze the utility of quick Sequential Organ Failure Assessment (qSOFA) in patients with uro-sepsis due to acute pyelonephritis (APN) with upper urinary tract calculi, we conducted this study. The role of qSOFA as a tool for rapid prognostication in patients with sepsis is emerging. But there has been a great debate on its utility. Literature regarding utility of qSOFA in uro-sepsis is scarce. Materials and Methods: Ours was a retrospective study including 162 consecutive patients who were admitted for APN with upper urinary tract calculi over a 3 and half years (total 42 months) period. We evaluated the accuracy of qSOFA in predicting inhospital mortality and intensive care unit (ICU) admissions and compared this with the predictive accuracy of systemic inflammatory response syndrome (SIRS). We used the Area Under Curve (AUC) of the Receiver Operator Characteristic curve to calculate it and also calculated the optimum cut off for qSOFA score. Results: The overall mortality and ICU admission rates were 7.4% and 12.9%, respectively. qSOFA had a higher predictive accuracy for in-hospital mortality (AUC, 0.981; 95% confidence interval [CI], 0.962-1.000) and ICU admissions (AUC, 0.977; 95% CI, 0.955-0.999) than SIRS. A qSOFA score of ≥2 was an optimum cut off for predicting prognosis. In a multivariate model qSOFA ≥2 was a highly significant predictor of in-hospital mortality and ICU admissions (p<0.001). Conclusions: qSOFA is a reliable and rapid bedside tool in patients with sepsis with accuracy more than SIRS in predicting inhospital mortality and ICU admissions.

Modification of sequential organ failure assessment score using acute kidney injury classification.

PURPOSE: To assess the predictive validity of a modified Sequential Organ Failure Assessment (SOFA) score, of which the renal component was replaced with Kidney Disease Improving Global Outcomes (KDIGO) classification of Acute Kidney Injury (AKI). MATERIALS AND METHODS: Using a prospective cohort study on AKI in Japan, we replaced the renal component of SOFA score with AKI stages according to the KDIGO criteria except that initiation of renal replacement therapy was assigned four points. We assessed the predictive validity of KDIGO-based SOFA score for hospital and ICU mortality by comparing the areas under the receiver operating characteristic curve (AUC) derived from logistic regression models with that of the original SOFA score. RESULTS: 2292 patients were registered. Overall hospital mortality was 11.6%, and ICU mortality was 5.1%. KDIGO-based SOFA score was moderately correlated with APACHE II score (rho = 0.476). The AUC for hospital and ICU mortality of KDIGO-based and the original SOFA score were 0.749 vs 0.745 (p = .393) and 0.790 vs 0.791 (p = .900). CONCLUSIONS: The prognostic performance of KDIGO-based SOFA score was not superior but comparable to that of the original SOFA score.

Early variation of quick sequential organ failure assessment score to predict in-hospital mortality in emergency department patients with suspected infection.

BACKGROUND: The quick sequential organ failure assessment (qSOFA) score showed good prognostic performance in patients with suspicion of infection in the emergency department (ED). However, previous studies only assessed the performance of individual values of qSOFA during the ED stay. As this score may vary over short timeframes, the optimal time of measurement, and the prognostic value of its variation are unclear. The objective of the present study was to prospectively assess the prognostic value of the change in qSOFA over the first 3 h (ΔqSOFA = qSOFA at 3 h-qSOFA at inclusion). PATIENTS AND METHODS: This is an international prospective cohort study conducted in 17 EDs in France, Belgium, and Spain. From November 2016 to March 2017, patients with a suspected infection and a qSOFA score of 2 or higher were included and followed up until death or hospital discharge. qSOFA was measured at inclusion, 1 h and 3 h. Primary end point was in-hospital mortality, truncated at 28 days. RESULTS: Of 534 recruited patients, 512 were included in the analysis. The qSOFA was improved at 3 h (ΔqSOFA < 0) in 287 (55%) patients. Overall in-hospital mortality was 27%: 44% when ΔqSOFA greater than 0, 36% when ΔqSOFA = 0, and 18% when ΔqSOFA less than 0. A positive ΔqSOFA was independently associated with reduced in-hospital mortality (adjusted hazard ratio of 0.48, 95% confidence interval: 0.34-0.68). After modeling qSOFA kinetics in the first 3 h, there was a significant difference in adjusted slopes between patients who died and those who survived (0.15, 95% confidence interval: 0.09-0.22, P < 0.001). CONCLUSION: In patients with suspected infection presenting to the ED with a qSOFA of 2 or higher, the early change in qSOFA is a strong independent predictor of mortality.