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Comparison of SIRS, qSOFA, and NEWS for the early identification of sepsis in the Emergency Department

  • Omar A. Usman
    Affiliations
    Center for Health Policy, Primary Care and Outcomes Research, Stanford University, 117 Encina Commons, Stanford, CA 94305-6006, United States of America

    Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, 795 Willow Road (152-MPD), Menlo Park, CA 94025, United States of America
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  • Asad A. Usman
    Affiliations
    Department of Anesthesiology and Critical Care, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States of America
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  • Michael A. Ward
    Correspondence
    Corresponding author at: 800 University Dr., Suite 310, Madison, WI 53705, United States of America.
    Affiliations
    Department of Emergency Medicine, University of Wisconsin-Madison, 800 University Dr. Suite 310, Madison, WI 53705, United States of America
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Published:November 07, 2018DOI:https://doi.org/10.1016/j.ajem.2018.10.058

      Abstract

      Objectives

      The increasing use of sepsis screening in the Emergency Department (ED) and the Sepsis-3 recommendation to use the quick Sepsis-related Organ Failure Assessment (qSOFA) necessitates validation. We compared Systemic Inflammatory Response Syndrome (SIRS), qSOFA, and the National Early Warning Score (NEWS) for the identification of severe sepsis and septic shock (SS/SS) during ED triage.

      Methods

      This was a retrospective analysis from an urban, tertiary-care academic center that included 130,595 adult visits to the ED, excluding dispositions lacking adequate clinical evaluation (n = 14,861, 11.4%). The SS/SS group (n = 930) was selected using discharge diagnoses and chart review. We measured sensitivity, specificity, and area under the receiver-operating characteristic (AUROC) for the detection of sepsis endpoints.

      Results

      NEWS was most accurate for triage detection of SS/SS (AUROC = 0.91, 0.88, 0.81), septic shock (AUROC = 0.93, 0.88, 0.84), and sepsis-related mortality (AUROC = 0.95, 0.89, 0.87) for NEWS, SIRS, and qSOFA, respectively (p < 0.01 for NEWS versus SIRS and qSOFA). For the detection of SS/SS (95% CI), sensitivities were 84.2% (81.5–86.5%), 86.1% (83.6–88.2%), and 28.5% (25.6–31.7%) and specificities were 85.0% (84.8–85.3%), 79.1% (78.9–79.3%), and 98.9% (98.8–99.0%) for NEWS ≥ 4, SIRS ≥ 2, and qSOFA ≥ 2, respectively.

      Conclusions

      NEWS was the most accurate scoring system for the detection of all sepsis endpoints. Furthermore, NEWS was more specific with similar sensitivity relative to SIRS, improves with disease severity, and is immediately available as it does not require laboratories. However, scoring NEWS is more involved and may be better suited for automated computation. QSOFA had the lowest sensitivity and is a poor tool for ED sepsis screening.

      Abbreviations:

      NEWS (National Early Warning Score), AVPU (Alert, Voice, Pain, Unresponsive), AUROC (area under the receiver-operating characteristic curve)

      Keywords

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      References

        • Rhodes A.
        • Evans L.E.
        • Alhazzani W.
        • Levy M.M.
        • Antonelli M.
        • Ferrer R.
        • et al.
        Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016.
        Crit Care Med. 2017; 45: 486-552https://doi.org/10.1097/CCM.0000000000002255
        • Funk D.
        • Sebat F.
        • Kumar A.
        A systems approach to the early recognition and rapid administration of best practice therapy in sepsis and septic shock.
        Curr Opin Crit Care. 2009; 15: 301-307https://doi.org/10.1097/MCC.0b013e32832e3825
        • Rivers E.
        • Nguyen B.
        • Havstad S.
        • Ressler J.
        • Muzzin A.
        • Knoblich B.
        • et al.
        Early goal-directed therapy in the treatment of severe sepsis and septic shock.
        N Engl J Med. 2001; 345: 1368-1377
        • Shapiro N.I.
        • Howell M.D.
        • Talmor D.
        • Donnino M.
        • Ngo L.
        • Bates D.W.
        Mortality in Emergency Department Sepsis (MEDS) score predicts 1-year mortality.
        Crit Care Med. 2007; 35: 192-198https://doi.org/10.1097/01.CCM.0000251508.12555.3E
        • Levy M.M.
        • Fink M.P.
        • Marshall J.C.
        • Abraham E.
        • Angus D.
        • Cook D.
        • et al.
        2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference.
        Intensive Care Med. 2003; 29: 530-538https://doi.org/10.1007/s00134-003-1662-x
        • Barriere S.L.
        • Lowry S.F.
        An overview of mortality risk prediction in sepsis.
        Crit Care Med. 1995; 23: 376-393
        • Crowe C.A.
        • Kulstad E.B.
        • Mistry C.D.
        • Kulstad C.E.
        Comparison of severity of illness scoring systems in the prediction of hospital mortality in severe sepsis and septic shock.
        J Emerg Trauma Shock. 2010; 3: 342-347https://doi.org/10.4103/0974-2700.70761
        • Macdonald S.P.J.
        • Arendts G.
        • Fatovich D.M.
        • Brown S.G.A.
        Comparison of PIRO, SOFA, and MEDS scores for predicting mortality in Emergency Department patients with severe sepsis and septic shock.
        Acad Emerg Med. 2014; 21: 1257-1263https://doi.org/10.1111/acem.12515
        • Shapiro N.I.
        • Wolfe R.E.
        • Moore R.B.
        • Smith E.
        • Burdick E.
        • Bates D.W.
        Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule.
        Crit Care Med. 2003; 31: 670-675https://doi.org/10.1097/01.CCM.0000054867.01688.D1
        • Williams J.M.
        • Greenslade J.H.
        • McKenzie J.V.
        • Chu K.
        • Brown A.F.T.
        • Lipman J.
        Systemic inflammatory response syndrome, quick sequential organ function assessment, and organ dysfunction: insights from a prospective database of ED patients with infection.
        Chest. 2017; 151: 586-596https://doi.org/10.1016/j.chest.2016.10.057
        • McLymont N.
        • Glover G.W.
        Scoring systems for the characterization of sepsis and associated outcomes.
        Ann Transl Med. 2016; 4 (527-527)https://doi.org/10.21037/atm.2016.12.53
        • Singer M.
        • Deutschman C.S.
        • Seymour C.W.
        • Shankar-Hari M.
        • Annane D.
        • Bauer M.
        • et al.
        The third international consensus definitions for sepsis and septic shock (Sepsis-3).
        JAMA. 2016; 315: 801https://doi.org/10.1001/jama.2016.0287
        • Simpson S.Q.
        New sepsis criteria: a change we should not make.
        Chest. 2016; 149: 1117-1118https://doi.org/10.1016/j.chest.2016.02.653
        • Vincent J.-L.
        • Martin G.S.
        • Levy M.M.
        qSOFA does not replace SIRS in the definition of sepsis.
        Crit Care. 2016; 20https://doi.org/10.1186/s13054-016-1389-z
        • Bone R.C.
        • Balk R.A.
        • Cerra F.B.
        • Dellinger R.P.
        • Fein A.M.
        • Knaus W.A.
        • et al.
        Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.
        Chest. 1992; 101: 1644-1655https://doi.org/10.1378/chest.101.6.1644
        • Opal S.M.
        The uncertain value of the definition for SIRS.
        Chest. 1998; 113: 1442-1443https://doi.org/10.1378/chest.113.6.1442
        • Vincent J.-L.
        Sepsis definitions.
        Lancet Infect Dis. 2002; 2: 135https://doi.org/10.1016/S1473-3099(02)00232-3
        • Alberti C.
        • Brun-Buisson C.
        • Goodman S.V.
        • Guidici D.
        • Granton J.
        • Moreno R.
        • et al.
        Influence of systemic inflammatory response syndrome and sepsis on outcome of critically ill infected patients.
        Am J Respir Crit Care Med. 2003; 168: 77-84https://doi.org/10.1164/rccm.200208-785OC
        • Seymour C.W.
        • Liu V.X.
        • Iwashyna T.J.
        • Brunkhorst F.M.
        • Rea T.D.
        • Scherag A.
        • et al.
        Assessment of clinical criteria for sepsis: for the third international consensus definitions for sepsis and septic shock (Sepsis-3).
        JAMA. 2016; 315: 762-774https://doi.org/10.1001/jama.2016.0288
        • Donnelly J.P.
        • Safford M.M.
        • Shapiro N.I.
        • Baddley J.W.
        • Wang H.E.
        Application of the third international consensus definitions for sepsis (Sepsis-3) classification: a retrospective population-based cohort study.
        Lancet Infect Dis. 2017; 17: 661-670https://doi.org/10.1016/S1473-3099(17)30117-2
        • Freund Y.
        • Lemachatti N.
        • Krastinova E.
        • Van Laer M.
        • Claessens Y.-E.
        • Avondo A.
        • et al.
        Prognostic accuracy of Sepsis-3 criteria for in-hospital mortality among patients with suspected infection presenting to the Emergency Department.
        JAMA. 2017; 317: 301-308https://doi.org/10.1001/jama.2016.20329
        • Finkelsztein E.J.
        • Jones D.S.
        • Ma K.C.
        • Pabón M.A.
        • Delgado T.
        • Nakahira K.
        • et al.
        Comparison of qSOFA and SIRS for predicting adverse outcomes of patients with suspicion of sepsis outside the intensive care unit.
        Crit Care. 2017; 21https://doi.org/10.1186/s13054-017-1658-5
        • Hayden G.E.
        • Tuuri R.E.
        • Scott R.
        • Losek J.D.
        • Blackshaw A.M.
        • Schoenling A.J.
        • et al.
        Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED.
        Am J Emerg Med. 2016; 34: 1-9https://doi.org/10.1016/j.ajem.2015.08.039
        • Jones S.L.
        • Ashton C.M.
        • Kiehne L.
        • Gigliotti E.
        • Bell-Gordon C.
        • Disbot M.
        • et al.
        Reductions in sepsis mortality and costs after design and implementation of a nurse-based early recognition and response program.
        Jt Comm J Qual Patient Saf. 2015; 41: 483-491
        • Rees J.E.
        • Mann C.
        Use of the patient at risk scores in the emergency department: a preliminary study.
        Emerg Med J EMJ. 2004; 21: 698-699https://doi.org/10.1136/emj.2003.006197
        • Subbe C.P.
        • Slater A.
        • Menon D.
        • Gemmell L.
        Validation of physiological scoring systems in the accident and emergency department.
        Emerg Med J EMJ. 2006; 23: 841-845https://doi.org/10.1136/emj.2006.035816
        • Corfield A.R.
        • Lees F.
        • Zealley I.
        • Houston G.
        • Dickie S.
        • Ward K.
        • et al.
        Utility of a single early warning score in patients with sepsis in the emergency department.
        Emerg Med J. 2014; 31: 482-487https://doi.org/10.1136/emermed-2012-202186
        • de Groot B.
        • Stolwijk F.
        • Warmerdam M.
        • Lucke J.A.
        • Singh G.K.
        • Abbas M.
        • et al.
        The most commonly used disease severity scores are inappropriate for risk stratification of older emergency department sepsis patients: an observational multi-centre study.
        Scand J Trauma Resusc Emerg Med. 2017; 25: 91https://doi.org/10.1186/s13049-017-0436-3
        • Keep J.W.
        • Messmer A.S.
        • Sladden R.
        • Burrell N.
        • Pinate R.
        • Tunnicliff M.
        • et al.
        National early warning score at Emergency Department triage may allow earlier identification of patients with severe sepsis and septic shock: a retrospective observational study.
        Emerg Med J. 2016; 33: 37-41https://doi.org/10.1136/emermed-2014-204465
        • Jones A.E.
        • Saak K.
        • Kline J.A.
        Performance of the mortality in emergency department Sepsis score for predicting hospital mortality among patients with severe sepsis and septic shock.
        Am J Emerg Med. 2008; 26: 689-692https://doi.org/10.1016/j.ajem.2008.01.009
        • Ghanem-Zoubi N.O.
        • Vardi M.
        • Laor A.
        • Weber G.
        • Bitterman H.
        Assessment of disease-severity scoring systems for patients with sepsis in general internal medicine departments.
        Crit Care. 2011; 15: R95
        • Andaluz D.
        • Ferrer R.
        SIRS, qSOFA, and organ failure for assessing sepsis at the emergency department.
        J Thorac Dis. 2017; 9: 1459-1462https://doi.org/10.21037/jtd.2017.05.36
        • ProCESS Investigators
        • Yealy D.M.
        • Kellum J.A.
        • Huang D.T.
        • Barnato A.E.
        • Weissfeld L.A.
        • et al.
        A randomized trial of protocol-based care for early septic shock.
        N Engl J Med. 2014; 370: 1683-1693https://doi.org/10.1056/NEJMoa1401602
        • Prytherch D.R.
        • Smith G.B.
        • Schmidt P.E.
        • Featherstone P.I.
        ViEWS—towards a national early warning score for detecting adult inpatient deterioration.
        Resuscitation. 2010; 81: 932-937https://doi.org/10.1016/j.resuscitation.2010.04.014
        • The Royal College of Physicians
        National early warning score (NEWS): standardising the assessment of acute-illness severity in the NHS.
        The Royal College of Physicians, London2012
        • Churpek M.M.
        • Snyder A.
        • Han X.
        • Sokol S.
        • Pettit N.
        • Howell M.D.
        • et al.
        Quick sepsis-related organ failure assessment, systemic inflammatory response syndrome, and early warning scores for detecting clinical deterioration in infected patients outside the intensive care unit.
        Am J Respir Crit Care Med. 2017; 195: 906-911https://doi.org/10.1164/rccm.201604-0854OC
        • R Core Team
        R: a language and environment for statistical computing.
        R Foundation for Statistical Computing, Vienna, Austria2017
        • Sing T.
        • Sander O.
        • Beerenwinkel N.
        • Lengauer T.
        ROCR: visualizing the performance of scoring classifiers.
        R package, 2015
        • LeDell E.
        • Petersen M.
        • van der Laan M.
        cvAUC: cross-validated area under the ROC curve confidence intervals.
        R package, 2014
        • Hanley J.A.
        • McNeil B.J.
        The meaning and use of the area under a receiver operating characteristic (ROC) curve.
        Radiology. 1982; 143: 29-36https://doi.org/10.1148/radiology.143.1.7063747
        • Hanley J.A.
        • McNeil B.J.
        A method of comparing the areas under receiver operating characteristic curves derived from the same cases.
        Radiology. 1983; 148: 839-843https://doi.org/10.1148/radiology.148.3.6878708
        • Askim Å.
        • Moser F.
        • Gustad L.T.
        • Stene H.
        • Gundersen M.
        • Åsvold B.O.
        • 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; 25https://doi.org/10.1186/s13049-017-0399-4
        • April M.D.
        • Aguirre J.
        • Tannenbaum L.I.
        • Moore T.
        • Pingree A.
        • Thaxton R.E.
        • et al.
        Sepsis clinical criteria in Emergency Department patients admitted to an intensive care unit: an external validation study of quick sequential organ failure assessment.
        J Emerg Med. 2017; 52: 622-631https://doi.org/10.1016/j.jemermed.2016.10.012
        • Talmor D.
        • Jones A.E.
        • Rubinson L.
        • Howell M.D.
        • Shapiro N.I.
        Simple triage scoring system predicting death and the need for critical care resources for use during epidemics.
        Crit Care Med. 2007; 35: 1251-1256https://doi.org/10.1097/01.CCM.0000262385.95721.CC
        • Roland D.
        • Coats T.J.
        An early warning? Universal risk scoring in emergency medicine.
        Emerg Med J EMJ. 2011; 28: 263https://doi.org/10.1136/emj.2010.106104
        • Morgan R.J.M.
        • Williams F.
        • Wright M.M.
        An early warning scoring system for detecting developing critical illness.
        Clin Intensive Care. 1997; 8: 100
        • Cuthbertson B.H.
        • Smith G.B.
        A warning on early-warning scores!.
        Br J Anaesth. 2007; 98: 704-706https://doi.org/10.1093/bja/aem121
        • Smith G.B.
        • Prytherch D.R.
        • Schmidt P.E.
        • Featherstone P.I.
        Review and performance evaluation of aggregate weighted “track and trigger” systems.
        Resuscitation. 2008; 77: 170-179https://doi.org/10.1016/j.resuscitation.2007.12.004
        • Jaimes F.
        • Garcés J.
        • Cuervo J.
        • Ramírez F.
        • Ramírez J.
        • Vargas A.
        • et al.
        The systemic inflammatory response syndrome (SIRS) to identify infected patients in the emergency room.
        Intensive Care Med. 2003; 29: 1368-1371https://doi.org/10.1007/s00134-003-1874-0
        • Subbe C.P.
        • Kruger M.
        • Rutherford P.
        • Gemmel L.
        Validation of a modified early warning score in medical admissions.
        QJM Mon J Assoc Physicians. 2001; 94: 521-526
        • Duckitt R.W.
        • Buxton-Thomas R.
        • Walker J.
        • Cheek E.
        • Bewick V.
        • Venn R.
        • et al.
        Worthing physiological scoring system: derivation and validation of a physiological early-warning system for medical admissions. An observational, population-based single-centre study.
        Br J Anaesth. 2007; 98: 769-774https://doi.org/10.1093/bja/aem097
        • Olsson T.
        • Terént A.
        • Lind L.
        Rapid emergency medicine score: a new prognostic tool for in-hospital mortality in nonsurgical emergency department patients.
        J Intern Med. 2004; 255: 579-587
        • Howell M.D.
        • Donnino M.W.
        • Talmor D.
        • Clardy P.
        • Ngo L.
        • Shapiro N.I.
        Performance of severity of illness scoring systems in Emergency Department patients with infection.
        Acad Emerg Med. 2007; 14: 709-714https://doi.org/10.1197/j.aem.2007.02.036