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The current definition of sepsis (Sepsis-3) encourages the use of a new tool, the quick sequential organ failure assessment (qSOFA), to identify patients at risk for poor outcomes (NEJM JW Emerg Med Apr 2016 and JAMA 2016; 315:762). The qSOFA is comprised of altered mental status, respiratory rate ≥22, and systolic blood pressure ≤100 mm Hg. The Sepsis-3 authors also recommend that providers consider infection in patients with two or more positive qSOFA criteria. This recommendation has been criticized for lacking face validity, given that none of the qSOFA criteria are specific to infection.
To assess the prognostic value of qSOFA, researchers performed a retrospective database review of roughly 1 million adult patients admitted to 85 U.S. hospitals from 2012 to 2015. Overall, 27% of patients were qSOFA-positive on admission. These patients had significantly higher rates of in-hospital mortality (6.7% vs. 0.8%) and ICU admission (28.5% vs. 6.5%) than qSOFA-negative patients. However, only 31% qSOFA-positive patients had suspected infection and 17.4% had suspected sepsis at the time of admission. At discharge, the proportion of qSOFA-positive patients with a diagnosis of infection or sepsis remained low (40.4% and 13.3%, respectively).
Anand V et al. Epidemiology of qSOFA criteria in undifferentiated patients and association with suspected infection and sepsis. Chest 2019 Apr 9; [e-pub]. (https://doi.org/10.1016/j.chest.2019.03.032)
Comment
The poor positive predictive value of qSOFA for identifying infection or sepsis in this large database study is not surprising. Providers are under increasing pressure from regulatory and reimbursement agencies to immediately diagnose and treat suspected sepsis, and many hospitals use quick screening tools like qSOFA to identify potentially septic patients. However, the use of this screening tool for infection or sepsis could result in an enormous number of patients receiving unnecessary and potentially harmful interventions and should be reevaluated.