Original Contributions| Volume 57, ISSUE 4, P453-460.e2, October 2019

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Clinical Scores and Formal Triage for Screening of Sepsis and Adverse Outcomes on Arrival in an Emergency Department All-Comer Cohort

Published:September 06, 2019DOI:



      Early recognition of sepsis remains a major challenge. The clinical utility of the Quick Sepsis-Related Organ Failure Assessment (qSOFA) score is still undefined. Several studies have tested its prognostic value. However, its ability to diagnose sepsis is still unknown.


      Our aim was to compare the performance of qSOFA, systemic inflammatory response syndrome (SIRS) criteria, National Early Warning Score (NEWS), and formal triage with the Emergency Severity Index (ESI) algorithm to identify patients with sepsis and predict adverse outcomes on arrival in an emergency department (ED) all-comer cohort.


      We included all patients presenting consecutively to the ED during a 3-week period. We used vital signs recorded at triage to calculate the study scores. Two independent assessors retrospectively assigned the primary outcome of sepsis according to Third International Consensus Definitions for Sepsis and Septic Shock criteria in a chart review process.


      There were 2523 cases included in the analysis and 39 (1.6%) had the primary outcome of sepsis. The area under the curve for sepsis was 0.79 (95% confidence interval [CI] 0.71–0.86) for qSOFA, 0.81 (95% CI 0.73–0.87) for SIRS, 0.85 (95% CI 0.77–0.92) for NEWS, and 0.77 (95% CI 0.70–0.83) for ESI.


      qSOFA offered high specificity for the prediction of sepsis and adverse outcomes. However, its low sensitivity does not support widespread use as a screening tool for sepsis. NEWS outperformed qSOFA for prediction of adverse outcomes and screening for sepsis.


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        • Levy M.M.
        • Evans L.E.
        • Rhodes A.
        The surviving sepsis campaign bundle: 2018 update.
        Intensive Care Med. 2018; 46: 997-1000
        • Singer M.
        • Deutschman C.S.
        • Seymour C.W.
        • et al.
        The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).
        JAMA. 2016; 315: 801-810
        • Singer M.
        • Shankar-Hari M.
        qSOFA, cue confusion.
        Ann Intern Med. 2018; 168: 293-295
        • Seymour C.W.
        • Liu V.X.
        • Iwashyna T.J.
        • et al.
        Assessment of clinical criteria for sepsis: for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).
        JAMA. 2016; 315: 762-774
        • Lo R.S.
        • Brabrand M.
        • Kurland L.
        • Graham C.A.
        Sepsis—where are the emergency physicians?.
        Eur J Emerg Med. 2016; 23: 159
        • Simpson S.Q.
        New sepsis criteria: a change we should not make.
        Chest. 2016; 149: 1117-1118
        • Franchini S.
        • Duca A.
        qSOFA should replace SIRS as the screening tool for sepsis.
        Crit Care. 2016; 20: 409
        • Umemura Y.
        • Ogura H.
        • Gando S.
        • et al.
        Assessment of mortality by qSOFA in patients with sepsis outside ICU: a post hoc subgroup analysis by the Japanese Association for Acute Medicine Sepsis Registry Study Group.
        J Infect Chemother. 2017; 23: 757-762
        • Freund Y.
        • Lemachatti N.
        • Krastinova E.
        • 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: 301-308
        • Singer A.J.
        • Ng J.
        • Thode Jr., H.C.
        • Spiegel R.
        • Weingart S.
        Quick SOFA scores predict mortality in adult emergency department patients with and without suspected infection.
        Ann Emerg Med. 2017; 69: 475-479
        • Askim Å.
        • Moser F.
        • Gustad L.T.
        • 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; 25: 56
        • Goulden R.
        • Hoyle M.-C.
        • Monis J.
        • et al.
        qSOFA, SIRS and NEWS for predicting inhospital mortality and ICU admission in emergency admissions treated as sepsis.
        Emerg Med J. 2018; 35: 345-349
        • Churpek M.M.
        • Snyder A.
        • Han X.
        • 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: 906-911
        • Rodriguez R.M.
        • Greenwood J.C.
        • Nuckton T.J.
        • et al.
        Comparison of qSOFA with current emergency department tools for screening of patients with sepsis for critical illness.
        Emerg Med J. 2018; 35: 350-356
        • Grossmann F.F.
        • Nickel C.H.
        • Christ M.
        • Schneider K.
        • Spirig R.
        • Bingisser R.
        Transporting clinical tools to new settings: cultural adaptation and validation of the Emergency Severity Index in German.
        Ann Emerg Med. 2011; 57: 257-264
        • Lauks J.
        • Mramor B.
        • Baumgartl K.
        • Maier H.
        • Nickel C.H.
        • Bingisser R.
        Medical team evaluation: effect on emergency department waiting time and length of stay.
        PLoS One. 2016; 11: e0154372
        • Royal College of Physicians
        National Early Warning Score (NEWS): Standardising the Assessment of Acute Illness Severity in the NHS.
        Royal College of Physicians, London2012
        • Bone R.C.
        • Balk R.A.
        • Cerra F.B.
        • et al.
        Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.
        Chest. 1992; 101: 1644-1655
        • McKibben L.
        • Horan T.
        • Tokars J.I.
        • et al.
        Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee.
        Am J Infect Control. 2005; 33: 217-226
        • Inada-Kim M.
        • Page B.
        • Maqsood I.
        • Vincent C.
        Defining and measuring suspicion of sepsis: an analysis of routine data.
        BMJ Open. 2017; 7: e014885
        • Worster A.
        • Bledsoe R.D.
        • Cleve P.
        • Fernandes C.M.
        • Upadhye S.
        • Eva K.
        Reassessing the methods of medical record review studies in emergency medicine research.
        Ann Emerg Med. 2005; 45: 448-451
        • Worster A.
        • Haines T.
        Advanced statistics: understanding medical record review (MRR) studies.
        Acad Emerg Med. 2004; 11: 187-192
        • Szakmany T.
        • Lundin R.M.
        • Sharif B.
        • et al.
        Sepsis prevalence and outcome on the general wards and emergency departments in Wales: results of a multi-centre, observational, point prevalence study.
        PLoS One. 2016; 11: e0167230
        • Moreno R.
        • Afonso S.
        • Fevereiro T.
        Incidence of sepsis in hospitalized patients.
        Curr Infect Dis Rep. 2006; 8: 346-350
        • Martin G.S.
        Sepsis, severe sepsis and septic shock: changes in incidence, pathogens and outcomes.
        Exp Rev Anti Infect Ther. 2012; 10: 701-706