Validation of Quick-Sepsis Organ Failure Assessment (Q-SOFA) In Prehospital Care

Validation of Quick-Sepsis Organ Failure Assessment (Q-SOFA) In Prehospital Care

The Third International Consensus Definitions for Sepsis Task Force has played a critical role in defining sepsis, providing guidelines for its identification in the in-patient setup as well as appropriate management procedures. By defining sepsis as “life-threatening organ dysfunction to a dysregulated host response to infection,” the task force recommended the use of qSOFA for easy identification of patients since 70% of those with 2 or 3 qSOFA scores were highly likely to die if no appropriate management was instituted in time (1). However, some studies carried out in the recent past have invalidated the scoring approach and opted to use other methods to identify patients at risk of dying from sepsis or severe sepsis, leading to organ failures such as the SOFA, LODS, and SIRS criteria. Hence, the literature review provides a critical analysis of the QSOFA score from literature with the view of revalidating it as the quickest and most reliable bedside tool for preventing the late diagnosis of organ failure.

A significant challenge that faces the qSOFA score is its acceptance as a reliable tool for early identification of sepsis and related complications. In a meta-analysis involving 121 studies carried out by Herwanto et al., these challenges were exposed as well as the approach to mitigate them that ensures the score remains an invaluable tool in the hospital and patient care setups (2). The authors realized that the acceptance of qSOFA by clinicians could be predicted on the evidence that it predicts outcomes consistently and reliably in various patient populations and differing setups. The authors used 121 studies comprising (n=1,716,017) patients to confirm that the score was capable of predicting sepsis outcomes in all populations and clinical settings (2). Also, the study revealed a modest qSOFA performance at 0.702 AUC for mortality. Herwanto et al. were also able to confirm that the tool was superior to other existing scoring systems and outperformed the SIRS criteria in all aspects.

Indeed, in a similar study conducted by Song et al. (3), a total of 23 studies were identified that contained (n=146,555) patients. The authors aimed at predicting the in-hospital mortality in the meta-analysis. Concerning sensitivity, the authors realized that qSOFA posted a positive score of 0.51 in comparison to 0.86 for the SIRS score. On the other hand, qSOFA posted a positive specificity score of 0.83 in comparison to 0.29 for SIRS. With these results, the authors affirmed that a positive qSOFA score had the highest sensitivity for detecting in-hospital sepsis-related mortality outside the ICU. Besides, the positive specificity score for the tool was also high concerning identifying acute organ dysfunction and the need for ICU admission as compared to SIRS criteria. However, the authors also realized that the qSOFA tool had low sensitivity that posed an excellent limitation for predicting adverse outcomes (3). Hence, in both studies (2,3), sensitivity arises as a limiting factor that may prevent the worldwide acceptability of the scoring tool by clinicians. The limitation is also confirmed by Dorsett et al. in a retrospective study that evaluates both specificity and sensitivity of the qSOFA score of ≥ 2. In this study, patients coming to the Emergency Department (ED) were categorized as either having sepsis (n=38) or not (n=71). Those with septic shock were (n=43). The results for the study indicated that a qSOFA score ≥ 2 was only 16.3% sensitive even though the specificity was over the roof at 97.3% (4). Hence, the authors concluded that sepsis is challenging, and this makes sensitive detection a hard task, especially in the prehospital setting, using the qSOFA score due to its low sensitivity (4). However, the authors are also quick to note that when qSOFA is combined with other clinical information, the sensitivity can rise significantly, leading to more accurate diagnoses of patients with sepsis or organ failure requiring emergency management.

In another study conducted using an international prospective cohort involving 30 participant emergency departments across four European countries, the authors aimed at prospective validation of the qSOFA as a mortality predictor by comparing its performance to other sepsis criteria such as SIRS and severe sepsis scores. Using a total of (n=879) patients with a median age of 67 years, of which 47% were women, Freund et al. found out that the qSOFA score outperformed SIRS and severe sepsis in predicting in-hospital mortality (5). The results showed an AUC of 0.8 compared to 0.65 for the other two scoring systems also;, the authors realized that the hazard ratio of qSOFA stood at 6.2 as compared to 3.5 for severe sepsis, yet another critical indicator of its effectiveness. As such, Freund et al. affirmed that qSOFA provided the highest prognostic accuracy for in-hospital mortality in the cohort of patients presenting to the emergency departments across the four countries who were suspected of having an infection (5). Such conclusions support the Task Force’s decision to incorporate the new scoring system in the emergency diagnosis of sepsis and related conditions across the world for favorable morbidity and mortality outcomes.

Another study that shows the performance of qSOFA is a retrospective cohort involving 422 adults admitted to a hospital with Staphylococcus aureus bacteremia. The authors used medical charts to calculate the qSOFA score, the SIRS criteria as well as the Pitt bacteremia score for the participants, and predictive values compared for the need for ICU admission at presentation, within 48 hours and after 72 hours (6). Also, the data was used to compare 30-day mortality. According to the authors, 22% of the patients had a qSOFA of ≥ 2. The results indicated that predictive performance was better with the qSOFA than SIRS criteria. In addition, patients who had ≥ 2 score had poor outcomes. Hence, the authors concluded that qSOFA is simple, easy to calculate and is more specific than other tools in identifying septic patients who are at the most significant risk of having poor outcomes. Such findings also mirror a study conducted by Probst et al. (7), who also concluded that an increase in qSOFA score of ≥ 2 exhibited better prognostic accuracy for predicting mortality in hospitals and, more so, the ICU. Hence, the authors were quick to point out that the tool can be used effectively in evaluating the risk of sepsis in patients with hematological conditions with the highest risk of death (7). Therefore, appropriate interventions can be instituted to change outcomes only when the clinicians fully understand the tools and integrate them appropriately.

To conclude, the literature review offers insight into the role of qSOFA in the management of patients within the hospital setup. Not only is a tool that effectively predicts sepsis and related outcomes but also the mortality associated with such diagnoses. Indeed, the review shows how remarkably useful the tool is, and its high positive specificity. Even though most of the studies reveal the low sensitivity as a significant limitation, the present study aims to show that qSOFA is still the most reliable bedside tool in the management of patients and should be integrated into all departments dealing with sepsis and organ failure daily.