Epidemiology of Quick Sequential Organ Failure Assessment Criteria in Undifferentiated Patients and Association With Suspected Infection and Sepsis

Abstract

Background: The role of Quick Sequential Organ Failure Assessment (qSOFA) criteria in sepsis screening and management is controversial, particularly as they were derived only in patients with suspected infection. We examined the epidemiology and prognostic value of qSOFA in undifferentiated patients.

Methods: We identified patients with ≥ 2 qSOFA criteria within 1 day of admission among all adults admitted to 85 US hospitals from 2012 to 2015 and assessed for suspected infection (using clinical cultures and administration of antibiotics) and sepsis (as defined on the basis of Sepsis-3 criteria). We also examined the discrimination of qSOFA for in-hospital mortality among patients with and without suspected infection, using regression models.

Results: Of 1,004,347 hospitalized patients, 271,500 (27.0%) were qSOFA-positive on admission. Compared with qSOFA-negative patients, qSOFA-positive patients were older (median age, 65 vs 58 years), required ICU admission more often (28.5% vs 6.5%), and had higher mortality (6.7% vs 0.8%) (P < .001 for all comparisons). Sensitivities of qSOFA for suspected infection and sepsis were 41.3% (95% CI, 41.1%-41.5%) and 62.8% (95% CI, 62.4%-63.1%), respectively; positive predictive values were 31.0% (95% CI, 30.8%-31.1%) and 17.4% (95% CI, 17.2%-17.5%). The area under the receiver operating characteristic curve for mortality was lower for qSOFA in patients with suspected infection vs those without (0.814 vs 0.875; P < .001).

Conclusions: Only one in three patients who are qSOFA-positive on admission has suspected infection, and one in six has sepsis. qSOFA also has low sensitivity for identifying suspected infection and sepsis, and its prognostic significance is not specific to infection. More sensitive and specific tools for sepsis screening and risk stratification are needed.

Keywords: epidemiology; infection; organ function/dysfunction; qSOFA; sepsis.

Figure 1

Flowchart for study cohort derivation. GCS = Glasgow Coma Scale; qSOFA = Quick Sequential Organ Failure Assessment; RR = respiratory rate; SBP = systolic blood pressure.

Figure 2

Fold change in rate of in-hospital mortality by deciles of baseline risk of death for ≥ 2 qSOFA criteria vs < 2 qSOFA criteria in patients with and without suspected infection on admission. The x axis divides the cohort into deciles of baseline risk, which were created on the basis of age, sex, race, and Elixhauser Comorbidity Index. The y axis shows the fold increase in the odds of death (log scale) for a patient with suspected infection or without suspected infection who meets ≥ 2 qSOFA criteria for each decile of risk. For example, a patient who falls into the 5th decile of baseline risk (based on moderate burden of comorbidities) with suspected infection (eg, pneumonia) has an approximately 10-fold increased odds of death if he has ≥ 2 qSOFA criteria vs < 2 qSOFA criteria. He has similarly increased odds of death with ≥ 2 qSOFA criteria vs < 2 qSOFA criteria even if he did not have suspected infection. See Figure 1 legend for expansion of abbreviation.