Columns, Patient Care

Is qSOFA the ‘Holy Grail’ of Sepsis Research?

Issue 1 and Volume 43.

 

Dorsett M, Kroll M, Smith C, et al. qSOFA has poor sensitivity for prehospital identification of severe sepsis and septic shock. Prehosp Emerg Care. 2017;21(4):489–497.

The Science

The authors reviewed the medical records, including the EMS report, of 152 patients arriving by EMS at a large urban ED and who were diagnosed with an infection (n = 71), sepsis (n = 38) or severe sepsis (n = 43).

The records were examined for signs and symptoms that are components of a sepsis scoring scheme called quick sequential organ failure assessment (qSOFA), which could’ve been performed by the EMS providers.

The qSOFA score ranges from 0 to 3, with one point awarded for each of the following, if present on exam: Systolic blood pressure < 100 mmHg; respiratory rate > 22 and altered mental status. A score of 2 or 3 has been proposed to correlate with the presence of sepsis.

They discovered that an EMS score of 2 was 16.3% sensitive (95% confidence interval [CI] 6.8–30.7%) and 97.3% specific (95% CI 92.1–99.4%) for patients confirmed to have severe sepsis.

Had the medics been allowed to add an additional point for such things as a pulse over 100, nursing home residence, age > 50, or history of a fever, the sensitivity of the qSOFA would’ve increased to 58.1% (95% CI 42.1–73.0%), but decreased the specificity to 78.0% (95% CI 69.0–85.4%)

During their stay in the ED, two-thirds of patients who met the EMS qSOFA criteria developed sufficient symptoms to have a qSOFA score of 2 or more. The most common factors causing the EMS score to remain less than 2 was the lack of hypotension and/or rapid respirations ( > 22).

The authors concluded that, “These findings suggest that the dynamic nature of sepsis can make sensitive detection difficult in the prehospital setting, although combining qSOFA with other clinical information (e.g., age, nursing home status, fever and tachycardia) can identify more patients with sepsis who may benefit from time critical interventions.”

Medic Wesley Comments

EMS has finally been tasked to look for things that impact outcomes. Our practice has grown in knowledge and scope, resulting in significant changes in the survival of our patients. However, it needs to be said that not everything that works in the hospital setting also works in the prehospital setting.

The author’s changes to qSOFA for the ED didn’t help until the patients had been there for hours. If it didn’t work in the ED with a large team of resources, why should it work in the field?

The inclusive criteria of qSOFA are vague when considering the elderly patient. To be honest, I could probably get a 3 on this scale before I have my first cup of coffee in the morning.

Once you add the “nursing home” factors of dehydration and environment, you could probably hit or miss with this scale on any patient contact.

Without on-site lab tests, the best we can do to help make the diagnosis of sepsis is to have a strong index of suspicion and, when possible, a good history.

By the way, isn’t it strange that we accept chronic dehydration in long-term care patients as the norm? But, that’s another story.

Doc Wesley Comments

Early goal-directed therapy of sepsis has been promoted by studies showing that the most important step in sepsis treatment is detection.

Sepsis is a sneaky condition and it can often present with vague, slowly progressive changes in signs and symptoms. The fact that it’s more common in the elderly population is well-known, but that only makes the condition even harder to detect because of the pre-existing conditions of dementia (i.e., altered mental status) and chronic dehydration, particularly in nursing home residents.

In the absence of lab tests like serum lactate, white blood cell count and cultures, we must rely on our clinical suspicion.

For these reasons, the development of a rapid and easily performed scoring system has been the Holy Grail of sepsis research.

This study confirms what several others have already done: There is no Holy Grail of sepsis research.

You can spend all the time you want calculating scores like qSOFA, Robson, Modified Robson, BAS 90-30-90, PRESEP, PRESS, Querra, or even the new and improved qSOFA PLUS proposed by this study—and you’ll still miss a lot of patients with sepsis.

So, take my advice: Do you have a nursing home patient with atypical measles syndrome? Just assume it’s sepsis. Start two large bore IVs and administer 40 mL/kg by the time you get to the ED.

Tell the doc your suspicion, then take a seat—and don’t worry about the SOFA.