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      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

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          Abstract

          Rationale: The 2016 definitions of sepsis included the quick Sepsis-related Organ Failure Assessment (qSOFA) score to identify high-risk patients outside the intensive care unit (ICU).

          Objectives: We sought to compare qSOFA with other commonly used early warning scores.

          Methods: All admitted patients who first met the criteria for suspicion of infection in the emergency department (ED) or hospital wards from November 2008 until January 2016 were included. The qSOFA, Systemic Inflammatory Response Syndrome (SIRS), Modified Early Warning Score (MEWS), and the National Early Warning Score (NEWS) were compared for predicting death and ICU transfer.

          Measurements and Main Results: Of the 30,677 included patients, 1,649 (5.4%) died and 7,385 (24%) experienced the composite outcome (death or ICU transfer). Sixty percent (n = 18,523) first met the suspicion criteria in the ED. Discrimination for in-hospital mortality was highest for NEWS (area under the curve [AUC], 0.77; 95% confidence interval [CI], 0.76–0.79), followed by MEWS (AUC, 0.73; 95% CI, 0.71–0.74), qSOFA (AUC, 0.69; 95% CI, 0.67–0.70), and SIRS (AUC, 0.65; 95% CI, 0.63–0.66) ( P < 0.01 for all pairwise comparisons). Using the highest non-ICU score of patients, ≥2 SIRS had a sensitivity of 91% and specificity of 13% for the composite outcome compared with 54% and 67% for qSOFA ≥2, 59% and 70% for MEWS ≥5, and 67% and 66% for NEWS ≥8, respectively. Most patients met ≥2 SIRS criteria 17 hours before the combined outcome compared with 5 hours for ≥2 and 17 hours for ≥1 qSOFA criteria.

          Conclusions: Commonly used early warning scores are more accurate than the qSOFA score for predicting death and ICU transfer in non-ICU patients. These results suggest that the qSOFA score should not replace general early warning scores when risk-stratifying patients with suspected infection.

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          Most cited references12

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          Hospital deaths in patients with sepsis from 2 independent cohorts.

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            The APACHE III Prognostic System

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              Hospitalizations, costs, and outcomes of severe sepsis in the United States 2003 to 2007.

              To assess trends in number of hospitalizations, outcomes, and costs of severe sepsis in the United States. Temporal trends study using the Nationwide Inpatient Sample. Adult patients with severe sepsis (defined as a diagnosis of sepsis and organ dysfunction) diagnosed between 2003 and 2007. We determined the weighted frequency of patients hospitalized with severe sepsis. We calculated age- and sex-adjusted population-based mortality rates for severe sepsis per 100,000 population and also used logistic regression to adjust in-hospital mortality rates for patient characteristics. We calculated inflation-adjusted costs using hospital-specific cost-to-charge ratios. We identified a rapid steady increase in the number of cases of severe sepsis, from 415,280 in 2003 to 711,736 in 2007 (a 71% increase). The total hospital costs for all patients with severe sepsis increased from $15.4 billion in 2003 to $24.3 billion in 2007 (57% increase). The proportion of patients with severe sepsis and only a single organ dysfunction decreased from 51% in 2003 to 45% in 2007 (p < .001), whereas the proportion of patients with three or four or more organ dysfunctions increased 1.19-fold and 1.51-fold, respectively (p < .001). During the same time period, we observed 2% decrease per year in hospital mortality for patients with severe sepsis (p < .001), as well as a slight decrease in the length of stay (9.9 days to 9.2 days; p < .001) and a significant decrease in the geometric mean cost per case of severe sepsis ($20,210 per case in 2003 and $19,330 in 2007; p = .025). The increase in the number of hospitalizations for severe sepsis coupled with declining in-hospital mortality and declining geometric mean cost per case may reflect improvements in care or increases in discharges to skilled nursing facilities; however, these findings more likely represent changes in documentation and hospital coding practices that could bias efforts to conduct national surveillance.
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                Author and article information

                Journal
                Am J Respir Crit Care Med
                Am. J. Respir. Crit. Care Med
                ajrccm
                American Journal of Respiratory and Critical Care Medicine
                American Thoracic Society
                1073-449X
                1535-4970
                1 April 2017
                1 April 2017
                1 April 2017
                : 195
                : 7
                : 906-911
                Affiliations
                [ 1 ]Department of Medicine
                [ 2 ]Center for Healthcare Delivery Science and Innovation, and
                [ 3 ]Department of Pharmacy, University of Chicago, Chicago, Illinois
                Author notes
                Correspondence and requests for reprints should be addressed to Matthew M. Churpek, M.D., M.P.H., Ph.D., University of Chicago Medical Center, Section of Pulmonary and Critical Care Medicine, 5841 South Maryland Avenue, MC 6076, Chicago, IL 60637. E-mail: matthew.churpek@ 123456uchospitals.edu
                Article
                PMC5387705 PMC5387705 5387705 201604-0854OC
                10.1164/rccm.201604-0854OC
                5387705
                27649072
                4a1308ee-e01d-4a50-b362-254001e05520
                Copyright © 2017 by the American Thoracic Society
                History
                : 25 April 2016
                : 19 September 2016
                Page count
                Figures: 2, Tables: 2, Pages: 6
                Categories
                Original Articles
                Critical Care

                early warning scores,qSOFA,organ dysfunction scores,sepsis,systemic inflammatory response syndrome

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