qSOFA Has Poor Sensitivity for Prehospital Identification of Severe Sepsis and Septic Shock

Objectives: Sepsis is a common and deadly disease process for which early recognition and intervention can significantly improve clinical outcomes. Despite this, sepsis remains underrecognized and therefore undertreated in the prehospital setting. Recent recommendations by the Society of Critical Care and European Society of Intensive Care Medicine advocate use of the qSOFA (quick Sequential [Sepsis-related] Organ Failure Assessment) score in non-ICU settings to screen for septic patients at greater risk for poor outcomes.

Methods: We retrospectively evaluated the sensitivity and specificity of a prehospital qSOFA score ≥ 2 for prehospital identification of patients with severe sepsis or septic shock. Emergency Department (ED) patients with confirmed or suspected infection were classified as having infection without sepsis (n = 71), sepsis (n = 38), or severe sepsis/septic shock (n = 43), where designation of severe sepsis/septic shock required evidence of end-organ dysfunction, hypoperfusion (lactate > 2), or vasopressor requirement.

Results: We found that a prehospital qSOFA score ≥ 2 was 16.3% sensitive (95% CI 6.8-30.7%) and 97.3% specific (95% CI 92.1-99.4%) for patients ultimately confirmed to have severe sepsis/septic shock in the ED. Adding an additional point to the prehospital qSOFA score for a pulse > 100, nursing home residence, age > 50, or reported fever increased the sensitivity to 58.1% (95% CI 42.1-73.0%) and decreased the specificity to 78.0% (95% CI 69.0-85.4%). During their ED stay, approximately two-thirds of patients meeting severe sepsis/septic shock criteria eventually met qSOFA criteria with a sensitivity of 67.4% (95% CI 51.5-80.9) and specificity of 86.2% (95% CI 78.3-92). Failure to meet qSOFA criteria prehospital was predominantly due to a systolic blood pressure and respiratory rate that did not yet meet predetermined thresholds.

Conclusions: 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 (age, nursing home status, fever, and tachycardia) can identify more patients with sepsis who may benefit from time critical interventions.