Sepsis patients in the emergency department: stratification using the Clinical Impression Score, Predisposition, Infection, Response and Organ dysfunction score or quick Sequential Organ Failure Assessment score?
OBJECTIVE
The aim of this study was to compare the stratification of sepsis patients in the emergency department (ED) for ICU admission and mortality using the Predisposition, Infection, Response and Organ dysfunction (PIRO) and quick Sequential Organ Failure Assessment (qSOFA) scores with clinical judgement assessed by the ED staff.


METHODS
This was a prospective observational study in the ED of a tertiary care teaching hospital. Adult nontrauma patients with suspected infection and at least two Systemic Inflammatory Response Syndrome criteria were included. The primary outcome was direct ED to ICU admission. The secondary outcomes were in-hospital, 28-day and 6-month mortality, indirect ICU admission and length of stay. Clinical judgement was recorded using the Clinical Impression Scores (CIS), appraised by a nurse and the attending physician. The PIRO and qSOFA scores were calculated from medical records.


RESULTS
We included 193 patients: 103 presented with sepsis, 81 with severe sepsis and nine with septic shock. Fifteen patients required direct ICU admission. The CIS scores of nurse [area under the curve (AUC)=0.896] and the attending physician (AUC=0.861), in conjunction with PIRO (AUC=0.876) and qSOFA scores (AUC=0.849), predicted direct ICU admission. The CIS scores did not predict any of the mortality endpoints. The PIRO score predicted in-hospital (AUC=0.764), 28-day (AUC=0.784) and 6-month mortality (AUC=0.695). The qSOFA score also predicted in-hospital (AUC=0.823), 28-day (AUC=0.848) and 6-month mortality (AUC=0.620).


CONCLUSIONS
Clinical judgement is a fast and reliable method to stratify between ICU and general ward admission in ED patients with sepsis. The PIRO and qSOFA scores do not add value to this stratification, but perform better on the prediction of mortality. In sepsis patients, therefore, the principle of 'treat first what kills first' can be supplemented with 'judge first and calculate later'.
Departments of Emergency Medicine.
Vincent M
VM
Quinten
Critical Care.|Pathology and Medical Biology, Medical Biology Section, University Medical Center Groningen (UMCG), Groningen, The Netherlands.
Matijs
M
van Meurs
Departments of Emergency Medicine.
Anna E
AE
Wolffensperger
Departments of Emergency Medicine.
Jan C
JC
Ter Maaten
Departments of Emergency Medicine.
Jack J M
JJM
Ligtenberg
D000368:Aged; D000369:Aged, 80 and over; D019540:Area Under Curve; D015331:Cohort Studies; D004636:Emergency Service, Hospital; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006784:Hospitals, Teaching; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D063305:Organ Dysfunction Scores; D010343:Patient Admission / Q000706:statistics & numerical data*; D011379:Prognosis; D011446:Prospective Studies; D012372:ROC Curve; D018570:Risk Assessment; D018805:Sepsis / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D012720:Severity of Illness Index; D012772:Shock, Septic / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D016019:Survival Analysis