Comparison of early warning and sepsis scores for mortality prediction in patients with suspected infection admitted to medical intensive care units

Year 2024, Volume: 7 Issue: 1, 73 - 79, 15.01.2024

Batuhan Başpınar , Efe Cem Erdat , Ebru Ersoy Ortaç , Arzu Topeli

https://doi.org/10.32322/jhsm.1403054

Abstract

Aims: To compare the mortality prediction efficiency of the Modified Early Warning Score (MEWS), Systemic Inflammatory Response Syndrome (SIRS), Sepsis Related Organ Failure Assessment (SOFA), and Quick Sepsis Related Organ Failure Assessment (qSOFA) calculated within 48 hours before ICU admission.
Methods: A prospective, noninterventional, observational cohort study enrolled adult patients admitted to medical intensive care units (ICU) with suspected infection in a tertiary care medical center. MEWS SIRS, SOFA, and qSOFA scores were calculated at four different time points: 48, 24, and 8 hours before and at the time of the ICU admission (0. hour). The scores were analyzed for hospital mortality.
Results: A total of 120 patients were included. The median age was 68 (IQR 59.8-79) years, and 44.2% of patients were male. Of the study population, 75.8% were admitted to the medical ICU from the emergency department, while the remaining were from the medical wards. Considering the scores observed 48 hours before ICU admission, Odds Ratio (OR) of SIRS≥2 and SOFA≥2 showed a value of 7.6 (95% CI: 1.5-38.0) and 13.2 (95% CI: 2.3-74.3), respectively, while no increase in risk was observed for MEWS and the qSOFA score. Receiver operating characteristic analysis (ROC) performed with the highest scores observed at any time within 48 hours before ICU admission (ICU admission values were omitted) regarding hospital mortality yielded area under the curve (AUC) values (95% CI) of 0.80 (0.72-0.89) for SOFA, 0.66 (0.54-0.76) for MEWS, 0.63 (0.51-0.74) for qSOFA, and 0.61 (0.49-0.73) for SIRS. SOFA had the highest sensitivity of 92.6% (82.7-100.0), whereas qSOFA had the highest specificity of 63.0% (49.1-77.0) for hospital mortality.
Conclusion: SOFA score is the most sensitive scoring system to predict hospital mortality in patients admitted to the medical ICU with suspected infection compared to MEWS, SIRS, and qSOFA. Nevertheless, the sepsis and early warning scores should be combined in clinical practice whenever possible.

Keywords

Early warning score, qSOFA, critical care, sepsis, SOFA, systemic inflammatory response syndrome

References

• Chiu C, Legrand M. Epidemiology of sepsis and septic shock. Curr Opin Anaesthesiol. 2021;34(2):71-76.
• Weng L, Xu Y, Yin P, et al. National incidence and mortality of hospitalized sepsis in China. Crit Care. 2023;27(1):84.
• Zhang Z, Chen L, Xu P, et al. Effectiveness of automated alerting system compared to usual care for the management of sepsis. NPJ Digital Med. 2022;5(1):101.
• Jacobi J. The pathophysiology of sepsis-2021 update: part 2, organ dysfunction and assessment. Am J Health Syst Pharm. 2022;79(6):424-436.
• Yan MY, Gustad LT, Nytrø Ø. Sepsis prediction, early detection, and identification using clinical text for machine learning: a systematic review. J Am Med Inform Assoc. 2022;29(3):559-575.
• Durusu Tanrıöver M, Halaçlı B, Sait B, Öcal S, Topeli A. Daily surveillance with early warning scores help predicthospital mortality in medical wards. Turk J Med Sci. 2016;46(6):1786-1791.
• Rababa M, Bani Hamad D, Hayajneh AA. Sepsis assessment and management in critically Ill adults: a systematic review. PLoS One. 2022;17(7):e0270711.
• Schertz AR, Lenoir KM, Bertoni AG, Levine BJ, Mongraw-Chaffin M, Thomas KW. Sepsis prediction model for determining sepsis vs SIRS, qSOFA, and SOFA. JAMA Netw Open. 2023;6(8):e2329729.
• Lan L, Zhou M, Chen X, Dai M, Wang L, Lih. Prognostic accuracy of SOFA, MEWS, and SIRS criteria in predicting the mortality rate of patients with sepsis: a meta-analysis. Nurs Crit Care. 2023;1-13. doi:10.1111/nicc.13016
• Jones D, Ludikhuize J. Improving outcomes from sepsis during rapid response team review. Aust Crit Care. 2022;35(4):332-333.
• Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: ınternational guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021;49(11):e1063-e1143.
• Andreassen S, Møller JK, Eliakim-Raz N, Lisby G, Ward L. A comparison of predictors for mortality and bacteraemia in patients suspected of infection. BMC Infect Dis. 2021;21:864.
• Chen QH, Shao J, Liu WL, et al. Predictive accuracy of sepsis-3 definitions for mortality among adult critically ill patients with suspected infection. Chin Med J. 2019;132(10):1147-1153.
• Freund Y, Lemachatti N, Krastinova E, et al. Prognostic accuracy of sepsis-3 criteria for ın-hospital mortality among patients with suspected ınfection presenting to the emergency department. JAMA. 2017;317(3):301.
• Gaini S, Relster MM, Pedersen C, Johansen IS. Prediction of 28-days mortality with sequential organ failure assessment (SOFA), quick SOFA (qSOFA) and systemic inflammatory response syndrome (SIRS) — a retrospective study of medical patients with acute infectious disease. Int J Infect Dis. 2019;78:1-7.
• de Freitas Garbero R, Simões AA, Martins GA, da Cruz LV, von Zuben VGM. SOFA and qSOFA at admission to the emergency department: diagnostic sensitivity and relation with prognosis in patients with suspected infection. Turk J Emerg Med. 2019;19(3): 106-110.
• Khwannimit B, Bhurayanontachai R, Vattanavanit V. Comparison of the accuracy of three early warning scores with SOFA score for predicting mortality in adult sepsis and septic shock patients admitted to intensive care unit. Heart Lung. 2019;48(3):240-244.
• Kim KS, Suh GJ, Kim K, et al. Quick sepsis-related organ failure assessment score is not sensitive enough to predict 28-day mortality in emergency department patients with sepsis: a retrospective review. Clin Exp Emerg Med. 2019;6(1):77-83.
• Kovach CP, Fletcher GS, Rudd KE, Grant RM, Carlbom DJ. Comparative prognostic accuracy of sepsis scores for hospital mortality in adults with suspected infection in non-ICU and ICU at an academic public hospital. PLoS One. 2019;14(9):e0222563.
• Machado FR, Cavalcanti AB, Monteiro MB, et al. Predictive accuracy of the quick sepsis-related organ failure assessment score in Brazil. a prospective multicenter study. Am J Respir Crit Care Med. 2020;201(7):789-798.
• Songsangjinda T, Khwannimit B. Comparison of severity score models based on different sepsis definitions to predict in-hospital mortality among sepsis patients in the intensive care unit. Med Intensiva. 2020;44(4):226-232.
• Tanrıöver MD, Yıldırım G. Does the implementation of modified early warning scores spare workforce by decreasing the frequency of nurse assessments? Acta Med. 2014;45(1):80-83.
• Raith EP, Udy AA, Bailey M, et al. Prognostic accuracy of the SOFA score, SIRS criteria, and qSOFA score for in-hospital mortality among adults with suspected infection admitted to the intensive care unit. JAMA. 2017;317(3):290-300.
• Solligård E, Damås JK. SOFA criteria predict infection-related in-hospital mortality in ICU patients better than SIRS criteria and the qSOFA score. BMJ Evidence Based Med. 2017;22:211
• Guirgis FW, Puskarich MA, Smotherman C, et al. Development of a simple sequential organ failure assessment score for risk assessment of emergency department patients with sepsis. J Intensive Care Med. 2020;35(3):270-278.
• Liu VX, Lu Y, Carey KA, et al. Comparison of early warning scoring systems for hospitalized patients with and without infection at risk for in-hospital mortality and transfer to the intensive care unit. JAMA Netw Open. 2020;3(5):e205191.
• Abdullah SOB, Sørensen RH, Nielsen FE. Prognostic accuracy of SOFA, qSOFA, and SIRS for mortality among emergency department patients with infections. Infect Drug Resist. 2021;14: 2763-2775.
• Topeli A, Baspinar B, Ortac Ersoy E. In search of the ideal risk score in sepsis. Am J Respir Crit Care Med. 2020;202(1):152-153.
• Liu YC, Luo YY, Zhang X, et al. Quick sequential organ failure assessment as a prognostic factor for infected patients outside the intensive care unit: a systematic review and meta-analysis. Intern Emerg Med. 2019;14(4):603-615.
• Canet E, Taylor DM, Khor R, Krishnan V, Bellomo R. qSOFA as predictor of mortality and prolonged ICU admission in emergency department patients with suspected infection. J Crit Care. 2018;48:118-123.
• Vaittinada Ayar P, Delay M, Avondo A, et al. Prognostic value of prehospital quick sequential organ failure assessment score among patients with suspected infection. Eur J Emerg Med. 2019;26(5):329-333.
• Jiang J, Yang J, Mei J, Jin Y, Lu Y. Head-to-head comparison of qSOFA and SIRS criteria in predicting the mortality of infected patients in the emergency department: a meta-analysis. Scand J Trauma Resusc Emerg Med. 2018;26(1):56.
• Finkelsztein EJ, Jones DS, Ma KC, et al. Comparison of qSOFA and SIRS for predicting adverse outcomes of patients with suspicion of sepsis outside the intensive care unit. Crit Care. 2017;21(1):73.
• Zhang K, Zhang X, Ding W, et al. National early warning score does not accurately predict mortality for patients with infection outside the intensive care unit: a systematic review and meta-analysis. Front Med. 2021;8:704358.
• Azijli K, Minderhoud T, Mohammadi P, et al. A prospective, observational study of the performance of MEWS, NEWS, SIRS and qSOFA for early risk stratification for adverse outcomes in patients with suspected infections at the emergency department. Acute Med. 2021;20(2):116-124.
• Mignot-Evers L, Raaijmakers V, Buunk G, et al. Comparison of SIRS criteria and qSOFA score for identifying culture-positive sepsis in the emergency department: a prospective cross-sectional multicentre study. BMJ Open. 2021;11(6):e041024.
• Luo J, Jiang W, Weng L, et al. Usefulness of qSOFA and SIRS scores for detection of incipient sepsis in general ward patients: a prospective cohort study. J Crit Care. 2019;51:13-18.
• Sabir L, Ramlakhan S, Goodacre S. Comparison of qSOFA and hospital early warning scores for prognosis in suspected sepsis in emergency department patients: a systematic review. Emerg Med J. 2022;39(4):284-294.
• Chen L, Zhengh, Chen L, Wu S, Wang S. National early warning score in predicting severe adverse outcomes of emergency medicine patients: a retrospective cohort study. J Multidiscip Healthc. 2021;14:2067-2078.
• Usul E, Korkut S, Kayipmaz AE, Halici A, Kavalci C. The role of the quick sequential organ failure assessment score (qSOFA) and modified early warning score (MEWS) in the pre-hospitalization prediction of sepsis prognosis. Am J Emerg Med. 2021;41:158-162.