By Samuel Nadler, MD, PhD
Critical Care, Pulmonary Medicine, The Polyclinic Madison Center, Seattle; Clinical Instructor, University of Washington, Seattle
Dr. Nadler reports no financial relationships relevant to this field of study.
SYNOPSIS: Compared with either score alone, using both SIRS and SOFA scores led to earlier and more complete recognition of sepsis in patients presenting to the emergency department.
SOURCE: Prasad PA, Fang MC, Abe-Jones Y, et al. Time to recognition of sepsis in the emergency department using electronic health record data: A comparative analysis of systemic inflammatory response syndrome, Sequential Organ Failure Assessment, and Quick Sequential Organ Failure Assessment. Crit Care Med 2020;48:200-209.
Early recognition of sepsis leads to earlier treatment and better outcomes. Multiple criteria for sepsis have been proposed, including the systemic inflammatory response syndrome (SIRS) criteria and, more recently, the Sequential Organ Failure Assessment (SOFA) and quick SOFA (qSOFA). This study examined which criteria would lead to the earliest and most complete recognition of sepsis using electronic medical records in a single academic center. Patients were selected if blood cultures were ordered or intravenous (IV) antibiotics were given within 72 hours of emergency department (ED) presentation. Of the 25,441 patients with blood cultures ordered, 17,701 also received IV antibiotics, and 16,612 patients met either SIRS or SOFA criteria within 72 hours of ED presentation.
The times when criteria were met after ED presentation were different for SIRS vs. SOFA. Of the cohort, 9,087 (54.7%) met SIRS criteria first at a median time of 26 minutes, while 7,037 (42.3%) met SOFA criteria first at a median time of 113 minutes. In patients first identified by SIRS, SOFA ultimately was positive in 83.1%, with a median delay of 118 minutes. Conversely, in patients with positive SOFA first, 67.7% later met SIRS criteria, with a median delay of 234 minutes. Not every patient identified by these criteria ultimately was diagnosed with sepsis. Of the patients meeting either SIRS or SOFA criteria, only 5,004 (31%) were discharged with a sepsis code and 873 (5.4%) had positive blood cultures. Of those discharged with sepsis codes, SIRS criteria were met first in 3,383 patients at a median time of two minutes, while SOFA criteria were met first in 1,621 patients at 77 minutes. Among those with positive blood cultures, SIRS criteria were met in 564 patients at a median of two minutes, while SOFA criteria were met first in 309 patients at a median time of 97 minutes.
As medical practice becomes more complex, there is increasing need to leverage electronic medical records and automated alerts to best care for patients. Which elements among the vast quantity of data generated in clinical practice are most useful will be a continuing question. This study examines the elements required for different sepsis scoring systems and the time to achieve each criterion after presentation in the ED. Neither score alone performed adequately, with delays in identification of 118 to 234 minutes if only one score was used. Using the scores in concert seemed to minimize the time to identification, but at the expense of accuracy. Of the 16,612 patients overall identified by either criterion, only 31% ultimately were discharged with a sepsis code (37.2% meeting SIRS criteria and 23% meeting SOFA criteria). We do not know how many patients did not meet sepsis criteria yet ultimately were found to have sepsis. Interestingly, qSOFA seemed more predictive of disease severity, although it was positive first in only 278 patients. Those patients meeting qSOFA criteria within 72 hours of presentation were more likely to die during the admission, to be admitted to the intensive care unit (ICU), and to receive vasopressor or mechanical ventilation than those who did not.
The time course to positivity with each score is informative. The SIRS score identified patients most quickly as heart rate and respiratory rate criteria were rapidly met (0 and 25 minutes, respectively). In contrast, SOFA more heavily relies on laboratory assessments, such as creatinine, bilirubin, platelets, and white blood cells, and those results take time. In both scoring systems, hypotension was a late criterion (229 and 278 minutes in SIRS and SOFA first groups, respectively). Thus, patients with underlying chronic medical conditions leading to laboratory abnormalities seemed to meet SOFA criteria first and more frequently than those without. SIRS was quicker to identify those without chronic conditions.
This study highlights the opportunities and risks of big data to assist in sepsis diagnosis. Scoring systems can be helpful in identifying patients with sepsis, but more work is needed to best define those criteria that will identify patients with sepsis most rapidly and accurately.