128 The Quick Sequential Organ Failure Assessment Identifies Septic Patients in the Out-of-Hospital Setting

Abstract

The primary objective is to determine whether a out-of-hospital quick Sequential Organ Failure Assessment (qSOFA) screening obtained by emergency medical services (EMS) providers correlates with emergency department (ED) sepsis diagnosis. Secondary objectives were to evaluate characteristics of the out-of-hospital qSOFA cohort as related to sepsis. This included EMS call information, patient demographics (age and sex), measured systemic inflammatory response syndrome (SIRS) criteria, lactate, placement of central venous access, and ED mortality. A qSOFA screen is positive when the respiratory rate is greater than 22, systolic blood pressure (SBP) is less than 90 mmHg, and there is an altered mental status (AMS). A retrospective hospital-based 911 EMS chart review was conducted for patients received at the hospital campus sites. The study period was 1/1/2014 to 6/30/2014. Out-of-hospital charts were filtered for the 2 vital sign criteria for qSOFA and matched with their respective ED charts by identifiers. The EMS charts were reviewed for out-of-hospital documentation of AMS by any of the following criteria: Glasgow Coma Scale under 15, AVPU score of V P or U, Chief Complaint of AMS, AMS documented by provider, Individual EMS chart review. EMS charts were excluded for patients less than 18 years, inqSOFA documentation, or patients in cardiac arrest who did not achieve return of spontaneous circulation. Additionally, duplicate or non-911 charts were removed. Researchers blinded to ED outcome performed EMS chart review. ED charts were reviewed to clarify which out-of-hospital qSOFA patients were septic vs. non-septic. ED septic patients were defined as an admit diagnosis of: sepsis, severe sepsis, septic shock or if the patient met more than 2 SIRS criteria and a documented infection. Researchers blinded to EMS chart performed ED outcome review. Within the study period, 271 EMS charts met the filter criteria for 2-value qSOFA. Of these, 28 were excluded as inter-facility transfer calls, leaving 243 true 911 responses remaining. AMS was not documented in 162 of the 243 leaving 81 remaining as screening positive for 3-value out-of-hospital qSOFA. Nine of 81 charts were removed due to insufficient ED documentation, leaving 72 for analysis. Forty-eight of the 72 patients were identified as ED Septic and 24 ED Non-Septic. The positive predictive value of the out-of-hospital qSOFA in our study was 66.67% (95% CI 55.8-77.6%). The ED septic cohort had a higher average number of SIRS criteria vs. non-septic: 2.67 vs. 1.41 respectively. Lactate values were equivalent at 4.10 vs. 4.06. Of the 53 patients that met > 2 SIRS criteria in the ED, 81.1% were Septic. Mortality was low overall, but higher in the ED septic (3/45, 7%) vs. non-septic (1/23, 4%). Central access was higher in ED septic (17/31, 55%) vs. non-septic (5/19, 26%). The qSOFA is a useful screening tool that requires no formal testing or equipment and can be used to identify patients who require prompt intervention and resuscitation. Sepsis remains a diagnostic difficulty for EMS providers due to absence of obvious findings. Vital signs and mental status are ubiquitously recorded by EMS. Close attention to derangements of these assist in the identification of critically ill patients. A positive qSOFA should prompt rapid ED evaluation. Additionally, the qSOFA likely has high inter-rater reliability, requires no special devices or equipment and can be repeated as needed during a call.