Abstract
BackgroundSequential Organ Failure Assessment (SOFA) and other illness prognostic scores predict adverse outcomes in critical patients. Their validation as a decision-making tool in the emergency department (ED) of secondary hospitals is not well established. The aim of this study was to compare SOFA, NEWS2, APACHE II, and SAPS II scores as predictors of adverse outcomes and decision-making tool in ED.MethodsData of 121 patients (age 73 ± 10 years, 58% males, Charlson Comorbidity Index 5.7 ± 2.1) with a confirmed sepsis were included in a retrospective study between January 2017 and February 2020. Scores were computed within the first 24 h after admission. Primary outcome was the occurrence of either in-hospital death or mechanical ventilation within 7 days. Secondary outcome was 30-day all-cause mortality.ResultsPatients older than 64 years (elderly) represent 82% of sample. Primary and secondary outcomes occurred in 40 and 44%, respectively. Median 30-day survival time of dead patients was 4 days (interquartile range 1–11). The best predictive score based on the area under the receiver operating curve (AUROC) was SAPS II (0.823, 95% confidence interval, CI, 0.744–0.902), followed by APACHE II (0.762, 95% CI 0.673–0.850), NEWS2 (0.708, 95% CI 0.616–0.800), and SOFA (0.650, 95% CI 0.548–0.751). SAPS II cut-off of 49 showed the lowest false-positive rate (12, 95% CI 5–20) and the highest positive predictive value (80, 95% CI 68–92), whereas NEWS2 cut-off of 7 showed the lowest false-negative rate (10, 95% CI 2–19) and the highest negative predictive value (86, 95% CI 74–97). By combining NEWS2 and SAPS II cut-offs, we accurately classified 64% of patients. In survival analysis, SAPS II cut-off showed the highest difference in 30-day mortality (Hazards Ratio, HR, 5.24, 95% CI 2.99–9.21, P < 0.001). Best independent negative predictors of 30-day mortality were body temperature, mean arterial pressure, arterial oxygen saturation, and hematocrit levels. Positive predictors were male sex, heart rate and serum sodium concentration.ConclusionsSAPS II is a good prognostic tool for discriminating high-risk patient suitable for sub-intensive/intensive care units, whereas NEWS2 for discriminating low-risk patients for low-intensive units. Our results should be limited to cohorts with a high prevalence of elderly or comorbidities.
Highlights
Sequential Organ Failure Assessment (SOFA) and other illness prognostic scores predict adverse outcomes in critical patients
The “quick” version of the SOFA score, a prognostic score used in emergency department (ED) [3], has shown low accuracy to predict mortality [4] and its performance can be lower than other prognostic scores commonly adopted in ED [5,6,7]
Since in our ED organization, patients were moved to Intensive Care Unit (ICU) when mechanical ventilation is needed, we considered this primary outcome fundamental for deciding which patient to address in a low- or high-intensity care unit
Summary
Sequential Organ Failure Assessment (SOFA) and other illness prognostic scores predict adverse outcomes in critical patients. Their validation as a decision-making tool in the emergency department (ED) of secondary hospitals is not well established. SOFA score discriminates septic patients at risk of disease progression and death better than previous “severe and inflammatory response syndrome” (SIRS) criteria in the Intensive Care Unit (ICU) [2]. This score has been developed in ICU setting and its usefulness outside ICU has not been well established. The usefulness of qSOFA to diagnose sepsis in ED remained a matter of debate [10] and SIRS criteria are still adopted in some ED [4], despite of current indications [11]
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