The prognostic value of sepsis scores and dichotomized triage score in patients presenting to the emergency department with fever: A prospective, observational study

ElsevierVolume 64, September 2022, 101213International Emergency NursingAbstractBackground

The performance of the Quick Sequential Organ Failure Assessment (qSOFA) score needs to be explored further in the emergency triage room. This study aims to explore the performance of triage (tqSOFA) versus the dichotomized triage score (DTS) in patients admitted to the emergency room triage with fever.

Methods

This research was designed as a prospective, observational study within a six-month period, including patients who presented to the emergency room triage with infrared fever ≥ 37.5 °C.

Results

771 patients were analyzed.The highest sensitivity for predicting overall hospitalization and intensive care admission was seen for DTS (95.4 %, 100 %; p < 0.0001, p < 0.0001, respectively) (AUC:0.697, 95 % CI 0.663 to 0.730; AUC:0.684, 95 % CI 0.650 to 0.717, respectively). The highest sensitivity for predicting 1st week and 1st month mortality was found for DTS (100 %, 96.3 %; p < 0.0001, p < 0.0001, respectively). However, the highest specificity for predicting 1st week and 1st month mortality was observed in tqSOFA (94.1 %, 95.16; p = 0.0845, p < 0.0001, respectively) (AUC:0.658, 95 % CI 0.623 to 0.691; AUC:0.698, 95 % CI 0.664 to 0.730, respectively).

Conclusion

We found DTS to be as effective as tqSOFA and SIRS in determining all hospitalization times and mortality.

Introduction

Sepsis has been defined as life-threatening organ dysfunction, involving irregular physiological and biochemical abnormalities by the host against the infection [1]. Due to high mortality and morbidity rates, it necessitates early diagnosis and treatment in the emergency department (ED) [2]. The systemic inflammatory response syndrome (SIRS) criteria comprise a good scoring system that is used for diagnosing sepsis [3]. However, their credibility has been questioned since non-infectious causes (pancreatitis, burns, hemorrhagic shock, ischemia, multiple trauma, etc.) can also yield SIRS-positive results, causing simple infections to be mistaken for sepsis. The quick Sequential Organ Failure Assessment (qSOFA) score can be used more practically in the ED. The qSOFA has been found useful in determining the prognosis without laboratory tests [4]. Research has shown that many scoring systems like SIRS, qSOFA, SOFA, the National Early Warning Score (NEWS), and the Modified Early Warning Score (MEWS) are useful in sepsis screening [5], [6]. Although, the most recent sepsis guidelines suggest that the qSOFA is a better screening tool for sepsis and septic shock compared to the other tools [7]. Studies have reported higher specificity and lower sensitivity for positive qSOFA scores compared to SIRS criteria (score ≥ 2) for the early detection of organ damage [3], [8], [9], [10]. The aim here is to explore the performance of triage qSOFA (tqSOFA) and SIRS versus Dichotomized Triage Score (DTS) for diagnosis and predicting sepsis complications in patients admitted to the ED with fever.

Section snippetsStudy design and participants

This research was designed as a prospective, observational study. We included patients 18 years of older who were admitted to the ED of a tertiary university hospital in 6 months period. Approval for the study was obtained from the ethics committee of our institution. Our institution is a tertiary healthcare university hospital with a capacity of 983 beds, 900,000 patients yearly, and nearly 100,000 ED admissions yearly. For this research, the inclusion criteria as patients with a fever

Results

For the study period, 818 patients were admitted to the ED. 47 of these patients were excluded, 2 for being aged under 18 years, 3 being pregnant, 31 for having their secondary admission, 8 for receiving no treatment, and 3 for having missing data. Our final analysis included 771 patients. The sample had a mean age of 44.64 ± 20.128 years, and 426 of the patients (55.3 %) were male. 500 (64.9 %) were found DTS-positive, 48 (6.2) tqSOFA-positive, and 502 (65.1) SIRS-positive. The 1st week

Discussion

Since the Sepsis-3 guideline was published, there has been extensive research on the prognostic quality of qSOFA for risk classification in the ED, compared against SIRS and other scoring systems [13], [14], [15], [16]. However, most of these studies were performed on specific populations (e.g., ED patients with suspected sepsis). One of the most important characteristics of our research is that we evaluated the current sepsis guideline criteria in the ED.

The triage is the process of

Limitations

This study had certain limitations. The most important was that our 1st week mortality rate was quite low (n = 8), leading to a wider confidence interval for our findings. Although, our 1st month mortality rate is consistent with the literature. Besides, this is a single-centered study; so, our findings cannot be generalized to other hospitals.

Conclusion

In conclusion, we found no benefit to using qSOFA in addition to DTS, which is already a well-functioning screening tool in the emergency room triage. Of course, qSOFA does have its uses, having the best selectivity for predicting mortality with fewer criteria. However, using qSOFA as a screening test may not be very accurate. SIRS has a much better sensitivity than qSOFA. Thus, the use of these criteria is directly associated with the pretest probability for sepsis. If clinical evaluation

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Ethical approval

Permission was obtained from the local ethics committee for the study at Akdeniz University School of Medicine.

Human rights

This research does not harm human rights regarding Ethical Principles for Medical Research Involving Human Subjects.

CRediT authorship contribution statement

Selda Özkavak: Medical Practices, Conceptualization, Data curation, Formal analysis, Investigation, Writing - orginal draft.  Oktay Eray: Medical Practices, Conceptualization, Formal analysis, Investigation, Writing – review & editing, Supervision.  Mustafa Korkut: Medical Practices, Conceptualization, Formal analysis, Investigation, Writing – review & editing, Supervision.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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