The prognostic utility of prehospital qSOFA in addition to emergency department qSOFA for sepsis in patients with suspected infection: A retrospective cohort study

PLOS ONE RESEARCH ARTICLE The prognostic utility of prehospital qSOFA in addition to emergency department qSOFA for sepsis in patients with suspected infection: A retrospective cohort study Ayaka Saito1¤, Itsuki Osawa ID2*, Junichiro Shibata1, Tomohiro Sonoo ID3,4, Kensuke Nakamura ID4, Tadahiro Goto ID3,5 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Faculty of Medicine, The University of Tokyo, Tokyo, Japan, 2 Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan, 3 TXP Medical Co. Ltd., Tokyo, Japan, 4 Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Ibaraki, Japan, 5 Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan ¤ Current address: Saku Central Hospital Advanced Care Center, Nagano, Japan * OPEN ACCESS Citation: Saito A, Osawa I, Shibata J, Sonoo T, Nakamura K, Goto T (2023) The prognostic utility of prehospital qSOFA in addition to emergency department qSOFA for sepsis in patients with suspected infection: A retrospective cohort study. PLoS ONE 18(2): e0282148. https://doi.org/ 10.1371/journal.pone.0282148 Editor: Inge Roggen, Universitair Kinderziekenhuis Koningin Fabiola: Hopital Universitaire des Enfants Reine Fabiola, BELGIUM Received: September 10, 2022 Abstract Background The quick sequential organ failure assessment (qSOFA) was widely used to estimate the risks of sepsis in patients with suspected infection in the prehospital and emergency department (ED) settings. Due to the insufficient sensitivity of qSOFA on arrival at the ED (ED qSOFA), the Surviving Sepsis Campaign 2021 recommended against using qSOFA as a single screening tool for sepsis. However, it remains unclear whether the combined use of prehospital and ED qSOFA improves its sensitivity for identifying patients at a higher risk of sepsis at the ED. Accepted: February 8, 2023 Published: February 24, 2023 Copyright: © 2023 Saito et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: The datasets generated and/or analyzed during the current study are not publicly available because data sharing is not approved by the ethics committee of Hitachi General Hospital. If readers are interested in our datasets, please contact the ethics committee of Hitachi General Hospital (+81-0294-23-111). Funding: The authors received no specific funding for this work. Methods We retrospectively analyzed the data from the ED of a tertiary medical center in Japan from April 2018 through March 2021. Among all adult patients (aged �18 years) transported by ambulance to the ED with suspected infection, we identified patients who were subsequently diagnosed with sepsis based on the Sepsis-3 criteria. We compared the predictive abilities of prehospital qSOFA, ED qSOFA, and the sum of prehospital and ED qSOFA (combined qSOFA) for sepsis in patients with suspected infection at the ED. Results Among 2,407 patients with suspected infection transported to the ED by ambulance, 369 (15%) patients were subsequently diagnosed with sepsis, and 217 (9%) died during hospitalization. The sensitivity of prehospital qSOFA �2 and ED qSOFA �2 were comparable (cstatistics for sepsis [95%CI], 0.57 [0.52–0.62] vs. 0.55 [0.50–0.60]). However, combined qSOFA (cutoff, �3 [max 6]) was more sensitive than ED qSOFA (cutoff, �2) for identifying PLOS ONE | https://doi.org/10.1371/journal.pone.0282148 February 24, 2023 1 / 12 PLOS ONE Competing interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Dr. Sonoo is the Chief Executive Officer of TXP Medical Co. Ltd. and reports grants from AI Hospital Research grant from Japan Cabinet Office. Dr. Goto is the Chief Scientific Officer of TXP Medical Co. Ltd. This does not alter our adherence to PLOS ONE policies on sharing data and materials. Predictive utility of prehospital qSOFA for sepsis sepsis (0.67 [95%CI, 0.62–0.72] vs. 0.55 [95%CI, 0.50–0.60]). Using combined qSOFA, we identified 44 (12%) out of 369 patients who were subsequently diagnosed with sepsis, which would have been missed using ED qSOFA alone. Conclusions Using both prehospital and ED qSOFA could improve the screening ability of sepsis among patients with suspected infection at the ED. Introduction Early identification of suspected sepsis and initiation of appropriate management play a crucial role in reducing the mortality of sepsis [1, 2]. To screen patients at high risk of sepsis among patients with suspected infection at the emergency department (ED), the Sepsis-3 Task Force recommended the use of the quick Sequential Organ Failure Assessment (qSOFA) score (i.e., qSOFA �2 should be considered as suspected sepsis) [3], a simple algorithm that has been widely used in the ED setting. Moreover, as qSOFA was originally developed for use outside the intensive care unit (ICU), discussions have been made to improve the quality of triage by using qSOFA in the prehospital setting [4–7]. Despite the initial recommendation to use qSOFA by the Sepsis-3 Task Force, several studies have shown that qSOFA is more specific but less sensitive compared with other screening tools (e.g., the systemic inflammatory response syndrome [SIRS] criteria) in predicting prognostic outcomes related to sepsis [8–12]. Thus, the Surviving Sepsis Campaign 2021 recommended against using qSOFA as a single screening tool for sepsis or septic shock [13]. The advantage of qSOFA is its simplicity compared to other scoring systems for estimating the risk of sepsis (e.g., SIRS criteria, National Early Warning Score [NEWS]). Thus, it would be valuable to devise a new scoring system that improves on qSOFA with its simplicity preserved. As Keivlan et al. reported that repeated measurements of qSOFA improved its predictive validity for sepsis compared to a single measurement of qSOFA [14], it may be beneficial to consider the combined use of prehospital and ED qSOFA for accurately screening patients at a higher risk of sepsis on arrival at the ED. Nonetheless, it remains unclear whether the combined use of prehospital and ED qSOFA improves its sensitivity for identifying patients at a higher risk of sepsis at the ED. To address this knowledge gap in the literature, we aimed to clarify whether the addition of prehospital qSOFA to ED qSOFA improves the predictive ability for sepsis in patients with suspected infection at the ED compared with the use of prehospital qSOFA or ED qSOFA alone. Methods Study design and setting This is a retrospective cohort study using data from the ED of Hitachi General Hospital from April 1, 2018, to March 31, 2021. Hitachi General Hospital is a tertiary medical center in Japan that covers a populati (...truncated)