A Comparative Study between SIRS, QSOFA, NEWS AND MEWS Score as Predictors for Inhospital Mortality of Patients Getting Admitted To ICU of a Tertiary Care Teaching Hospital
Aarjuv Majmundar *
Department of Medicine, SBKS Medical College, Vadodara, India.
Sucheta Lakhani
Department of Microbiology, SBKS Medical College, Vadodara, India.
Smit Shah
Department of Medicine, SBKS Medical College, Vadodara, India.
Jitendra D. Lakhani
Department of Medicine, SBKS Medical College, Vadodara, India.
*Author to whom correspondence should be addressed.
Abstract
Sepsis screening in the Emergency Department (ED) is necessary for the rational management of patients. Multiple severity screening scores such as Systemic Inflammatory Response Syndrome (SIRS), quick Sepsis-related Organ Failure Assessment (qSOFA), National Early Warning Score (NEWS), and the Modified Early Warning Score (MEWS) are available. Though "Sepsis-3" recommends the use of the qSOFA score. This study seeks to validate each of these scores in a critical care setting and identify the score with the greatest predictive value for in hospital mortality. This comparative study included 188 patients determined to have sepsis. The information required for calculating SIRS, qSOFA, NEWS, and MEWS was extracted with careful history taking, patient assessment, and necessary investigations. The sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver-operating characteristic (AUROC) for each scoring system were measured for Intensive Care Unit (ICU) mortality. qSOFA had the highest specificity (73.61%) and the lowest sensitivity (36.02%). SIRS and NEWS scores had the highest sensitivity (77.78%) while SIRS had the lowest specificity (23.88%). The NEWS score had a specificity of 41.79%. MEWS score had an intermediate sensitivity of 76.36% and specificity of 63.91%. The ability to predict ICU mortality was highest for MEWS≥5 score (AUC 0.76; 95 % CI 0.68-0.84) compared to NEWS≥5 (AUC 0.61; 95% CI 0.52-0.71), qSOFA≥2 (AUC 0.56; 95% CI 0.46-0.66), and SIRS≥2 (AUC 0.49; 95% CI 0.37-0.61). By comparing HSROC curves, the MEWS score showed higher overall prognostic accuracy than SIRS, qSOFA and NEWS. Among qSOFA, SIRS, NEWS, and MEWS, the MEWS score showed the highest overall prognostic accuracy. However, no scoring system showed both high sensitivity and specificity for predicting the accuracy of mortality in patients with sepsis.
Keywords: Sepsis scoring, SIRS, qSOFA, NEWS, MEWS
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References
Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810.
Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001; 29:13031310
Martin GS, Mannino DM, Eaton S, et al. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003;348:15461554.
Liu V, Escobar GJ, Greene JD, et al. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA 2014; 312:9092.
Martin GS. Sepsis, severe sepsis and septic shock: Changes in incidence, pathogens and outcomes. Expert Rev Anti Infect Ther. 2012;10:701706.
Hall MJ, Williams SN, DeFrances CJ, et al. Inpatient Care for Septicemia or Sepsis: A Challenge for Patients And Hospitals, 2000–2008. National Center for Health Statistics. Data Brief No. 62. June 2011.
Available at: http://www.cdc.gov/nchs/data/databriefs/db62.pdf. Accessed June 24, 2016.
HCUP National Inpatient Sample (NIS): Healthcare Cost and Utilization Project (HCUP); 2013. Rockville, MD. Agency for Healthcare Research and Quality, Available at: at www.hcup-us.ahrq.gov/nisoverview.jsp. Accessed June 24, 2016.
Torio CM, Moore BJ. National Inpatient Hospital Costs: The Most Expensive Conditions by Payer; 2013.
Available: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb204-Most-Expensive-Hospital-Conditions.jsp. Accessed September 7, 2017.
O’Brien J. The Cost of Sepsis. CDC Safe Healthcare Blog; 2015.
Available:http://blogs.cdc.gov/safehealthcare/the-cost-of-sepsis/
Accessed March 3, 2016
Judd WR, Stephens DM, Kennedy CA. Clinical and economic impact of a quality improvement initiative to enhance early recognition and treatment of sepsis. Ann Pharmacother 2014; 48:12691275
Whiles BB, Deis AS, Simpson SQ. Increased time to initial antimicrobial administration is associated with progression to septic shock in severe sepsis patients. Crit Care Med.2017; 45:623629
Ferrer R, Martin-Loeches I, Phillips G, et al. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: Results from a guideline-based performance improvement program. Crit Care Med. 2014;42: 17491755
Filbin MR, Arias SA, Camargo CA Jr, et al. Sepsis visits and antibiotic utilization in U.S. emergency departments*. Crit Care Med. 2014;42:528535
Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34: 15891596.
Liu VX, Fielding-Singh V, Greene JD, et al. The timing of early antibiotics and hospital mortality in sepsis. Am J Respir Crit Care Med. 2017;196:856863
Pruinelli L, Westra BL, Yadav P, et al. Delay within the 3-hour surviving sepsis campaign guideline on mortality for patients with severe sepsis and septic shock. Crit Care Med. 2018; 46:500505
Jones SL, Ashton CM, Kiehne LB, et al. Outcomes and resource use of sepsis-associated stays by presence on admission, severity, and hospital type. Med Care. 2016;54:303310
Mellhammar L, Linder A, Tverring J, et al. NEWS2 is Superior to qSOFA in Detecting Sepsis with Organ Dysfunction in the Emergency Department. J Clin Med. 2019;8(8):1128.
Published 2019 Jul 29.
DOI:10.3390/jcm8081128
Bone RC, Balk RA, Cerra FB, et al.Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest. 1992;101: 1644–55.
Wagner T, Sinning C, Haumann J, Magnussen C, Blankenberg S, Reichenspurner H, Grahn H. qSOFA Score Is Useful to Assess Disease Severity in Patients With Heart Failure in the Setting of a Heart Failure Unit (HFU). Front Cardiovasc Med. 2020;7:574768.
Morgan RJM, Williams F, Wright MM. An Early Warning Scoring System for detecting developing critical illness. Clin Intens Care 1997; 8:100
Williams B, Alberti G, Ball C, et al. National Early Warning Score (NEWS): standardising the assessment of acute-illness severity in the NHS. Lond R Coll Physicians 2012.
Stenhouse C, Coates S, Tivey M, Allsop P, Parker T. Prospective evaluation of a Modified Early Warning Score to aid earlier detection of patients developing critical illness on a general surgical ward. State of the Art Meeting, Intensive Care Society, London; 1999.
Finkelsztein, E.J., Jones, D.S., Ma, K.C. et al. Comparison of qSOFA and SIRS for predicting adverse outcomes of patients with suspicion of sepsis outside the intensive care unit. Crit Care 21. 2017;73 .
Freund Y, Lemachatti N, Krastinova E, et al. Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients With Suspected Infection Presenting to the Emergency Department. JAMA. 2017;317(3):301–308.
DOI:10.1001/jama.2016.20329
Henning DJ, Puskarich MA, Self WH, et al. An emergency department validation of the SEP-3 sepsis and septic shock definitions and comparison with 1992 consensus definitions. Ann Emerg Med 2017;70:544–52.
Askim Å, Moser F, Gustad LT, et al. Poor performance of quick-SOFA (qSOFA) score in predicting severe sepsis and mortality - a prospective study of patients admitted with infection to the emergency department. Scand J Trauma Resusc Emerg Med. 2017;25:56.
DOI: 10.1186/S13049-017-0399-4
Singer AJ, Ng J, Thode HC, et al. Quick SOFA scores predict mortality in adult emergency department patients with and without suspected infection. Ann Emerg Med. 2017;69:475–9.
Hwang SY, Jo IJ, Lee SU, et al. Low accuracy of positive qSOFA criteria for predicting 28-day mortality in critically Ill septic patients during the early period after emergency department presentation. Ann Emerg Med. 2018;71.
Goulden R, Hoyle MC, Monis J, et al. qSOFA, SIRS and NEWS for predicting inhospital mortality and ICU admission in emergency admissions treated as sepsis. Emerg Med J. 2018;35(6):345- 349.
DOI:10.1136/emermed-2017-207120.
Churpek MM, Zadravecz FJ, Winslow C, et al. Incidence and prognostic value of the systemic inflammatory response syndrome and organ dysfunctions in ward patients. Am J Respir Crit Care Med. 2015; 192:958–64.
Doi:10.1164/Rccm.201502-0275oc.
de Groot B, Lameijer J, de Deckere ER, et al. The prognostic performance of the predisposition, infection, response and organ failure (PIRO) classification in high-risk and low-risk emergency department sepsis populations: comparison with clinical judgement and sepsis category. Emerg Med J. 2014;31:292–300.
Evans, L., Rhodes, A., Alhazzani, W. et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47:1181-1247.