Assessment of qSOFA in the Latin America Sepsis Institute Database
Assessment of qSOFA in the Latin America Sepsis Institute Database
Recently, the Society of Critical Care Medicine (SCCM) and the European Society of Intensive
 Care Medicine (ESICM) have published new definitions of sepsis, known as Sepsis 3, based on a
 fairly robust analysis of large, essentially American, databases. In addition to the new
 definition, a new screening score was suggested, named quickSOFA (qSOFA). This score is
 positive if two of three variables are present: respiratory rate higher than 22 ipm, reduced
 level of consciousness and systolic blood pressure lower than 100 mmHg. Although the receiver
 operator characteristics (ROC) curves suggest an adequate predictive validity for the new
 score, a lot of controversy around its sensitivity as a screening tool mainly in settings
 with high mortality rates. Current national Brazilian data show that sepsis mortality in our
 country, especially in public hospitals from the Unified Health System (SUS), is very high
 and well above world mortality. The impact of using the qSOFA in these settings is not known.
 In this context, the present study aims to evaluate the potential impact of using qSOFA as a
 screening tool in Brazilian private and public institutions. The hypothesis is that the use
 of qSOFA as a screening tool will have a low sensitivity. As a consequence, patients with the
 diagnosis of sepsis, with organ dysfunction, will not be detected by this tool. The
 hypothesis was also that those patients with a qSOFA negative will have a high mortality
 rate, mainly in Brazilian public hospitals.
All hospitals in the Latin America Sepsis Institute network were invited to participate. This
 is a national based quality improvement initiative aiming to improve compliance with the
 sepsis bundles and mortality. The hospitals were instructed to include all patients that
 presented with the diagnosis of sepsis or septic shock in the emergency department (ED),
 wards or ICU. The diagnosis of sepsis was based on the previous criteria used by the network,
 which means presence of suspected infection and an infection-associated organ dysfunction.
 Organ dysfunction was defined by the presence of any of the following: systolic blood
 pressure <90 mmHg or mean arterial pressure <65 mmHg or fall in systolic blood pressure> 40
 mmHg; creatinine> 2.0 mg / dl or diuresis less than 0.5 ml/kg/h in the last 2 hours,
 bilirubin> 2mg/dl, platelet count<100,000, lactate> 2 mmol/dl (or above the reference value),
 coagulopathy (RNI> 1.5 or APTT>60 sec), PaO2/FiO2 ratio <300 or recent or increased O2 need
 to maintain SpO2> 90. Suspected of infection was based on the clinical suspicious by the
 attending physician. All patients under end-of-life care and those previously included in the
 database in the same hospital admission were excluded.

 The case managers were instructed to collect the 3 components of the qSOFA criteria, namely
 reduced level of consciousness, respiratory rate higher than 22 bpm and systolic blood
 pressure lower than 100 mmHg). In patients included from the ED, these components were
 checked at the time of triage. In patients in the wards or in the ICU, the 3 components were
 considered if presented any time in the 24 hours prior to the diagnosis of sepsis.

 Outcomes Primary outcome was hospital mortality. Secondary endpoints included admission to
 ICU and length of ICU stay of more than 48 hours. A secondary composite outcome was hospital
 mortality plus ICU length of stay higher than two days (for those admitted to the ICU).
Inclusion Criteria:

 -  Suspected source of infection

 -  Presence of any of the following organ dysfunction

 -  Systolic blood pressure <90 mmHg or mean arterial pressure <65 mmHg or fall in
 systolic blood pressure> 40 mmHg.

 -  Creatinine> 2.0 mg / dl or diuresis less than 0.5 ml/kg/h in the last 2 hours OR

 -  Bilirubin> 2mg/dl,

 -  Platelet count<100,000,

 -  Lactate> 2 mmol/dl (or above the reference value),

 -  Coagulopathy (RNI> 1.5 or APTT>60 sec),

 -  PaO2/FiO2 ratio <300 or recent or increased O2 need to maintain SpO2> 90

 Exclusion Criteria:

 -  End of life care

 -  Previous sepsis episode in the same hospital admission