Sepsis Scores for the Emergency Department

Abstract

This research portfolio investigates the management of sepsis, particularly the use of severity scores, in the Emergency Department (ED). Sepsis is a major cause of morbidity and mortality worldwide. Optimal management involves early identification and treatment of sepsis, ideally as soon as possible on arrival to hospital. To facilitate this, various severity scores have been developed over the years to predict patients likely to have a poor outcome. However, many of these scores were designed for the Intensive Care Unit (ICU), and only a minority were developed specifically for sepsis. Previously it was recommended that Quick Sequential Organ Failure Assessment Score (qSOFA) be used in the ED setting. This score is based on the Sequential Organ Failure Assessment Score (SOFA), which is an ICU score that includes some parameters only readily obtainable in the ICU setting. A modified SOFA score (mSOFA) was recently developed as a variation of the original SOFA score with parameters easily obtained in the ED. This research portfolio aims to provide an overview of the changes in identification and management of sepsis over time, with an emphasis on the use of severity scores for sepsis in the ED setting, and a focus on qSOFA and the newly developed mSOFA score. The portfolio includes three original pieces of research: a clinical audit, a systematic review, and an observational study, as well as an overview of sepsis and the use of severity scores in ED through the years. The audit, which evaluates time to antibiotics in sepsis, indicates relatively poor compliance with time to antibiotics targets in a major adult ED. It provides suggestions on how this may be improved, including recommending use of a formal sepsis score as part of a clinical pathway for identifying and treating sepsis in the ED. The systematic review evaluates severity scores used to predict mortality in ED patients with sepsis. Although heterogeneity in study design and variation in score accuracy across different settings makes direct comparison between scores inappropriate, it appears that qSOFA performed well compared to other scores. Finally, an observational cohort study explores whether a recently suggested ED specific score (mSOFA) is more accurate than the currently recommended score (qSOFA) in our setting, with the view of informing the choice of sepsis score for our sepsis pathway.