Tip: SIRS beats qSOFA for sepsis screening

Note: A recent study published in the Annals of Internal Medicine compared and summarized the prognostic accuracy of the quick sepsis related organ failure assessment (qSOFA) and the systemic inflammatory response syndrome (SIRS) criteria for prediction of mortality in adult patients with suspected infections. Ultimately, the study found that qSOFA has poor sensitivity and moderate specificity for short-term mortality. The SIRS criteria, on the other hand, had greater sensitivity, supporting its use for screening patients and as a prompt treatment initiation. This study, which is referenced in the article, can be read here.

by Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS

A newly published report from the Annals of Internal Medicine found that systemic inflammatory response syndrome (SIRS) criteria had greater sensitivity than quick sepsis related organ failure assessment (qSOFA) as a screening test to initiate treatment for sepsis in non-intensive care unit (ICU) patients.

The current authoritative clinical standard for the diagnosis of sepsis (known as Sepsis-3) adopted by the Surviving Sepsis Campaign now defines sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection.” Organ dysfunction defining sepsis is identified by an increase in baseline Sequential (Sepsis-Related) Organ Failure Assessment (SOFA) score of two points or more. As of March 2017, sepsis is no longer authoritatively defined as SIRS due to infection.

The original Sepsis-3 definition consensus published in the Journal of the American Medical Association in February 2016 also acknowledged that implementation of the Sepsis-3 definition using the full SOFA score would be difficult outside the intensive care unit (ICU) setting. An unvalidated screening test called qSOFA was suggested for screening of patients with an infection. The presence of two or more of three findings should prompt the determination of the full SOFA score change:

• Respiratory rate ≥ 22/min
• Altered mentation
• Systolic blood pressure ≤ 100 mmHg

Since the publication and adoption of Sepsis-3, a clinical concern has persisted about the predictive value of qSOFA as a screening test because it has not been prospectively evaluated or validated for this purpose in non-ICU patients.

Now a report of data analysis from 38 studies, “Prognostic Accuracy of the Quick Sequential Organ Failure Assessment for Mortality in Patients With Suspected Infection,” compares the ability of SIRS and qSOFA to predict mortality in patients with infection (confirmed or suspected) was published in February 2018 in the Annals of Internal Medicine. The findings demonstrated that SIRS criteria had greater sensitivity than qSOFA as a screening test and to prompt initiation of treatment for sepsis in non-ICU patients.

The clear implication is that, outside the ICU, SIRS criteria probably represent a better screening test and indication for initial treatment than qSOFA. The study also confirms the validity of the CMS Inpatient Quality Reporting (IQR) sepsis performance measure (called “SEP-1”) for initiating treatment of “severe” sepsis which relies on SIRS criteria.

Because providers have become so familiar with SIRS criteria as indicators of sepsis, applying SIRS in non-ICU patients as the preferred screening test for sepsis and indication for initiating “severe” sepsis protocols should be a simple and easily implemented process so long as providers do not use SIRS to establish the diagnosis of sepsis but rather to prompt full SOFA scoring upon which the definitive diagnosis should rest.

The involved stakeholders at all hospitals should consider the approach to sepsis screening and initiation of “severe” sepsis protocols that best suit their needs keeping in mind the results of this study and the CMS IQR sepsis measure standards.

Editor’s note: This article originally appeared on Pinson and Tang’s website, www.pinsonandtang.com/resources. Pinson and Tang are the authors of the 2018 CDI Pocket Guide and the new Outpatient CDI Pocket Guide: Focusing on HCCs.