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• Reply to Zhou and Wu
  Robert Goulden, Emmanuel Nsutebu
  Published on: 14 June 2018
• The relationship between qSOFA score and NEWS score
  Xianshi Zhou, Fanwei Wu
  Published on: 8 June 2018

• Published on: 14 June 2018

  Reply to Zhou and Wu

  • Robert Goulden, Academic foundation doctor Royal Liverpool University Hospital
  • Other Contributors:
    • Emmanuel Nsutebu, Consultant Infectious Diseases Physician and Associate Medical Director for Deterioration and Sepsis

  We would like to thank Zhou and Wu for their thoughtful comments on our paper.

  The discrepancy in Table 1 between the first and second to last row is due to an error. The first row should note ‘Admitted to ICU (n=53)’.

  The NEWS, SIRS, and qSOFA scores were directly recorded in the patient electronic medical record (EMR), and our initial step was to extract these scores from the EMR. When these values were missing, the individual components of the scores were extracted from paper records, and the scores calculated. The high number of missing values of the qSOFA were due to the fact that it was not routinely recorded until part way through the study period. The fact that 6% of subjects still had missing values after manual chart review resulted from one or more of the components of any of the three scores not being recorded (or the record being missing) when the patient initially presented to the emergency department (ED).

  Regarding the time window, the qSOFA, NEWS, and SIRS scores used in our analysis were all based on their initial values when the patient was assessed, which would typically be within minutes of ED arrival. This therefore reflects the values upon which clinicians initially treating the patients would base their decisions.

  The high proportion of patients who died that were not admitted to ICU reflects the fact that many patients with advanced age and co-morbidities ultimately die from infection, which at some stage may meet sepsis...

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  We would like to thank Zhou and Wu for their thoughtful comments on our paper.

  The discrepancy in Table 1 between the first and second to last row is due to an error. The first row should note ‘Admitted to ICU (n=53)’.

  The NEWS, SIRS, and qSOFA scores were directly recorded in the patient electronic medical record (EMR), and our initial step was to extract these scores from the EMR. When these values were missing, the individual components of the scores were extracted from paper records, and the scores calculated. The high number of missing values of the qSOFA were due to the fact that it was not routinely recorded until part way through the study period. The fact that 6% of subjects still had missing values after manual chart review resulted from one or more of the components of any of the three scores not being recorded (or the record being missing) when the patient initially presented to the emergency department (ED).

  Regarding the time window, the qSOFA, NEWS, and SIRS scores used in our analysis were all based on their initial values when the patient was assessed, which would typically be within minutes of ED arrival. This therefore reflects the values upon which clinicians initially treating the patients would base their decisions.

  The high proportion of patients who died that were not admitted to ICU reflects the fact that many patients with advanced age and co-morbidities ultimately die from infection, which at some stage may meet sepsis diagnostic criteria. ICU admission would neither be appropriate or likely to change the prognosis of such patients. The IMPreSS study was primarily a study of ICU patients with sepsis (86% were admitted to ICU), thus by definition a different population to our study of ED all-comers who were universally screened for sepsis(1). A strength of our study is that, unlike much existing ICU-based sepsis research, it looks at this broader ED patient population. This also has relevance to the last issue raised, namely the suggestion that SOFA would be a fairer comparator. Calculating SOFA in the ED at initial assessement is generally not feasible and thus cannot realistically form the basis of initial clinical decisions. As the Sepsis 3 authors note, “the SOFA score is not intended to be used as a tool for patient management”(2), thus qSOFA was created as a prognostic tool which could be used in settings such as the ED. This was therefore the appropriate comparator to use in our study.

  References
  1. Rhodes A, Phillips G, Beale R, et al. The Surviving Sepsis Campaign bundles and outcome: results from the International Multicentre Prevalence Study on Sepsis (the IMPreSS study). Intensive Care Med 2015;41(9):1620–8.
  2. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016;315(8):801–10.

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  Conflict of Interest:
  None declared.

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• Published on: 8 June 2018

  The relationship between qSOFA score and NEWS score

  • Xianshi Zhou, Emergency department physician Guangdong Provincial Hospital of Chinese Medicine
  • Other Contributors:
    • Fanwei Wu, Chinese Medicine Practioners

  The relationship between qSOFA score and NEWS score

  We read with interest the paper by Goulden R and colleagues 1 who compare the efficacy of qSOFA, SIRS and NEWS score in predicting the inhospital mortality of septic patients. Though the research seems to be scientific, we still have some concerns to put forward.
  To begin with, there are some minor errs existed in Table 1 of the commented paper 1, as indicated in the first row of Table 1, the total number who was admitted to the intensive care unit (ICU) was 52, however, the second row from the bottom of Table 1 indicates 53 persons had ICU admission, so, how to explain this discordance?
  Additionally, according to the data provided by Goulden R et al, the study initially included 1942 patients, nevertheless, to our surprise, 1117 (58%) of them had missing values of qSOFA score, far more than the number of 103 (5%) and 335 (17%) who had missing SIRS scores and missing NEWS scores respectively. There were still 6% missing values in the final analysis of 1818 patients, though most of missing values were supplemented by manual review of paper charts, thus, we are afraid that the major missing values were from qSOFA score, which will result in underestimated sensitivity of qSOFA in predicting the inhospital mortality. As we all know, the qSOFA score contains 3 elements 2 - respiratory rate, mental status, and systolic blood pressure, while NEWS score incorporates 7 elements - respiratory rate, mental stat...

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  The relationship between qSOFA score and NEWS score

  We read with interest the paper by Goulden R and colleagues 1 who compare the efficacy of qSOFA, SIRS and NEWS score in predicting the inhospital mortality of septic patients. Though the research seems to be scientific, we still have some concerns to put forward.
  To begin with, there are some minor errs existed in Table 1 of the commented paper 1, as indicated in the first row of Table 1, the total number who was admitted to the intensive care unit (ICU) was 52, however, the second row from the bottom of Table 1 indicates 53 persons had ICU admission, so, how to explain this discordance?
  Additionally, according to the data provided by Goulden R et al, the study initially included 1942 patients, nevertheless, to our surprise, 1117 (58%) of them had missing values of qSOFA score, far more than the number of 103 (5%) and 335 (17%) who had missing SIRS scores and missing NEWS scores respectively. There were still 6% missing values in the final analysis of 1818 patients, though most of missing values were supplemented by manual review of paper charts, thus, we are afraid that the major missing values were from qSOFA score, which will result in underestimated sensitivity of qSOFA in predicting the inhospital mortality. As we all know, the qSOFA score contains 3 elements 2 - respiratory rate, mental status, and systolic blood pressure, while NEWS score incorporates 7 elements - respiratory rate, mental status, systolic blood pressure, oxygen saturations, oxygen supplemental, temperature and heart rate, therefore, the NEWS score actually covers all the basic essences of qSOFA score, and we can not understand why the simple qSOFA score unexpectedly had more missing values than the complicated NEWS score which actually contains qSOFA score itself based on the same population.
  Furthermore, as a meta analysis 3 demonstrated, the timing of the qSOFA score measurement could siginicantly influence the sensitivity of qSOFA score. In fact, in the study 2 which developed qSOFA, the time window was defined from 48 hours before to 24 hours after the onset of infection which was the time when the first of the two events (antibiotics administration and body fluid cultures collecting) occurred. Nevertheless, Goulden R et al 1 had no limits in the time window of calculating qSOFA, which might cause biased sensitivity of qSOFA.
  Notablely, as the first paragraph of ‘limitations’ section of the commented paper 1 indicates, most of dead patients (94%) were not admitted to ICU, then Goulden R et al concluded that invasive organ support was not deemed necessary or appropriate for most of the patients. However, we can not agree with this viewpoint, as a matter of fact, if more invasive organ support had been given outside the ICU, or more patients with serious condition had been admitted to the ICU, more lives could be saved according to the current available evidence 4.
  Finally, we are not surprised at the result that NEWS score had higher sensitivity in predicting inhospital mortality of septic patients than qSOFA score as the former actually contains the latter in essential elements. In fact, qSOFA score is neither part of the definition nor clinical criteria of sepsis according to the newest definition for sepsis - Sepsis 3.0 2, it just acts like a ‘simple rule’ 5, which is to be designed as an supplementary tool to raise our attention of suspicious sepsis as soon as possible but not to diagnose sepsis. Thus, it would be more useful and persuasive if we had included and compared SOFA score (one clinical criteria of sepsis) with the other 3 score systems (qSOFA, SIRS and NEWS score) in this study.

  Xianshi Zhou, 1 Fanwei Wu 2
  1Emergency Department, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China.
  2 Famous doctor hall, Bao’ an TCM hospital group, Shenzhen, China

  Correspondence to Fanwei Wu, Famous doctor hall, Bao’an TCM hospital group, at Number 25 in the 2nd Yu’an Road, Bao’an District, Shenzhen, 518133, China. Email: wfwiso9000@21cn.com.
  Contributors Xianshi Zhou was responsible for the critical questions of the manuscript, Fanwei Wu wrote the draft, both authors revised and approved the last version of this manuscript.
  Competing interests None declared.
  Ethical Approval and Consent to participate Not applicable
  Funding None.
  Acknowledgments None.

  References:
  1 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: 345-9
  (DOI: 10.1136/emermed-2017-207120, PMID:29467173)
  2 Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016; 315: 801-10
  (DOI: 10.1001/jama.2016.0287, PMID:26903338)
  3 Song JU, Sin CK, Park HK, et al. Performance of the quick Sequential (sepsis-related) Organ Failure Assessment score as a prognostic tool in infected patients outside the intensive care unit: a systematic review and meta-analysis. Crit Care. 2018; 22: 28
  (DOI: 10.1186/s13054-018-1952-x, PMID:29409518)
  4 Rhodes A, Phillips G, Beale R, et al. The Surviving Sepsis Campaign bundles and outcome: results from the International Multicentre Prevalence Study on Sepsis (the IMPreSS study). Intensive Care Med. 2015; 41: 1620-8
  (DOI: 10.1007/s00134-015-3906-y, PMID:26109396)
  5 Foex BA. Sepsis-3 and simple rules. Emerg Med J. 2018; 35: 343-4
  (DOI: 10.1136/emermed-2018-207668, PMID:29720476)

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  Conflict of Interest:
  None declared.

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