Quick Sequential Organ Failure Assessment as a prognostic factor for infected patients outside the intensive care unit: a systematic review and meta-analysis

  • Yan-Cun LiuEmail author
  • Yuan-Yuan Luo
  • Xingyu Zhang
  • Song-Tao Shou
  • Yu-Lei Gao
  • Bin Lu
  • Chen Li
  • Yan-Fen ChaiEmail author
CE- Systematic review


Quick Sequential Organ Failure Assessment (qSOFA) was proposed to replace SIRS as a new screening tool for the identification of septic patients at high mortality. However, researches from infected patients outside of ICU especially in Emergency Department (ED) drew contradictory conclusions on the prognostic value of qSOFA. This systematic review evaluated qSOFA as a prognostic marker of infected patients outside of ICU. The primary outcome was hospital mortality or 28- or 30-day mortality. Data were pooled based on sensitivity and specificity. Twenty-four trials with 121,237 participants were included. qSOFA had a poor sensitivity (0.58 [95% CI 0.47–0.67], 0.54 [95% CI 0.43–0.65]) and moderate specificity (0.69 [95% CI 0.48–0.84], 0.77 [95% CI 0.66–0.86]) for prediction of mortality in patients outside of ICU and ED patients only. Studies that used in-hospital mortality showed a higher sensitivity (0.61 [95% CI 0.50–0.71] vs 0.32 [95% CI 0.15–0.49]) and lower specificity (0.70 [95% CI 0.59–0.82] vs 0.92 [95% CI 0.85–0.99]) than studies that used 28 or 30-day mortality. Studies with overall mortality < 10% showed higher specificity (0.89 [95% CI 0.82–0.95] vs 0.62 [95% CI 0.48–0.76]) than studies with overall mortality ≥ 10%. There is no difference in the accuracy of diagnosis of sepsis between positive qSOFA scores and SIRS criteria. qSOFA was poor sensitivity and moderate specificity in predicting mortality of infected patients outside of ICU especially in ED. Combining qSOFA and SIRS may be helpful in predicting mortality.


qSOFA Emergency Department Mortality Sepsis Meta-analysis 



We thank professor Shu-Zhang Cui of Emergency Department of Tianjin Medical University General Hospital for the guidance of analysis.

Author contributions

Y-CL had the idea for and designed the study, searched the scientific literature, collected, analyzed, and interpreted data, and wrote critically revised the report. Y-YL searched the scientific literature, collected data, and drafted and critically revised the report. XZ statistically analyzed and interpreted the data. S-TS, Y-LG, BL and CL helped to search the scientific literature and collect the data. Y-FC had the idea for and designed the study, supervised the study, and gave administrative, technical, and material support.


This study was supported by grants from the National Natural Science Foundation (nos. 81601714, 81701931, 81871593).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Statement of human and animal rights

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent



  1. 1.
    Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, Kumar A, Sevransky JE, Sprung CL, Nunnally ME, Rochwerg B, Rubenfeld GD, Angus DC, Annane D, Beale RJ, Bellinghan GJ, Bernard GR, Chiche JD, Coopersmith C, De Backer DP, French CJ, Fujishima S, Gerlach H, Hidalgo JL, Hollenberg SM, Jones AE, Karnad DR, Kleinpell RM, Koh Y, Lisboa TC, Machado FR, Marini JJ, Marshall JC, Mazuski JE, McIntyre LA, McLean AS, Mehta S, Moreno RP, Myburgh J, Navalesi P, Nishida O, Osborn TM, Perner A, Plunkett CM, Ranieri M, Schorr CA, Seckel MA, Seymour CW, Shieh L, Shukri KA, Simpson SQ, Singer M, Thompson BT, Townsend SR, Van der Poll T, Vincent JL, Wiersinga WJ, Zimmerman JL, Dellinger RP (2017) Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med. Google Scholar
  2. 2.
    Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR (2001) Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 29(7):1303–1310CrossRefGoogle Scholar
  3. 3.
    Lagu T, Rothberg MB, Shieh MS, Pekow PS, Steingrub JS, Lindenauer PK (2012) Hospitalizations, costs, and outcomes of severe sepsis in the United States 2003–2007. Crit Care Med 40(3):754–761. CrossRefGoogle Scholar
  4. 4.
    Wang HE, Jones AR, Donnelly JP (2017) Revised national estimates of emergency department visits for sepsis in the United States. Crit Care Med 45(9):1443–1449. CrossRefGoogle Scholar
  5. 5.
    Investigators P, Rowan KM, Angus DC, Bailey M, Barnato AE, Bellomo R, Canter RR, Coats TJ, Delaney A, Gimbel E, Grieve RD, Harrison DA, Higgins AM, Howe B, Huang DT, Kellum JA, Mouncey PR, Music E, Peake SL, Pike F, Reade MC, Sadique MZ, Singer M, Yealy DM (2017) Early, goal-directed therapy for septic shock—a patient-level meta-analysis. N Engl J Med 376(23):2223–2234. CrossRefGoogle Scholar
  6. 6.
    Viale P, Tedeschi S, Scudeller L, Attard L, Badia L, Bartoletti M, Cascavilla A, Cristini F, Dentale N, Fasulo G, Legnani G, Trapani F, Tumietto F, Verucchi G, Virgili G, Berlingeri A, Ambretti S, De Molo C, Brizi M, Cavazza M, Giannella M (2017) Infectious diseases team for the early management of severe sepsis and septic shock in the Emergency Department. Clin Infectious Dis 65(8):1253–1259. CrossRefGoogle Scholar
  7. 7.
    Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ (1992) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 101(6):1644–1655CrossRefGoogle Scholar
  8. 8.
    Kaukonen KM, Bailey M, Pilcher D, Cooper DJ, Bellomo R (2015) Systemic inflammatory response syndrome criteria in defining severe sepsis. N Engl J Med 372(17):1629–1638. CrossRefGoogle Scholar
  9. 9.
    Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A, Rubenfeld G, Kahn JM, Shankar-Hari M, Singer M, Deutschman CS, Escobar GJ, Angus DC (2016) Assessment of clinical criteria for sepsis: for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 315(8):762–774. CrossRefGoogle Scholar
  10. 10.
    Innocenti F, Tozzi C, Donnini C, De Villa E, Conti A, Zanobetti M, Pini R (2018) SOFA score in septic patients: incremental prognostic value over age, comorbidities, and parameters of sepsis severity. Intern Emerg Med 13(3):405–412. Google Scholar
  11. 11.
    Fernando SM, Tran A, Taljaard M, Cheng W, Rochwerg B, Seely AJE, Perry JJ (2018) Prognostic accuracy of the quick sequential organ failure assessment for mortality in patients with suspected infection: a systematic review and meta-analysis. Ann Intern Med. Google Scholar
  12. 12.
    Serafim R, Gomes JA, Salluh J, Povoa P (2018) A comparison of the Quick-SOFA and systemic inflammatory response syndrome criteria for the diagnosis of sepsis and prediction of mortality: a systematic review and meta-analysis. Chest 153(3):646–655. CrossRefGoogle Scholar
  13. 13.
    Song JU, Sin CK, Park HK, Shim SR, Lee J (2018) 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 22(1):28. CrossRefGoogle Scholar
  14. 14.
    Maitra S, Som A, Bhattacharjee S (2018) Accuracy of quick Sequential Organ Failure Assessment (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria for predicting mortality in hospitalized patients with suspected infection: a meta-analysis of observational studies: predictive accuracy of qSOFA: a meta-analysis. Clin Microbiol Infect. Google Scholar
  15. 15.
    Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MM, Sterne JA, Bossuyt PM, Group Q (2011) QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 155(8):529–536. CrossRefGoogle Scholar
  16. 16.
    Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, Bernard GR, Chiche JD, Coopersmith CM, Hotchkiss RS, Levy MM, Marshall JC, Martin GS, Opal SM, Rubenfeld GD, van der Poll T, Vincent JL, Angus DC (2016) The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 315(8):801–810. CrossRefGoogle Scholar
  17. 17.
    Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, International Sepsis Definitions C (2003) 2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference. Intensive Care Med 29(4):530–538. CrossRefGoogle Scholar
  18. 18.
    Reitsma JB, Glas AS, Rutjes AW, Scholten RJ, Bossuyt PM, Zwinderman AH (2005) Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol 58(10):982–990. CrossRefGoogle Scholar
  19. 19.
    April MD, Aguirre J, Tannenbaum LI, Moore T, Pingree A, Thaxton RE, Sessions DJ, Lantry JH (2017) Sepsis clinical criteria in Emergency Department patients admitted to an intensive care unit: an external validation study of quick sequential organ failure assessment. J Emerg Med 52(5):622–631. CrossRefGoogle Scholar
  20. 20.
    Askim A, Moser F, Gustad LT, Stene H, Gundersen M, Asvold BO, Dale J, Bjornsen LP, Damas JK, Solligard E (2017) 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 Resuscitation Emerg Med 25(1):56. CrossRefGoogle Scholar
  21. 21.
    Churpek MM, Snyder A, Han X, Sokol S, Pettit N, Howell MD, Edelson DP (2017) Quick sepsis-related organ failure assessment, systemic inflammatory response syndrome, and early warning scores for detecting clinical deterioration in infected patients outside the intensive care unit. Am J Respir Crit Care Med 195(7):906–911. CrossRefGoogle Scholar
  22. 22.
    Donnelly JP, Safford MM, Shapiro NI, Baddley JW, Wang HE (2017) Application of the Third International Consensus Definitions for Sepsis (Sepsis-3) classification: a retrospective population-based cohort study. Lancet Infect Dis 17(6):661–670. CrossRefGoogle Scholar
  23. 23.
    Finkelsztein EJ, Jones DS, Ma KC, Pabon MA, Delgado T, Nakahira K, Arbo JE, Berlin DA, Schenck EJ, Choi AM, Siempos II (2017) Comparison of qSOFA and SIRS for predicting adverse outcomes of patients with suspicion of sepsis outside the intensive care unit. Crit Care 21(1):73. CrossRefGoogle Scholar
  24. 24.
    Forward E, Konecny P, Burston J, Adhikari S, Doolan H, Jensen T (2017) Predictive validity of the qSOFA criteria for sepsis in non-ICU inpatients. Intensive Care Med 43(6):945–946. CrossRefGoogle Scholar
  25. 25.
    Freund Y, Lemachatti N, Krastinova E, Van Laer M, Claessens YE, Avondo A, Occelli C, Feral-Pierssens AL, Truchot J, Ortega M, Carneiro B, Pernet J, Claret PG, Dami F, Bloom B, Riou B, Beaune S, French Society of Emergency Medicine Collaborators G (2017) Prognostic accuracy of sepsis-3 criteria for in-hospital mortality among patients with suspected infection presenting to the Emergency Department. Jama 317(3):301–308. CrossRefGoogle Scholar
  26. 26.
    Gonzalez Del Castillo J, Julian-Jimenez A, Gonzalez-Martinez F, Alvarez-Manzanares J, Pinera P, Navarro-Bustos C, Martinez-Ortiz de Zarate M, Llopis-Roca F, Deban Fernandez M, Gamazo-Del Rio J, Garcia-Lamberechts EJ, Martin-Sanchez FJ, Representing the Infectious Disease Group of the Spanish Emergency Medicine S (2017) Prognostic accuracy of SIRS criteria, qSOFA score and GYM score for 30-day-mortality in older non-severely dependent infected patients attended in the emergency department. Eur J Clin Microbiol Infectious Dis 36(12):2361–2369. CrossRefGoogle Scholar
  27. 27.
    Guirgis FW, Puskarich MA, Smotherman C, Sterling SA, Gautam S, Moore FA, Jones AE (2017) Development of a simple sequential organ failure assessment score for risk assessment of Emergency Department patients with sepsis. J Intensive Care Med. Google Scholar
  28. 28.
    Haydar S, Spanier M, Weems P, Wood S, Strout T (2017) Comparison of QSOFA score and SIRS criteria as screening mechanisms for emergency department sepsis. Am J Emerg Med 35(11):1730–1733. CrossRefGoogle Scholar
  29. 29.
    Henning DJ, Puskarich MA, Self WH, Howell MD, Donnino MW, Yealy DM, Jones AE, Shapiro NI (2017) An Emergency Department validation of the SEP-3 sepsis and septic shock definitions and comparison with 1992 consensus definitions. Ann Emerg Med 70(4):544–552. (e545) CrossRefGoogle Scholar
  30. 30.
    Huson MA, Kalkman R, Grobusch MP, van der Poll T (2017) Predictive value of the qSOFA score in patients with suspected infection in a resource limited setting in Gabon. Travel Med Infectious Dis 15:76–77. CrossRefGoogle Scholar
  31. 31.
    Hwang SY, Jo IJ, Lee SU, Lee TR, Yoon H, Cha WC, Sim MS, Shin TG (2017) 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. Google Scholar
  32. 32.
    Kolditz M, Scherag A, Rohde G, Ewig S, Welte T, Pletz M, Group CS (2016) Comparison of the qSOFA and CRB-65 for risk prediction in patients with community-acquired pneumonia. Intensive Care Med 42(12):2108–2110. CrossRefGoogle Scholar
  33. 33.
    Moskowitz A, Patel PV, Grossestreuer AV, Chase M, Shapiro NI, Berg K, Cocchi MN, Holmberg MJ, Donnino MW, Center for Resuscitation S (2017) Quick sequential organ failure assessment and systemic inflammatory response syndrome criteria as predictors of critical care intervention among patients with suspected infection. Crit Care Med 45(11):1813–1819. CrossRefGoogle Scholar
  34. 34.
    Park HK, Kim WY, Kim MC, Jung W, Ko BS (2017) Quick sequential organ failure assessment compared to systemic inflammatory response syndrome for predicting sepsis in emergency department. J Crit Care 42:12–17. CrossRefGoogle Scholar
  35. 35.
    Peake SL, Delaney A, Bailey M, Bellomo R (2017) Potential Impact of the 2016 consensus definitions of sepsis and septic shock on future sepsis research. Ann Emerg Med 70(4):553–561. (e551) CrossRefGoogle Scholar
  36. 36.
    Quinten VM, van Meurs M, Wolffensperger AE, Ter Maaten JC, Ligtenberg JJM (2017) Sepsis patients in the emergency department: stratification using the clinical impression score, predisposition, infection, response and organ dysfunction score or quick sequential organ failure assessment score? Eur J Emerg Med. Google Scholar
  37. 37.
    Ranzani OT, Prina E, Menendez R, Ceccato A, Cilloniz C, Mendez R, Gabarrus A, Barbeta E, Bassi GL, Ferrer M, Torres A (2017) New Sepsis Definition (Sepsis-3) and community-acquired pneumonia mortality. A validation and clinical decision-making study. Am J Respir Crit Care Med 196(10):1287–1297. CrossRefGoogle Scholar
  38. 38.
    Shetty A, MacDonald SP, Williams JM, van Bockxmeer J, de Groot B, Esteve Cuevas LM, Ansems A, Green M, Thompson K, Lander H, Greenslade J, Finfer S, Iredell J (2017) Lactate ≥ 2 mmol/L plus qSOFA improves utility over qSOFA alone in emergency department patients presenting with suspected sepsis. Emerg Med Aust EMA 29(6):626–634. CrossRefGoogle Scholar
  39. 39.
    Wang JY, Chen YX, Guo SB, Mei X, Yang P (2016) Predictive performance of quick sepsis-related organ failure assessment for mortality and ICU admission in patients with infection at the ED. Am J Emerg Med 34(9):1788–1793. CrossRefGoogle Scholar
  40. 40.
    Weigle H, Trigonis R, Bunn D, Krakauer D, Long L, Perkins J (2016) 345 severe sepsis: what gets it right? A comparison of the quick sequential organ failure assessment versus systemic inflammatory response syndrome criteria. Ann Emerg Med 68(4):S132–S133CrossRefGoogle Scholar
  41. 41.
    Williams JM, Greenslade JH, McKenzie JV, Chu K, Brown AFT, Lipman J (2017) Systemic inflammatory response syndrome, quick sequential organ function assessment, and organ dysfunction: insights from a prospective database of ED patients with infection. Chest 151(3):586–596. CrossRefGoogle Scholar

Copyright information

© Società Italiana di Medicina Interna (SIMI) 2019

Authors and Affiliations

  1. 1.Department of Emergency MedicineTianjin Medical University General HospitalTianjinPeople’s Republic of China
  2. 2.Department of SurgeryEmory University School of MedicineAtlantaUSA

Personalised recommendations