Internal and Emergency Medicine

, Volume 13, Issue 3, pp 405–412 | Cite as

SOFA score in septic patients: incremental prognostic value over age, comorbidities, and parameters of sepsis severity

  • Francesca InnocentiEmail author
  • Camilla Tozzi
  • Chiara Donnini
  • Eleonora De Villa
  • Alberto Conti
  • Maurizio Zanobetti
  • Riccardo Pini


Several widely used scoring systems for septic patients have been validated in an ICU setting, and may not be appropriate for other settings like Emergency Departments (ED) or High-Dependency Units (HDU), where a relevant number of these patients are managed. The purpose of this study is to find reliable tools for prognostic assessment of septic patients managed in an ED-HDU. In 742 patients diagnosed with sepsis/severe sepsis/septic shock, not-intubated, admitted in ED between June 2008 and April 2016, SOFA, qSOFA, PIRO, MEWS, Charlson Comorbidity Index, MEDS, and APACHE II were calculated at ED admission (T0); SOFA and MEWS were also calculated after 24 h of ED-High-Dependency Unit stay (T1). Discrimination and incremental prognostic value of SOFA score over demographic data and parameters of sepsis severity were tested. Primary outcome is 28-day mortality. Twenty-eight day mortality rate is 31%. The different scores show a modest-to-moderate discrimination (T0 SOFA 0.695; T1 SOFA 0.741; qSOFA 0.625; T0 MEWS 0.662; T1 MEWS 0.729; PIRO: 0.646; APACHE II 0.756; Charlson Comorbidity Index 0.596; MEDS 0.674, all p < 0.001). At a multivariate stepwise Cox analysis, including age, Charlson Comorbidity Index, MEWS, and lactates, SOFA shows an incremental prognostic ability both at T0 (RR 1.165, IC 95% 1.009–1.224, p < 0.0001) and T1 (RR 1.168, IC 95% 1.104–1.234, p < 0.0001). SOFA score shows a moderate prognostic stratification ability, and demonstrates an incremental prognostic value over the previous medical conditions and clinical parameters in septic patients.


Sepsis Vital signs Lactate Prognostic scores Organ dysfunction scores 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Statement of human and animal rights

The study is consistent with the principles of the Declaration of Helsinki of clinical research involving human subjects.

Informed consent

Informed consent was obtained from all individual participants included in the study when they were called for follow-up.


  1. 1.
    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 29:1303–1310CrossRefPubMedGoogle Scholar
  2. 2.
    Martin GS, Mannino DM, Eaton S, Moss M (2003) The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 348:1546–1554CrossRefPubMedGoogle Scholar
  3. 3.
    Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, Moreno R, Carlet J, Le Gall JR, Payen D (2006) Sepsis in European intensive care units: results of the SOAP study. Crit Care Med 34:344–353CrossRefPubMedGoogle Scholar
  4. 4.
    Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb S, Beale RJ, Vincent JL, Moreno R (2013) Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012. Intensive Care Med 39:165–228CrossRefPubMedGoogle Scholar
  5. 5.
    Cardoso T, Carneiro AH, Ribeiro O, Teixeira-Pinto A, Costa-Pereira A (2010) Reducing mortality in severe sepsis with the implementation of a core 6-hour bundle: results from the Portuguese community-acquired sepsis study (SACiUCI study). Critical Care 14(3):R83. doi: 10.1186/cc9008 CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829CrossRefPubMedGoogle Scholar
  7. 7.
    Shapiro NI, Wolfe RE, Moore RB, Smith E, Burdick E, Bates DW (2003) Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule. Crit Care Med 31:670–675CrossRefPubMedGoogle Scholar
  8. 8.
    Vincent JL, Moreno R, Takala J, Willatts S, De MA, Bruining H, Reinhart CK, Suter PM, Thijs LG (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 22:707–710CrossRefPubMedGoogle Scholar
  9. 9.
    Rubulotta F, Marshall JC, Ramsay G, Nelson D, Levy M, Williams M (2009) Predisposition, insult/infection, response, and organ dysfunction: a new model for staging severe sepsis. Crit Care Med 37:1329–1335CrossRefPubMedGoogle Scholar
  10. 10.
    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 315:801–810CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Innocenti F, Bianchi S, Guerrini E, Vicidomini S, Conti A, Zanobetti M, Pini R (2014) Prognostic scores for early stratification of septic patients admitted to an emergency department-high dependency unit. Eur J Emerg Med 21:254–259CrossRefPubMedGoogle Scholar
  12. 12.
    Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G (2003) 2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference. Crit Care Med 31:1250–1256CrossRefPubMedGoogle Scholar
  13. 13.
    Kyriacos U, Jelsma J, Jordan S (2011) Monitoring vital signs using early warning scoring systems: a review of the literature. J Nurs Manag 19:311–330CrossRefPubMedGoogle Scholar
  14. 14.
    Charlson M, Szatrowski TP, Peterson J, Gold J (1994) Validation of a combined comorbidity index. J Clin Epidemiol 47:1245–1251CrossRefPubMedGoogle Scholar
  15. 15.
    Howell MD, Talmor D, Schuetz P, Hunziker S, Jones AE, Shapiro NI (2011) Proof of principle: the predisposition, infection, response, organ failure sepsis staging system. Crit Care Med 39:322–327CrossRefPubMedGoogle Scholar
  16. 16.
    Peres BD, Melot C, Lopes FF, Nguyen B, Vincent JL (2002) The Multiple Organ Dysfunction Score (MODS) versus the Sequential Organ Failure Assessment (SOFA) score in outcome prediction. Intensive Care Med 28:1619–1624CrossRefGoogle Scholar
  17. 17.
    Pettila V, Pettila M, Sarna S, Voutilainen P, Takkunen O (2002) Comparison of multiple organ dysfunction scores in the prediction of hospital mortality in the critically ill. Crit Care Med 30:1705–1711CrossRefPubMedGoogle Scholar
  18. 18.
    Timsit JF, Fosse JP, Troche G, De LA, Alberti C, Garrouste-Org Azoulay E, Chevret S, Moine P, Cohen Y (2001) Accuracy of a composite score using daily SAPS II and LOD scores for predicting hospital mortality in ICU patients hospitalized for more than 72 h. Intensive Care Med 27:1012–1021CrossRefPubMedGoogle Scholar
  19. 19.
    Jansen TC, van Bommel J, Woodward R, Mulder PG, Bakker J (2009) Association between blood lactate levels, Sequential Organ Failure Assessment subscores, and 28-day mortality during early and late intensive care unit stay: a retrospective observational study. Crit Care Med 37:2369–2374CrossRefPubMedGoogle Scholar
  20. 20.
    Ho KM, Lee KY, Williams T, Finn J, Knuiman M, Webb SA (2007) Comparison of Acute Physiology and Chronic Health Evaluation (APACHE) II score with organ failure scores to predict hospital mortality. Anaesthesia 62:466–473CrossRefPubMedGoogle Scholar
  21. 21.
    Yu S, Leung S, Heo M, Soto GJ, Shah RT, Gunda S, Gong MN (2014) Comparison of risk prediction scoring systems for ward patients: a retrospective nested case-control study. Crit Care 18:R132CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    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 34:1788–1793CrossRefPubMedGoogle Scholar
  23. 23.
    Ferreira FL, Bota DP, Bross A, Melot C, Vincent JL (2001) Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA 286:1754–1758CrossRefPubMedGoogle Scholar
  24. 24.
    Jones AE, Trzeciak S, Kline JA (2009) The sequential organ failure assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation. Crit Care Med 37:1649–1654CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Martin GS, Mannino DM, Moss M (2006) The effect of age on the development and outcome of adult sepsis. Crit Care Med 34:15–21CrossRefPubMedGoogle Scholar
  26. 26.
    Yang Y, Yang KS, Hsann YM, Lim V, Ong BC (2010) The effect of comorbidity and age on hospital mortality and length of stay in patients with sepsis. J Crit Care 25:398–405CrossRefPubMedGoogle Scholar
  27. 27.
    Nguyen HB, Loomba M, Yang JJ, Jacobsen G, Shah K, Otero RM, Suarez A, Parekh H, Jaehne A, Rivers EP (2010) Early lactate clearance is associated with biomarkers of inflammation, coagulation, apoptosis, organ dysfunction and mortality in severe sepsis and septic shock. J Inflamm (Lond) 7:6CrossRefGoogle Scholar
  28. 28.
    Kruse O, Grunnet N, Barfod C (2011) Blood lactate as a predictor for in-hospital mortality in patients admitted acutely to hospital: a systematic review. Scand J Trauma Resusc Emerg Med 19:74CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Vincent JL, Silva Quintairos E, Couto L Jr, Taccone FS (2016) The value of blood lactate kinetics in critically ill patients: a systematic review. Crit Care 20:257CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Hilderink MJ, Roest AA, Hermans M, Keulemans YC, Stehouwer CD, Stassen PM (2014) Predictive accuracy and feasibility of risk stratification scores for 28-day mortality of patients with sepsis in an emergency department. Eur J Emerg Med 22(5):331–337. doi: 10.1097/MEJ.0000000000000185
  31. 31.
    Nguyen HB, Van GC, Batech M, Banta J, Corbett SW (2012) Comparison of predisposition, insult/infection, response, and organ dysfunction, acute physiology and chronic health evaluation II, and Mortality in Emergency Department Sepsis in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. J Crit Care 27:362–369CrossRefPubMedGoogle Scholar
  32. 32.
    Carlet J, Cohen J, Calandra T, Opal SM, Masur H (2008) Sepsis: time to reconsider the concept. Crit Care Med 36:964–966CrossRefPubMedGoogle Scholar
  33. 33.
    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 315:762–774CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Moskowitz A, Andersen LW, Cocchi M, Donnino MW (2016) The misapplication of severity-of-illness scores toward clinical decision making. Am J Respir Crit Care Med 194:256–258CrossRefPubMedGoogle Scholar

Copyright information

© SIMI 2017

Authors and Affiliations

  1. 1.High-Dependency Unit, Department of Clinical and Experimental MedicineAzienda Ospedaliero-Universitaria CareggiFlorenceItaly

Personalised recommendations