What is the most evidence-based tool to assess sepsis in inpatients?

Most Evidence-Based Tool for Assessing Sepsis in Inpatients

The Sequential Organ Failure Assessment (SOFA) score is the most evidence-based tool for assessing the presence of sepsis in hospitalized patients, as recommended by the Surviving Sepsis Campaign guidelines. 1

Understanding Sepsis Assessment Tools

SOFA Score

The SOFA score quantifies organ dysfunction across six systems:

1. Respiratory system - PaO2/FiO2 ratio
2. Coagulation - Platelet count
3. Liver - Bilirubin level
4. Cardiovascular - Mean arterial pressure and vasopressor requirements
5. Central nervous system - Glasgow Coma Scale
6. Renal - Creatinine level or urine output

The SOFA score has demonstrated superior predictive ability for in-hospital mortality with an area under the receiver operating characteristic curve (AUC) of 0.75 at initial assessment and 0.84 at 72 hours 2.

Quick SOFA (qSOFA)

For initial rapid assessment, qSOFA can be used as a screening tool, consisting of three criteria:

• Altered mental status
• Systolic blood pressure ≤100 mmHg
• Respiratory rate ≥22 breaths/min

However, qSOFA has limited sensitivity (34%) despite good specificity (90%) for detecting sepsis 3.

National Early Warning Score (NEWS)

Recent evidence suggests NEWS may outperform qSOFA for early detection of sepsis:

• Higher sensitivity (86% vs 34%)
• Better accuracy (72% vs 60%)
• Superior performance for predicting ICU admission and 28-day mortality 3

Implementation Recommendations

1. Initial Screening: Use qSOFA as a rapid bedside screening tool for potentially infected patients
2. Comprehensive Assessment: Follow positive qSOFA with full SOFA score calculation
3. Ongoing Monitoring: Calculate delta SOFA (change in SOFA over time) to track clinical trajectory

Clinical Application Algorithm

1. For all inpatients with suspected infection:

   • Calculate qSOFA score immediately
   • If qSOFA ≥2, proceed to full SOFA assessment
   • If qSOFA <2 but high clinical suspicion, still proceed to SOFA

2. Calculate complete SOFA score:

   • Score <2 indicates low risk
   • Score ≥2 with suspected infection confirms sepsis diagnosis
   • Score ≥2 with hypotension requiring vasopressors or lactate >2 mmol/L indicates septic shock

3. Monitor SOFA score at regular intervals (every 6-12 hours):

   • Increasing scores indicate worsening organ dysfunction
   • Decreasing scores suggest clinical improvement

Common Pitfalls and Caveats

• Overreliance on qSOFA: While specific, qSOFA lacks sensitivity and should not be used alone to rule out sepsis 4
• Delayed Recognition: Waiting for multiple organ failure before initiating treatment increases mortality
• Failure to Reassess: Single SOFA calculations are less valuable than tracking changes over time
• Ignoring Clinical Judgment: No scoring system replaces clinical assessment; high suspicion should prompt treatment regardless of scores

Evidence Quality Assessment

The recommendation for SOFA is based on high-quality evidence from the Surviving Sepsis Campaign guidelines 1, which represent international consensus from critical care and infectious disease experts. The SOFA score's predictive ability has been validated in multiple studies, showing consistent performance for mortality prediction in septic patients 2.

While NEWS shows promise in recent research 3, it has not yet been incorporated into major sepsis guidelines, making SOFA the current gold standard for comprehensive sepsis assessment in inpatients.