qSOFA in Sepsis Management
qSOFA should NOT be used as a screening tool for sepsis in the emergency department, but rather as a prognostic indicator for mortality risk in patients already identified with suspected infection—use NEWS2 (score ≥7 = high risk) for initial screening and risk stratification instead. 1, 2, 3
Why qSOFA Fails as a Screening Tool
The fundamental problem with qSOFA is its poor sensitivity of only 28-42% for identifying sepsis, compared to NEWS2's superior 84-86% sensitivity. 2, 3 This means qSOFA will miss the majority of septic patients who need urgent intervention. Multiple studies confirm qSOFA performs poorly as a diagnostic tool in emergency departments, with sensitivity as low as 33% at triage. 4, 5, 6, 7
The Surviving Sepsis Campaign 2021 explicitly recommends AGAINST using qSOFA as a single screening tool due to insufficient sensitivity. 2
The Correct Approach: Use NEWS2 for Screening
Calculate NEWS2 score immediately for any patient with suspected infection, using six bedside parameters: respiratory rate, oxygen saturation, supplemental oxygen requirement, systolic blood pressure, heart rate, level of consciousness, and temperature. 8, 1
NEWS2 Risk Stratification and Action Thresholds:
- Score ≥7 (High Risk): Re-evaluate every 30 minutes; administer antibiotics within 1 hour 8, 1
- Score 5-6 (Moderate Risk): Re-evaluate every hour; antibiotics within 3 hours 8, 1
- Score 1-4 (Low Risk): Re-evaluate every 4-6 hours; antibiotics within 6 hours 8
- Score 0 (Very Low Risk): Standard monitoring protocol 8
Critical caveat: A score of 3 in ANY single NEWS2 parameter may indicate increased sepsis risk regardless of total score. 8 Additionally, override the NEWS2 score and escalate care immediately if any of these danger signs are present: mottled or ashen appearance, non-blanching petechial/purpuric rash, or cyanosis of skin/lips/tongue. 8
When qSOFA IS Useful: Prognostication
Once sepsis is suspected or diagnosed, qSOFA ≥2 identifies patients at >10% mortality risk who require immediate full SOFA score assessment and ICU-level care. 1, 2, 9 The three qSOFA criteria are: respiratory rate ≥22/min, systolic BP ≤100 mmHg, and altered mental status (GCS <15). 1
Patients with qSOFA ≥2 have:
- 30-day mortality of 32.9% vs 9.1% in those with qSOFA <2 9
- 4.83-fold increased odds of death (independent predictor) 9
- Increased likelihood of ICU admission ≥3 days 2
The Complete Algorithm
Suspect infection based on clinical presentation (fever, chills, hypothermia, leukocytosis, neutropenia, signs of hemodynamic compromise) 8
Obtain blood cultures before antibiotics if possible, ideally immediately before scheduled antibiotic dose to minimize blood levels 8
If NEWS2 ≥5 or clinical danger signs present: Calculate full SOFA score (assessing respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems) 1
Diagnose sepsis if SOFA increases ≥2 points from baseline 1
Identify septic shock if vasopressors needed for MAP ≥65 mmHg AND lactate >2 mmol/L despite adequate fluid resuscitation 1
Use qSOFA ≥2 to identify highest-risk patients requiring most aggressive interventions and ICU transfer 1, 2
Fluid Resuscitation in Sepsis
Administer rapid crystalloid bolus of at least 20 mL/kg for patients with sepsis and tissue hypoperfusion. 8 Assess response by monitoring for ≥10% increase in systolic/mean arterial pressure, ≥10% reduction in heart rate, and/or improvement in mental status, peripheral perfusion, and urine output. 8 Some adult patients may require several liters during the first 24 hours. 8
Common Pitfalls to Avoid
- Never rely on qSOFA alone for initial sepsis screening—you will miss >50% of septic patients 2, 4, 7
- Don't wait for laboratory results to calculate NEWS2—it uses only bedside vital signs 3
- Don't ignore a single abnormal NEWS2 parameter even if total score is low 8
- Don't delay antibiotics to meet arbitrary timing targets in low-risk patients—the timeframes are maximums, not targets 8