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Evaluation of Repeated Quick Sepsis-Related Organ Failure Assessment Measurements Among Patients With Suspected Infection*

Kievlan, Daniel R., MD, MSc1,2; Zhang, Li A., PhD3; Chang, Chung-Chou H., PhD4; Angus, Derek C., MD, MPH1,2; Seymour, Christopher W., MD, MSc1,2,5

doi: 10.1097/CCM.0000000000003360
Clinical Investigations

Objectives: Among patients with suspected infection, a single measurement of the quick Sepsis-related Organ Failure Assessment has good predictive validity for sepsis, yet the increase in validity from repeated measurements is unknown. We sought to determine the incremental predictive validity for sepsis of repeated quick Sepsis-related Organ Failure Assessment measurements over 48 hours compared with the initial measurement.

Design: Retrospective cohort study.

Setting: Twelve hospitals in southwestern Pennsylvania in 2012.

Patients: All adult medical and surgical encounters in the emergency department, hospital ward, postanesthesia care unit, and ICU.

Interventions: None.

Measurements and Main Results: Among 1.3 million adult encounters, we identified those with a first episode of suspected infection. Using the maximum quick Sepsis-related Organ Failure Assessment score in each 6-hour epoch from onset of suspected infection until 48 hours later, we characterized repeated quick Sepsis-related Organ Failure Assessment with: 1) summary measures (e.g., mean over 48 hr), 2) crude trajectory groups, and 3) group-based trajectory modeling. We measured the predictive validity of repeated quick Sepsis-related Organ Failure Assessment using incremental changes in the area under the receiver operating characteristic curve for in-hospital mortality beyond that of baseline risk (age, sex, race/ethnicity, and comorbidity). Of 37,591 encounters with suspected infection, 1,769 (4.7%) died before discharge. Both the mean quick Sepsis-related Organ Failure Assessment at 48 hours (area under the receiver operating characteristic, 0.86 [95% CI, 0.85–0.86]) and crude trajectory groups (area under the receiver operating characteristic, 0.83 [95% CI, 0.83–0.83]) improved predictive validity compared with initial quick Sepsis-related Organ Failure Assessment (area under the receiver operating characteristic, 0.79 [95% CI, 0.78–0.80]) (p < 0.001 for both). Group-based trajectory modeling found five trajectories (quick Sepsis-related Organ Failure Assessment always low, increasing, decreasing, moderate, and always high) with greater predictive validity than the initial measurement (area under the receiver operating characteristic, 0.85 [95% CI, 0.84–0.85]; p < 0.001).

Conclusions: Repeated measurements of quick Sepsis-related Organ Failure Assessment improve predictive validity for sepsis using in-hospital mortality compared with a single measurement of quick Sepsis-related Organ Failure Assessment at the time a clinician suspects infection.

1Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

2Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

3RAND Corporation, Santa Monica, CA.

4Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

5Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

*See also p. 2046.

This work was performed at the University of Pittsburgh School of Medicine.

Drs. Kievlan, Angus, and Seymour contributed to study concept and design; Drs. Kievlan and Seymour contributed to acquisition of data; Drs. Kievlan, Zhang, Chang, Angus, and Seymour contributed to analysis and interpretation of data; Dr. Kievlan contributed to first drafting of the article; Drs. Kievlan, Zhang, Chang, Angus, and Seymour contributed to critical revision of the article for important intellectual content; Drs. Kievlan, Chang, and Seymour contributed to statistical analysis; Drs. Kievlan and Seymour contributed to sdministrative, technical, and material support; Dr. Seymour contributed to study supervision: Drs. Kievlan and Seymour contributed to data access and responsibility and they had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals/.lww.com/ccmjournal).

Supported, in part, by the National Institutes of Health, T32HL007820 (to Dr. Kievlan) and R35GM119519 (to Drs. Chang, Angus, and Seymour).

Dr. Kievlan’s institution received funding from National Heart, Lung, and Blood Institute, and he disclosed that Drs. Chang, Angus, and Seymour received support from the National Institute of General Medical Services. Drs. Kievlan, Zhang, Chang, and Seymour received support for article research from the National Institutes of Health (NIH). Drs. Zhang’s and Seymour’s institutions received funding from the NIH. Dr. Seymour received funding from Beckman Coulter.

For information regarding this article, E-mail: daniel.kievlan@gmail.com

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