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Sepsis Surveillance Using Adult Sepsis Events Simplified eSOFA Criteria Versus Sepsis-3 Sequential Organ Failure Assessment Criteria*

Rhee, Chanu, MD, MPH1,2; Zhang, Zilu, MS1; Kadri, Sameer S., MD, MS3; Murphy, David J., MD, PhD4; Martin, Greg S., MD, MSc4; Overton, Elizabeth, MS4; Seymour, Christopher W., MD, MSc5; Angus, Derek C., MD, MPH5; Dantes, Raymund, MD, MPH6,7; Epstein, Lauren, MD, MS6; Fram, David, BA8; Schaaf, Richard, SM8; Wang, Rui, PhD1; Klompas, Michael, MD, MPH1,2 for the CDC Prevention Epicenters Program

doi: 10.1097/CCM.0000000000003521
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Objectives: Sepsis-3 defines organ dysfunction as an increase in the Sequential Organ Failure Assessment score by greater than or equal to 2 points. However, some Sequential Organ Failure Assessment score components are not routinely recorded in all hospitals’ electronic health record systems, limiting its utility for wide-scale sepsis surveillance. The Centers for Disease Control and Prevention recently released the Adult Sepsis Event surveillance definition that includes simplified organ dysfunction criteria optimized for electronic health records (eSOFA). We compared eSOFA versus Sequential Organ Failure Assessment with regard to sepsis prevalence, overlap, and outcomes.

Design: Retrospective cohort study.

Setting: One hundred eleven U.S. hospitals in the Cerner HealthFacts dataset.

Patients: Adults hospitalized in 2013-2015.

Interventions: None.

Measurements and Main Results: We identified clinical indicators of presumed infection (blood cultures and antibiotics) concurrent with either: 1) an increase in Sequential Organ Failure Assessment score by 2 or more points (Sepsis-3) or 2) 1 or more eSOFA criteria: vasopressor initiation, mechanical ventilation initiation, lactate greater than or equal to 2.0 mmol/L, doubling in creatinine, doubling in bilirubin to greater than or equal to 2.0 mg/dL, or greater than or equal to 50% decrease in platelet count to less than 100 cells/μL (Centers for Disease Control and Prevention Adult Sepsis Event). We compared area under the receiver operating characteristic curves for discriminating in-hospital mortality, adjusting for baseline characteristics. Of 942,360 patients in the cohort, 57,242 (6.1%) had sepsis by Sequential Organ Failure Assessment versus 41,618 (4.4%) by eSOFA. Agreement between sepsis by Sequential Organ Failure Assessment and eSOFA was good (Cronbach’s alpha 0.81). Baseline characteristics and infectious diagnoses were similar, but mortality was higher with eSOFA (17.1%) versus Sequential Organ Failure Assessment (14.4%; p < 0.001) as was discrimination for mortality (area under the receiver operating characteristic curve, 0.774 vs 0.759; p < 0.001). Comparisons were consistent across subgroups of age, infectious diagnoses, and comorbidities.

Conclusions: The Adult Sepsis Event’s eSOFA organ dysfunction criteria identify a smaller, more severely ill sepsis cohort compared with the Sequential Organ Failure Assessment score, but with good overlap and similar clinical characteristics. Adult Sepsis Events may facilitate wide-scale automated sepsis surveillance that tracks closely with the more complex Sepsis-3 criteria.

1Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston MA.

2Department of Medicine, Brigham and Women’s Hospital, Boston, MA.

3Department of Critical Care Medicine, Clinical Center, National Institutes of Health, Bethesda, MD.

4Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Emory Critical Care Center, Atlanta, GA.

5The Clinical Research, Investigation and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

6Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.

7Division of Hospital Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA.

8Commonwealth Informatics, Waltham, MA.

*See also p. 467.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, or the National Institutes of Health.

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).

Presented, in part, at the 2018 Society of Critical Care Medicine Conference (Abstract #1411) (San Antonio, TX, February 26, 2018).

Dr. Rhee’s institution received funding from Agency for Healthcare Research and Quality (K08HS025008). Dr. Kadri received support from National Institutes of Health (NIH) Intramural funds. Drs. Rhee, Martin, Overton, Wang, and Klompas’ institutions received funding from Centers for Disease Control and Prevention (CDC) (U54CK000484). Drs. Seymour and Angus received support for article research from the NIH (R35GM119519). Ms. Zhang and Mr. Fram disclosed work for hire. Drs. Kadri and Epstein disclosed government work. Dr. Martin’s institution received funding from and Cheetah Medical; he received funding from Grifols; and he received support for article research from the CDC. Mr. Fram and Mr. Schaaf’s institution received funding from Harvard Pilgrim Healthcare Institute. Dr. Klompas received honoraria for lectures from Washington State Hospital Association, Dell Medical School, and Beth Israel Deaconess Hospital Plymouth. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: crhee@bwh.harvard.edu

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