CONVERSATIONS ABOUT EMS RESEARCH
Is qSOFA the Holy Grail of sepsis research?
By Keith Wesley, MD, FACEP, FAEMS & Karen Wesley, NREMT-P
Dorsett M, Kroll M, Smith C, et al. qSOFA has
poor sensitivity for prehospital identification
of severe sepsis and septic shock. Prehosp
Emerg Care. 2017; 21( 4):489–497.
The authors reviewed the medical records,
including the EMS report, of 152 patients
arriving by EMS at a large urban ED and who
were diagnosed with an infection (n = 71),
sepsis (n = 38) or severe sepsis (n = 43).
The records were examined for signs and
symptoms that are components of a sepsis scoring scheme called quick sequential organ failure assessment (qSOFA),
which could’ve been performed by the
The qSOFA score ranges from 0 to 3, with
one point awarded for each of the following,
if present on exam: Systolic blood pressure
< 100 mmHg; respiratory rate > 22 and altered
mental status. A score of 2 or 3 has been
proposed to correlate with the presence
They discovered that an EMS score of 2
was 16.3% sensitive (95% confidence interval
[CI] 6. 8–30.7%) and 97.3% specific (95% CI
92.1–99.4%) for patients confirmed to have
Had the medics been allowed to add an
additional point for such things as a pulse
over 100, nursing home residence, age > 50,
or history of a fever, the sensitivity of the
qSOFA would’ve increased to 58.1% (95%
CI 42.1–73.0%), but decreased the specific-ity to 78.0% (95% CI 69.0–85.4%)
During their stay in the ED, two-thirds
of patients who met the EMS qSOFA criteria developed sufficient symptoms to have a
qSOFA score of 2 or more. The most common factors causing the EMS score to remain
less than 2 was the lack of hypotension and/
or rapid respirations ( > 22).
The authors concluded that, “These
findings suggest that the dynamic nature of
sepsis can make sensitive detection difficult
in the prehospital setting, although com-
bining qSOFA with other clinical informa-
tion (e.g., age, nursing home status, fever
and tachycardia) can identify more patients
with sepsis who may benefit from time crit-
MEDIC WESLEY COMMENTS
EMS has finally been tasked to look for
things that impact outcomes. Our practice
has grown in knowledge and scope, resulting
in significant changes in the survival of our
patients. However, it needs to be said that not
everything that works in the hospital setting
also works in the prehospital setting.
The author’s changes to qSOFA for the
ED didn’t help until the patients had been
there for hours. If it didn’t work in the ED
with a large team of resources, why should
it work in the field?
The inclusive criteria of qSOFA are vague
when considering the elderly patient. To
be honest, I could probably get a 3 on this
scale before I have my first cup of coffee in
Once you add the “nursing home” factors
of dehydration and environment, you could
probably hit or miss with this scale on any
Without on-site lab tests, the best we can
do to help make the diagnosis of sepsis is to
have a strong index of suspicion and, when
possible, a good history.
By the way, isn’t it strange that we accept
chronic dehydration in long-term care
patients as the norm? But, that’s another story.
DOC WESLEY COMMENTS
Early goal-directed therapy of sepsis has
been promoted by studies showing that the
most important step in sepsis treatment
Sepsis is a sneaky condition and it can
often present with vague, slowly progressive
changes in signs and symptoms. The fact
that it’s more common in the elderly popu-
lation is well-known, but that only makes the
condition even harder to detect because of
the pre-existing conditions of dementia (i.e.,
altered mental status) and chronic dehydra-
tion, particularly in nursing home residents.
In the absence of lab tests like serum lactate, white blood cell count and cultures, we
must rely on our clinical suspicion.
For these reasons, the development of a
rapid and easily performed scoring system
has been the Holy Grail of sepsis research.
This study confirms what several others
have already done: There is no Holy Grail
of sepsis research.
You can spend all the time you want calculating scores like q SOFA, Robson, Modified
Tell the doc your suspicion, then take a
seat—and don’t worry about the SOFA. JEMS
Keith Wesley, MD, FACEP, is the medical
director for HealthEast Medical Transporta-
tion in St. Paul, Minn., and United EMS in
Wisconsin Rapids, Wis. He can be reached
Karen Wesley, NREMT-P, is a paramedic and
educator for Mayo Clinic Medical Transport
and is the medic team leader for the Eau Claire
County (Wis.) Regional SWAT team. She can
be reached at email@example.com.
Learn more from Keith Wesley at the
EMS Today Conference, Feb. 21–23, in
Charlotte, N.C. EMS Today.com