Performance of the Quick Sequential Organ Failure Assessment in an emergency department

Abstract

Objective  To assess the performance of qSOFA for identifying sepsis in an emergency department.

Methods  This retrospective cohort study was conducted at a private hospital in São Paulo, Brazil, between 2018 and 2019. Data were extracted from the medical records of all individuals treated with suspected sepsis and assessed using the qSOFA tool, according to demographic, clinical, and outcome variables. Statistical analysis was performed using Student’s t-test, chi-square test, and McNemar’s test.

Results  A total of 5,017 patients with suspected sepsis were assessed using qSOFA, of which 88% had a negative qSOFA score and 12% a positive qSOFA. Individuals with a positive qSOFA (score>2) had a higher percentage of sepsis diagnosis, with a statistically significant association. Patients with a positive qSOFA were 49% men and 37.3% women, with a mean age of 74.28 years. It was observed that there was a similarity in the percentages between the scored variables of the qSOFA scale (systolic blood pressure (SBP) ≤ 100 mmHg or MAP < 65 mmHg, respiratory rate (RR) ≥ 22 rpm and level of consciousness). The most prevalent site of infection was the respiratory (55.7%). In relation to the outcome, 6.8% of sepsis cases progressed to death.

Conclusion  In this study, the qSOFA score showed good specificity (94%) and low sensitivity (32%) for detecting sepsis in an emergency department, demonstrating its effectiveness. This tool can be considered, due to its ease of application and worldwide knowledge, in the identification of sepsis.

Keywords:
Sepsis; Emergency medical services; Organ dysfunction scores; Dimensional measurement accuracy

Resumo

Objetivo  Avaliar o desempenho do qSOFA para identificação de sepse em um serviço de emergência.

Métodos  Coorte retrospectiva, realizado em um hospital privado em São Paulo, Brasil no período de 2018 e 2019. Os dados foram extraídos de prontuários de todos os indivíduos atendidos com suspeita de sepse e avaliados pela ferramenta qSOFA, conforme as variáveis demográficas, clínicas e desfecho. A análise estatística foi realizada por meio do teste T-student, Qui-Quadrado e McNemar.

Resultados  Foram avaliados pelo instrumento qSOFA 5.017 pacientes com suspeita de sepse, destes 88% apresentaram escore qSOFA negativo e 12% qSOFA positivo. Indivíduos com qSOFA positivo (pontuação >2) apresentaram maior percentual de diagnóstico de sepse, com associação estatisticamente significante. Os pacientes com qSOFA positivo eram 49% homens e 37,3% mulheres, com média de idade de 74,28 anos, observou-se que houve similaridade das porcentagens entre as variáveis pontuadas da escala qSOFA (pressão arterial sistólica (PAS) ≤ 100 mmHg ou PAM < 65 mmHg, frequência respiratória (FR) ≥ 22 rpm e nível de consciência). O sítio de infecção mais prevalente foi o respiratório (55,7%). Relacionado ao desfecho 6,8% dos casos de sepse evoluíram a óbito.

Conclusão  Neste estudo o escore qSOFA apresentou boa especificidade (94%) e baixa sensibilidade (32%) para detecção de sepse no serviço de emergência, o que demonstra que o score foi efetivo. Esta ferramenta pode ser considerada, devido sua fácil aplicação e seu conhecimento difundido mundialmente, na identificação da sepse.

Descritores:
Sepse; Serviços médicos de emergência; Escores de disfunção orgânica; Precisão da medição dimensional

Resumen

Objetivo  Evaluar el rendimiento de la qSOFA para la identificación de la sepsis en un servicio de urgencias.

Métodos  Cohorte retrospectiva, realizada en un hospital privado de São Paulo, Brasil, en el período comprendido entre 2018 y 2019. Los datos se extrajeron de las historias clínicas de todos los individuos atendidos con sospecha de sepsis y evaluados mediante la herramienta qSOFA, según las variables demográficas, clínicas y de resultado. El análisis estadístico se realizó mediante las pruebas test-T de Student, ji cuadrado y McNemar.

Resultados  Se evaluaron 5017 pacientes con sospecha de sepsis mediante el instrumento qSOFA, de los cuales el 88 % presentó un puntaje qSOFA negativo y el 12 % un puntaje qSOFA positivo. Los individuos con qSOFA positivo (puntaje >2) presentaron un mayor porcentaje de diagnóstico de sepsis, con una asociación estadísticamente significativa. De los pacientes con qSOFA positivo, un 49 % eran hombres y un 37,3 % mujeres, con edad promedio de 74,28 años. Se observó una similitud en los porcentajes de las variables puntuadas en la escala qSOFA (presión arterial sistólica [PAS] ≤ 100 mmHg o presión arterial promedio [PAP] < 65 mmHg, frecuencia respiratoria (FR) ≥ 22 rpm y nivel de conciencia). El sitio de infección más prevalente fue el respiratorio (55,7 %). Con relación al desenlace, el 6,8 % de los casos de sepsis evolucionaron hacia la muerte.

Conclusión  En este estudio, el puntaje de la escala qSOFA presentó una buena especificidad (94 %) y una baja sensibilidad (32 %) para la detección de sepsis en el servicio de urgencias, lo que demuestra que la escala fue eficaz. Esta herramienta puede considerarse para la identificación de la sepsis, debido a su fácil aplicación y su conocimiento difundido en todo el mundo.

Descriptores:
Sepsis; Servicios médicos de urgencia; Puntuaciones en la disfunción de órganos; Precisión de la medición dimensional

Introduction

Overcrowding in emergency departments (EDs) has become a major public health concern. High demand has created an imbalance between quality and service delivery.(¹)In this context, highly prevalent diseases that pose a risk to life and are time-dependent for a better prognosis may have delayed treatment due to lack of identification, causing unfavorable outcomes.(¹) It is important that there are strategies for screening and subsequent implementation of effective therapeutic measures.(²)

Worldwide, it is estimated that there were 48.9 million cases and 11 million deaths from sepsis in 2017.(³)In Brazil, the incidence of sepsis increased by 50.5% from 2006 to 2015.(⁴) The mean cost of hospitalization for sepsis is US$17,359.30 and approximately 59% of patients treated in Brazil die.(⁵)Furthermore, sepsis has a social impact, as most survivors experience a worsening quality of life, including decreased income, new disabilities, and increased comorbidities.(⁶) The increase in sepsis is related to population aging, the increase in the number of invasive procedures and the widespread use of immunosuppressive, chemotherapeutic and antimicrobial drugs.(⁷)

Sepsis is defined as the body’s dysregulated inflammatory response to an infectious agent. Progression can lead to septic shock, with disorganized circulatory, cellular, and metabolic responses that increase the mortality rate if not detected early.(⁸)

Thus, sepsis falls within the category of prevalent and time-dependent diseases for better prognosis, and one identification strategy that has been used is the quick Sequential Organ Failure Assessment (qSOFA). This score is a tool for analyzing organ dysfunctions, easy and quick to use at the bedside, and identifies adult patients with a higher probability of unfavorable clinical outcomes. The qSOFA is an adapted version of the original Sequential Organ Failure Assessment scale, which does not require laboratory tests, only assessment of systolic blood pressure, respiratory rate (RR), and level of consciousness.(⁸)There is still no consensus on its applicability in EDs, due to the different sensitivity and specificity percentages, suggesting that the combination with other parameters and scales favors the increase of these percentages.(⁹,¹⁰)

Publications on qSOFA are more frequently focused on prognostic prediction due to its use in identifying sepsis. The complex and dynamic care setting in EDs makes identifying these cases challenging. However, with the rapid applicability of the scale, combined with globally disseminated knowledge, sensitivity, and specificity analysis for identifying sepsis becomes relevant. Its use can reduce morbidity and mortality and increase early detection rates for this prevalent disease in EDs. In this context, nurses’ role is essential in the early identification of patients’ clinical manifestations, initiation of care protocols, and prioritization of care,(¹¹)making them a key player in using the scale as a decision-making tool in ED screening. This study aimed to assess the performance of qSOFA for identifying sepsis in an ED.

Methods

This is a retrospective cohort study that was conducted in accordance with SRrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines.(¹²)It was conducted in four Emergency Care Units (ECUs) of a large private hospital in the city of São Paulo, Brazil.

The population consisted of all medical records of individuals treated at the ECU risk stratification, aged 18 years or older, with clinical suspicion of sepsis, assessed using the qSOFA tool, in 2018 and 2019. Individuals with incomplete variables of interest in their medical records were excluded from the study.

The research information was obtained from the hospital’s database system, tabulated and anonymized in Excel^® spreadsheets. Demographic (sex and age), clinical (adherence to the sepsis package of measures, presumed sepsis source, qSOFA score calculated in the risk stratification, confirmed sepsis/septic shock diagnosis), and outcome variables (discharge from the emergency unit, Intensive Care Unit admission, and death) were collected.

The qSOFA was calculated according to the following criteria: systolic blood pressure (SBP) ≤ 100 mmHg or mean arterial pressure (MAP) < 65 mmHg, RR ≥ 22 rpm, and level of consciousness (Glasgow Coma Scale < 15). Each variable is assigned one point in the score, which can vary from 0 to 3. The qSOFA score is considered positive when it presents a value ≥ 2, defining suspicion of sepsis and a higher risk of death, and negative when <2, canceling the suspicion of sepsis.(⁸)

Sepsis diagnosis and outcomes were extracted from the discharge record made by a physician in the system.

Statistical analysis was performed using R and the Statistical Package for the Social Sciences (SPSS) version 19. The association between qSOFA and age was assessed using Student’s t-test. The association between qSOFA and categorical variables (sex, package adherence, hospitalization location, focus, and outcome) was assessed using the chi-square test. The McNemar test was used for sepsis/septic shock diagnosis.

To assess the performance of the qSOFA score in identifying sepsis, the predictor variable was the score, and the outcome variable was sepsis/septic shock diagnosis. Score performance was calculated using sensitivity (the probability of a positive result in patients (true positive)) and specificity (the probability of a negative result in non-patients (true negative). The confusion matrix shown in Chart 1 was used.

Chart 1
Confusion matrix

	Sick (presence)	Not sick (absence)
Positive test	True positive (TP)	False positive (FP)
Negative test	False negative (FN)	True negative (TN)

Where, sensitivity = TP/TP+FN and specificity = TN/FP+TN.

Complementary analysis was performed using the Kappa concordance coefficient, interpreted according to Altman as (<0.2) poor, (0.21 to 0.4) reasonable, (0.41 to 0.6) moderate, (0.61 to 0.8) good and (0.8 to 1) very good.(¹³)

To analyze the associations of variables, a significance level of 5% (p-value < 0.05) was considered.

The study was approved by the institution’s Research Ethics Committee, under Protocol 4258336 (Certificate of Presentation of Ethical Consideration 12397219.0.0000.0071) and followed the Brazilian National Health Council (Resolution 466/2012) ethical precepts.

Results

The study population consisted of 5,017 patients with suspected sepsis in an ED, assessed by qSOFA, of which 88% (n=4,414) had a negative qSOFA score and 12% (n=603) a positive qSOFA. The demographic profile of these patients showed similarity between men (52.1%) and women (47.9%), with a mean age of 74.31 years (+17.48). There was no association between qSOFA and age (p=0.9693) or sex (p=0.1141). As for the epidemiological profile, 23% (n=1,167) of patients developed sepsis or septic shock, and 32% of these had a positive qSOFA (n=378). There were 167 patients (3.3%) who presented death as the final outcome. An association was observed between the death outcome and the positive qSOFA score (p<0.0001). The other outcomes are related to hospitalization (n 161 = 3.2%); were discharged from the emergency room; and 703 (14%) were transferred to the Intensive Care Unit (Table 1).

Table 1
Description of demographic variables, presence of sepsis/septic shock, and outcome (n=5,017)

Variables	qSOFA		p-value
	Negative n(%)	Positive n(%)
Number of patients	4414(88)	603(12)
Mean age (SD*)	74.31(17.4)	74.28(17.9)	0.9693*
Sex
Male	2318(52.5)	296(49)	0.1141**
Female	3625(82.1)	225(37.3)
Sepsis/septic shock
Positive	789(17.9)	378(62.7)	< 0.0001***
Negative	3625(82.1)	225(37.3)
Outcome
Alive	4288(97.1)	562(93.2)	< 0.0001**
Death	126(2.9)	41(6.8)

• n = Number of cases; *Student’s t-test; **Chi-square test, ***McNemar’s test.

The most prevalent infection sites for positive qSOFA (n 603 = 12%) in this sample were the following systems: respiratory (55.7%); urinary (16.8%); digestive (12%); skin and soft tissue (2.8%); bone (0.3%); bloodstream (1.5%); central nervous (10.3%); and without clarified focus (0.7%). However, no association was evidenced between the focus and qSOFA (p = 0.9402). In the assessment of variables scored by qSOFA (Table 2), it can be observed that, of all the patients assessed, 14.5% presented alterations in the Glasgow scale, 34.3% in RR and 9.9% in SBP or MAP. When assessing patients with positive qSOFA, it was observed that there was similarity in percentages between variables; however, all variables were associated with positive qSOFA (p<0.0001).

Table 2
Association of Glasgow Coma Scale, respiratory rate, systolic and mean blood pressure with qSOFA (n=5,017)

Variables	qSOFA		p-value*
	Negative n(%)	Positive n(%)
Number of patients	4414(88)	603(12)
Change in Glasgow
No	3985(90.3)	303(50.2)	<0.0001
Yes	429(9.7)	300(49.8)
Change in respiratory rate
No	2983(67.6)	315(52.2)	<0.0001
Yes	1431(32.4)	288(47.8)
SBP ≤ 90 or MAP < 65 mmHg
No	4204(95.2)	315(52.2)	<0.0001
Yes	210(4.8)	288(57.8)

• n = number of cases; *Chi-square test.

Healthcare professionals’ adherence to the sepsis bundle of measures during care at the ECU was 62.2% (n=3,119), of which 16.4% (n=513) had a positive qSOFA. Of the 1,898 cases in which there was no adherence to the bundle, 4.7% (n=90) had a positive qSOFA. There was a significant association between adherence to the bundle and indication of sepsis by qSOFA (p<0.0001). Considering that the sepsis variable indicates patients’ true diagnosis, the positive and negative predictive values of qSOFA were assessed (Table 3). It was observed that 72.3% (n=3,625) of them had a true negative (TN) result; 15.7% (n=789) had false negative (FN) result; 4.5% (n=225) of patients had a false positive (FP) result; and 7.5% (n=378) had true positive (TP) result for sepsis, according to qSOFA. There was a significant association between the positive qSOFA and the sepsis diagnosis described in medical records (p<0.0001).

Table 3
Performance of qSOFA to screen for sepsis in the study population (n=5,017)

qSOFA	Final sepsis or septic shock diagnosis
	Positive n	Negative n	Total n	p-value*
Positive	378	225	603	<0,0001
Negative	789	3625	4414
Total	1167	3.850	5017

• *McNemar test.

The number of patients diagnosed with sepsis/septic shock was higher than those identified by qSOFA (p<0.0001). The sensitivity and specificity values of qSOFA for identifying sepsis were 0.32 and 0.94, respectively, representing low sensitivity and good specificity. A complementary analysis was performed to assess the agreement between the confirmation of sepsis diagnosis and qSOFA, resulting in a Kappa coefficient of 0.32 (95% CI: 0.21 to 0.4; p-value ≤0.001), which, considering the stratification proposed by Altman, indicates reasonable agreement.

Discussion

The demographic profile in this study showed a high mean age (74.31 years) and similar frequencies related to the sex of patients with sepsis. Studies demonstrate similarity of data, with a mean age of 62.5,(¹¹) 64.1(¹⁴) and 79 years old,(¹⁵) no gender preponderance in two studies(¹⁴,¹⁵)and divergence with a proportion of 63.4% for males and 36.6% for females,(¹¹) which could be related to the population characteristics of each location. There is a relationship between population aging and the causes of hospitalization for sepsis.(¹⁶)

In this study, sepsis or septic shock diagnosis had a prevalence of 23% (n=1,167) of cases. This corroborates studies carried out in a Brazilian ED, which demonstrated 18.1% of cases (n=127)(¹⁴)and a study carried out in Hong Kong that demonstrated 27.6% cases (n=601).(¹⁵) However, it differs from another Brazilian study that presented 58.2% cases (n=122).(¹¹) A systematic review states that the proportion of patients with sepsis varies from 0.41% to 63.6%, due to variations in unbalanced data, presented with very small numbers of patients with sepsis compared to the study populations.(¹⁷)

Individuals with a positive qSOFA (score >2) had a higher percentage of sepsis diagnoses, with a statistically significant association between these variables in this study. Studies have found the same association,(¹¹,¹⁸) describing that the higher the score, the more severe the organ dysfunction caused by sepsis.(¹⁸)

Regarding the outcome, our study showed a rate of 3.3% of cases resulting in death, with an association between the outcome and a positive qSOFA score (p<0.0001). This differs from the mortality rates presented in other studies, such as the increasing sepsis mortality rate in Brazil from 7.2% in 2011 to 11.1% in 2021 of all records in the Mortality Information System.(¹⁹) When specifically assessing an ED in southern Brazil, patients with sepsis had a 53% death rate, with the rate increasing to 77% related to septic shock diagnosis.(²⁰) When assessing global mortality from sepsis, rates vary from 15% to 25% in high-income countries, while mortality from septic shock can reach 30% to 40%; in contrast, in low-income countries, these rates exceed 40% in sepsis and 50% in septic shock.(²¹)

In this study, the respiratory system was the main focus of sepsis (54.6%) in patients. In the literature, this site is described as the most prevalent secondary, mainly to pneumonia,(²²,²³) followed by abdominal infection, catheter-related bloodstream infection, and urinary tract infection.(²³)

Regarding the variables scored by qSOFA, our study showed a higher rate of change in RR (34.3%) in all patients studied, while in cases with sepsis there was similarity in the scores for changes in consciousness (49.8%), RR (47.8%), and blood pressure (57.8%). A Brazilian study demonstrated that the qSOFA variable that obtained the highest number of changes was RR greater than 22 bpm (52.4%), while in the presence of sepsis, septic shock, and death, patients with altered level of consciousness were more prevalent.(¹¹) A study that assessed 1,427 patients in an ED, of which 417 had sepsis (29.2%), demonstrated a greater change in RR with an average of 25 bpm in sepsis compared to 23 bpm in patients without sepsis, the average pressure in turn presented 88 to 77 in the groups respectively, while consciousness assessment remained unchanged in the groups.(²⁴)A study showed that RR ≥22/min had the strongest association with severity, with superior diagnostic value compared to SBP and level of consciousness.(²⁵) The increased RR in sepsis occurs due to the compensatory mechanism to minimize tissue hypoxia. Furthermore, the respiratory system is the most prevalent source of sepsis, due to community-acquired and nosocomial infections.(²⁶)

In this study, adherence to the sepsis bundle of measures was 62.2% (n=3,119), of which only 16.4% had a positive qSOFA. A retrospective analysis of the Latin American Sepsis Institute database, which assessed 21,103 patients, showed that, after implementing improvements through continuing education, creating guidelines for empirical antibiotic therapy, and a screening tool, adherence to the six-hour sepsis response bundle increased from 13.5% to 58.2% in private institutions and from 7.4% to 15.7% in public institutions, with reduced mortality rates and improved quality indicators.(²⁷)

Assessing a test’s accuracy requires assessing its sensitivity and specificity, which reflects its ability to detect the presence of a disease. Specificity refers to the probability of a positive result for the presence of the disease, and sensitivity refers to a negative result for its absence.(²⁸)

As for the qSOFA score in predicting sepsis diagnosis in the emergency room, this study demonstrated good specificity (94%) and low sensitivity (32%), demonstrating that the score was effective in detecting sepsis. When compared with other studies that used qSOFA for sepsis detection and diagnosis, we found similar data. A Brazilian (n=122) and Japanese (n=2407) study found that for qSOFA > 2, there was a specificity of 86%(¹¹) and 71%,(⁹) and sensitivity of 66%(¹¹) and 55%,(⁹)respectively. In contrast, a study from New Delhi (n=240) presented a specificity of 54.08% and sensitivity of 68.18% of the score, justifying that the higher sensitivity rate is a reflection of the high loss rate in the sepsis assessment (11.7%).(²⁹)

A systematic review identified 94% combined specificity and 37% combined sensitivity, lower values when compared with other scores such as Early Warning Score and Systemic Inflammatory Response Syndrome (SIRS).(³⁰) Another review showed qSOFA specificity between 89.1% and 98% and sensitivity ranging from 16.7% to 48.6%.(³¹)

Regarding predictive values, our study found 7.5% (n=378) TP and 72.3% (n=3,625) TN results, which differs from other studies. A study conducted in New Delhi showed a positive predictive value (TP) of 25% and a negative predictive value (TN) of 88.3%.(²⁹) A literature review compared the predictive value of qSOFA ≥ 2 with the SIRS score ≥ 2, demonstrating that the positive predictive value for qSOFA ≥ 2 was 36.4%, 57%, and 89%, indicating that qSOFA ≥ 2 is more likely to detect sepsis than SIRS ≥ 2. The negative predictive value of qSOFA ≥ 2 was 69%, 95%, and 96.5%.(³¹) These findings demonstrate that there is still no consensus on the indication for the use of qSOFA; however, there is still no other score that can be used with greater accuracy.

A study reveals that qSOFA’s sensitivity in predicting sepsis was lower compared to the SIRS criteria, but it showed better prognostic accuracy for 30-day mortality compared to SIRS (p<0.05). The qSOFA can be a useful tool for assessing sepsis severity and prognosis, but it does not reveal specific organ dysfunctions. The use of other scales or parameters is suggested, as the qSOFA score assesses a single point in time and cannot capture rapid changes in patients’ clinical status.(³²)

It is important to emphasize that, due to the frequent rates of septic patients in emergency rooms and their potential severity, strategies for early recognition and treatment of this pathology should be priorities in healthcare services in order to promote better survival indicators and better care for this patient profile.(³³)The importance of nurses’ role in identifying these cases is emphasized, since, in most EDs, they are responsible for clinical assessment in risk stratifications and prioritization of care, and consequently, they successively assess patients under observation in these units.

This study had limitations such as being conducted in a single center and at a private institution, which may not reflect the national reality, and not being comparable with other scores. Further studies should be conducted to assess the use of the scale for identifying sepsis.

Conclusion

In this study, the qSOFA score showed good specificity (94%) and low sensitivity (32%) for detecting sepsis in an ED. The qSOFA is an easy-to-use, low-cost tool that uses routinely assessed parameters and can be combined with other clinical assessment parameters. Due to the dynamic nature of care and the complexity of patients in an ED, reducing morbidity and mortality from sepsis depends on early identification and appropriate treatment. Therefore, further studies seeking more accurate assessment are essential.

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• Data availability:
  The survey data are available in the article.

Edited by

• Associate Editor:
  Marcia Barbieri (https://orcid.org/0000-0002-4662-1983) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brasil.

Data availability

The survey data are available in the article.

Publication Dates

• Publication in this collection
  20 Apr 2026
• Date of issue
  2026

History

• Received
  11 Mar 2025
• Accepted
  18 Aug 2025