Background: Depending on the criterion applied, the systemic inflammatory response syndrome (SIRS) criteria and the Sequential Organ Failure Assessment (SOFA) criteria initially identify distinct populations that present to the emergency department (ED) with suspected sepsis (Prasad et al., SHM 2018). Our work has shown that 52% of patients meet SIRS criteria first and 48% meet SOFA criteria first. Little is known about differences in timing of treatment and management among those who initially present with SIRS criteria compared to those who initially present with SOFA criteria. Our objective was to compare demographics and the timing of treatment of sepsis among patients who met SIRS first to those who met SOFA first.
Methods: We extracted data from the electronic health record (EHR) on all adults presenting to a single academic ED between 6/1/2012-12/31/2016 with 1) suspected infection (blood culture plus intravenous antibiotics administered) and 2) an EHR-derived SOFA score≥2, within 72 hours of ED arrival. Data on demographics, organ dysfunction, and timing of treatment (antibiotics, vasopressors, ICU admission, hypotension via systolic blood pressure<90 mmHg, lactate>2, acute respiratory failure defined as P/F<300) within 72 hours of ED presentation were compared, stratifying by first definition met, SIRS (≥2 SIRS criteria met) or SOFA (SOFA score ≥2).
Results: In this cohort of 14,587 patients, 7,037 met SOFA first and 7,550 met SIRS first (Table). Median time to first definition was 1.7 hours longer among those who met SOFA first compared to those who met SIRS first (median 2.0 versus 0.2 hours, p<0.0001). Patients who met SOFA first were older (median 65 versus 61 years, p<0.0001), more likely to have chronic renal failure (29.4% versus 19.3%, p<0.0001) and chronic liver disease (18.2% versus 11.5%, p<0.0001) but less likely to have cancer (17.2% versus 19.8%, p<0.0001). The same results were noted when the SOFA score was adjusted for chronic renal or chronic liver disease. Those who met SOFA first less quickly received antibiotics (median 4.1 versus 2.6 hours, p<0.0001) than the SIRS first group. Those who met SOFA first were less likely to be admitted to the ICU (19.7% versus 24.2%, p<0.0001) but more quickly progressed to hypotension (median 4.8 versus 5.8 hours, p=0.011) and acute respiratory failure (median 1.6 versus 2.6 hours, p<0.0001). There was no significant difference in vasopressor receipt.
Conclusions: We found that SIRS and SOFA initially identified patients with differing demographics and severity of illness. Patients meeting SOFA first were older with more comorbid conditions and more rapidly progressed to respiratory and cardiovascular dysfunction. In comparison to patients identified by SIRS criteria, those who initially presented with SOFA criteria received antibiotics later in the disease course.