Modification of qSOFA Increases Mortality Prediction Accuracy in Sepsis Patients


  • Erik Jaya Gunawan Universitas Ciputra Surabaya
  • Salmon Charles Pardoman Tua Siahaan Universitas Ciputra Surabaya
  • Areta Idarto Universitas Ciputra Surabaya
  • Florence Pribadi Universitas Ciputra Surabaya
  • Lidya Handayani Universitas Ciputra Surabaya



Mortality, qSOFA, ROX index


The Quick Sequential Organ Failure Assessment (qSOFA) is a simple parameter, however, its sensitivity as a mortality predictor is low. This study aimed to improve the predictor performance of qSOFA for in-hospital mortality. This study was a retrospective single-centered cohort using medical record data. This study included 150 patients aged 18-80 years old, who experienced sepsis and received ICU care between September 2021 and August 2022. qSOFA and modified ROX index (mROX) were calculated based on the most severe condition recorded in the emergency department (ED). Each variable's area under the receiver operating characteristic (AUROC) curve, sensitivity, and specificity were compared to predict in-hospital mortality. qSOFA scores ≥2 and mROX values ≤3.20 were independent factors that increased the risk of in-hospital mortality (OR 3.69 and 21.50; p 0.004 and 0.005, respectively). The combination of qSOFA scores ≥2 and mROX value ≤3.20 as in-hospital mortality predictors resulted in AUROC 0.791 with a sensitivity of 71.7% and specificity of 75.7%. The AUROC, sensitivity, and specificity of the combination of qSOFA and mROX were higher than qSOFA (0.766, 70.8%, 70.3%) or mROX (0.760, 68.1%, 67.6%) alone. In conclusion, the combination of qSOFA scores ≥2 and mROX values ≤3.20 increase the sensitivity and specificity for predicting in-hospital mortality in sepsis patients.


Download data is not yet available.


Singer M, Deutschman CS, Seymour C, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Journal of the American Medical Association (JAMA). 2016; 315(8): 801–810.

Rudd KE, Johnson SC, Agesa KM, et al. Global, Regional, and National Sepsis Incidence and Mortality, 1990–2017: Analysis for the Global Burden of Disease Study. The Lancet. 2020; 395(10219): 200–211.

Purba AKR, Mariana N, Aliska G, et al. The Burden and Costs of Sepsis and Reimbursement of Its Treatment in a Developing Country: An Observational Study on Focal Infections in Indonesia. International Journal of Infectious Diseases. 2020; 96: 211–228.

Bauer M, Gerlach H, Vogelmann T, Preissing F, Stiefel J, and Adam D. Mortality in Sepsis and Septic Shock in Europe, North America and Australia Between 2009 and 2019-Results from a Systematic Review and Meta-Analysis. Critical Care. 2020; 24(1): 1-9.

Kim H Il and Park S. Sepsis: Early Recognition And Optimized Treatment. Tuberculosis and Respiratory Diseases. 2019; 82(1): 6–14.

Liu VX, Fielding-Singh V, Greene JD, et al. The Timing of Early Antibiotics and Hospital Mortality in Sepsis. American Journal of Respiratory and Critical Care Medicine. 2017; 196(7): 856–863.

Kumar A, Roberts D, Wood KE, et al. Duration of Hypotension before Initiation of Effective Antimicrobial Therapy is the Critical Determinant of Survival in Human Septic Shock. Critical Care Medicine. 2006; 34(6): 1589–1596.

Siewers K, Abdullah SMO Bin, Sørensen RH, and Nielsen FE. Time to Administration of Antibiotics and Mortality in Sepsis. Journal of the American College of Emergency Physicians Open. 2021;2(3): 1-8.

Im Y, Kang D, Ko RE, et al. Time-To-Antibiotics and Clinical Outcomes in Patients with Sepsis and Septic Shock: A Prospective Nationwide Multicenter Cohort Study. Critical Care. 2022; 26(1): 1-10.

Goulden R, Hoyle MC, Monis J, et al. qSOFA, SIRS and NEWS for Predicting Inhospital Mortality and ICU Admission in Emergency Admissions Treated as Sepsis. Emergency Medicine Journal. 2018; 35(6): 345–349.

Abdullah SO Bin, Sørensen RH, and Nielsen FE. Prognostic Accuracy of SOFA, qSOFA, and SIRS for Mortality among Emergency Department Patients with Infections. Infection and Drug Resistance. 2021; 14: 2763–2775.

Nkonge E, Kituuka O, Ocen W, Ariaka H, Ogwal A, and Ssekitoleko B. Comparison of qSOFA and SIRS Scores for the Prediction of Adverse Outcomes of Secondary Peritonitis among Patients Admitted on the Adult Surgical Ward in a Tertiary Teaching Hospital in Uganda: A Prospective Cohort Study. BMC Emergency Medicine. 2021; 21(1): 1-8.

Roca O, Caralt B, Messika J, et al. An Index Combining Respiratory Rate and Oxygenation to Predict Outcome of Nasal High-Flow Therapy. The American Journal of Respiratory and Critical Care Medicine. 2019; 199(11): 1368–1376.

Prower E, Grant D, Bisquera A, et al. The ROX Index Has Greater Predictive Validity than NEWS2 for Deterioration in Covid-19. EClinicalMedicine. 2021; 35: 1-9.

Vega ML, Dongilli R, Olaizola G, et al. COVID-19 Pneumonia and ROX Index: Time to Set a New Threshold for Patients Admitted Outside the ICU. Pulmonology. 2022; 28(1): 13–17.

Song JU, Sin CK, Park HK, Shim SR, and Lee J. Performance of the Quick Sequential (Sepsis-Related) Organ Failure Assessment Score as a Prognostic Tool in Infected Patients Outside the Intensive Care Unit: A Systematic Review and Meta-Analysis. Critical Care. 2018; 22(1): 1-13.

Churpek MM, Zadravecz FJ, Winslow C, Howell MD, and Edelson DP. Incidence and Prognostic Value of the Systemic Inflammatory Response Syndrome and Organ Dysfunctions in Ward Patients. American Journal of Respiratory and Critical Care Medicine. 2015; 192(8): 958–964.

Ruan H, Ke D, and Liao D. Prognostic Accuracy of qSOFA and SIRS for Mortality in the Emergency Department: A Meta-Analysis and Systematic Review of Prospective Studies. Emergency Medicine International. 2022; 2022: 1–11.

Li Y, Yan C, Gan Z, et al. Prognostic Values of SOFA Score, qSOFA Score, and LODS Score for Patients with Sepsis. Annals of Palliative Medicine. 2020; 9(3): 1037–1044.

Candel BGJ, de Groot B, Nissen SK, Thijssen WAMH, Lameijer H, and Kellett J. The Prediction of 24-H Mortality by the Respiratory Rate and Oxygenation Index Compared with National Early Warning Score in Emergency Department Patients: An Observational Study. European Journal of Emergency Medicine. 2023; 30(2): 110–116.

Vaporidi K, Akoumianaki E, Telias I, Goligher EC, Brochard L, and Georgopoulos D. Respiratory Drive in Critically Ill Patients Pathophysiology and Clinical Implications. American Journal of Respiratory and Critical Care Medicine. 2020; 201(1): 20–32.

Hu Q, Hao C, and Tang S. From Sepsis to Acute Respiratory Distress Syndrome (ARDS): Emerging Preventive Strategies Based on Molecular and Genetic Researches. Bioscience Reports. 2020; 40(5): 1-9.

Kim WY and Hong SB. Sepsis and Acute Respiratory Distress Syndrome: Recent Update. Tuberculosis and Respiratory Diseases. 2016; 79(2): 53–57.

Jarczak D, Kluge S, and Nierhaus A. Sepsis—Pathophysiology And Therapeutic Concepts. Frontiers in Medicine. 2021; 8: 1-22.

Garrido D, Assioun JJ, Keshishyan A, Sanchez-Gonzalez MA, and Goubran B. Respiratory Rate Variability As A Prognostic Factor In Hospitalized Patients Transferred To The Intensive Care Unit. Cureus. 2018; 10(1): 1–5.

Guarino M, Gambuti E, Alfano F, et al. Predicting In-Hospital Mortality For Sepsis: A Comparison between qSOFA and Modified qSOFA in A 2-Year Single-Centre Retrospective Analysis. European Journal of Clinical Microbiology & Infectious Diseases. 2021; 40(4): 825–831.



2024-02-29 — Updated on 2024-02-29



Research Article