Advanced Emergency Nursing Journal

Vol. 40, No. 2, pp. 138–143

Copyright 
C 2018 Wolters Kluwer Health, Inc. All rights reserved.

Comparison of Sepsis-3 Criteria Versus

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SIRS Criteria in Screening Patients for

Sepsis in the Emergency Department
Brian W. Gilbert, PharmD, BCPS
Lanae Faires, PharmD, BCPS
Amber Meister, PharmD, BCPS, BCCCP
Joel Huffman, PharmD
Rebecca K. Faber, RN, MSN

Abstract
The objective of our study was to assess the percentage of patients who met qSOFA criteria, SIRS
criteria, both, or none of either criterion and received an International Classification of Diseases,
Tenth Revision (ICD-10) code for sepsis after admission from the emergency department (ED).
This was a single-center retrospective chart review of medical patients admitted through the ED.
Patients were included if they were older than 18 years, were admitted to an inpatient unit through
the ED, and received antibiotics within 48 hr of admission. All patients included were evaluated for
the presence of SIRS and qSOFA criteria and then stratified into 1 of 4 groups. Group 1 consisted
of patients who exhibited neither SIRS criteria nor qSOFA criteria (fewer than 2 of both SIRS and
qSOFA criteria). Group 2 consisted of patients with only SIRS criteria (more than 2 SIRS criteria but
fewer than 2 qSOFA criteria). Group 3 consisted of patients with only qSOFA criteria (more than 2
qSOFA criteria but fewer than 2 SIRS criteria), and Group 4 consisted of patients with both qSOFA
and SIRS criteria (more than 2 qSOFA and SIRS criteria). A of total 100 patients were included,
with 49 patients stratified into Group 1, 37 into Group 2, 2 into Group 3, and 12 into Group 4. With
respect to the primary endpoint, Group 1 had a total of 7 patients (14.3%) who received an ICD-10
code for sepsis or septic shock, Group 2 had 15 patients (40.5%), Group 3 had 1 patient (50%), and
Group 4 had 9 patients (75%). The utilization of both qSOFA and SIRS criteria resulted in a higher
percentage of patients who were designated an ICD-10 code for sepsis whereas patients who did
not exhibit either criterion still had roughly 15% of patients designated an ICD-10 code for sepsis.
Key words: ED sepsis, qSOFA, sepsis, sepsis screening, SIRS

S
EPSIS REMAINS one of the leading
causes of morbidity and mortality world-
wide, accounting for more than $23.7
billion in health care costs in 2015 (Cohen
Author Affiliation: Wesley Medical Center, Wichita,
Kansas.
Disclosure: The authors report no conflicts of interest.
Corresponding Author: Brian W. Gilbert, PharmD,
BCPS, Wesley Medical Center, 550 N Hillside, Wichita,
KS 67214 (brian.gilbert.pharmd@gmail.com).
DOI: 10.1097/TME.0000000000000187
et al., 2015). Understanding of sepsis patho-
physiology has changed, with more empha-
sis being placed on an overall dysregula-
tion in host responses rather than just only
a disruption in proinflammatory and anti-
inflammatory cytokines (Dorsett et al., 2017;
Freund et al., 2017; Jouffroy et al., 2017;
Singer et al., 2016). Although knowledge
of the pathogenesis of sepsis has changed,
changes in the clinical criteria for the iden-
tification of sepsis have lagged until recently

138

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 April–June 2018 r Vol. 40, No. 2
(Singer et al., 2016). Since 1991, the classic
definition of sepsis was two or more systemic
inflammatory response syndrome (SIRS; see
Table 1) criteria plus a suspected or known
infection. The Third International Consen-
sus Definitions for Sepsis and Septic Shock
(Sepsis-3) promote the utilization of the Se-
quential Organ Failure Assessment (SOFA)
score and quick SOFA score (qSOFA; see
Table 1). Some of the pros on the utilization
of qSOFA are that it can be performed at the
bedside without invasive procedures or mon-
itoring and has higher specificity than SIRS
criteria. The utility of SIRS criteria at identify-
ing sepsis has been called into question, with
its lack of specificity and inability to stage the
disease. However, current data regarding the
utility of Sepsis-3 criteria compared with tradi-
tional systemic SIRS criteria in the emergency
department (ED) are scarce and mixed. With
the identification of sepsis being highly dis-
cussed within the literature, it is important
for physicians, advanced nurse practitioners,
physician assistants, nurses, and pharmacists
alike to be able to aid in screening for sepsis to
initiate timely treatment. The purpose of this
study was to compare the rates of sepsis Inter-
national Classification of Diseases, Tenth Re-
vision (ICD-10) code allocation based upon
stratification of whether a patient exhibited
solely SIRS criteria, solely qSOFA criteria,
Table 1. SIRS vs. qSOFA
SIRS vs. qSOFA
SIRS
HR: More than 90 beats/min
WBC count: More than 12,000 or less than
4,000
Fever: More than 38 ◦ C or less than 36 ◦ C
RR: More than 20 breaths/min
qSOFA
RR: 22 or more breaths/min
SBP: 100 mmHg or less
GCS score: 13 or less
Note. GCS = Glasgow Coma Scale; HR = heart rate; RR
= respiratory rate; SBP = systolic blood pressure; WBC
= white blood cell.
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
SIRS vs. qSOFA in the ED 139
both sets of criteria, or exhibited neither of
the criteria when being admitted through
the ED.
METHODS
This was a single-center retrospective chart
review pilot study of medical patients admit-
ted through the ED. Patients were evaluated
utilizing a pharmacy screening software, Vigi-
Lanz, between June 2016 and August 2017.
Patients were included if they were older
than 18 years, were admitted to an inpatient
unit through the ED, and received antibiotics
within 48 hr of admission whether on the
floor or in the ED. Trauma patients were ex-
cluded from this study. All patients included
were evaluated for the presence of SIRS crite-
ria and qSOFA criteria and then stratified into
one of four groups based on the number of
criteria met for SIRS or qSOFA (see Figure 1).
Group 1 consisted of patients who did not
exhibit either SIRS criteria or qSOFA criteria
(fewer than two of both SIRS and qSOFA cri-
teria). Group 2 was made up of patients with
only SIRS criteria (two or more SIRS criteria
but fewer than two qSOFA criteria). Group
3 consisted of patients who met only qSOFA
criteria (two or more qSOFA criteria but fewer
than two SIRS criteria), and Group 4 consisted
of patients who met both qSOFA and SIRS
Figure 1. Stratification of patients. ED = emer-
gency department; SIRS
 140 Advanced Emergency Nursing Journal

criteria (two or more qSOFA and SIRS crite-

patients with
ria). The primary endpoint of this study was

less than 13
GCS score

5 (10%)

1 (50%)
10 (83%)
the percentage of patients who received an

No. of
ICD-10 code for sepsis or septic shock based

0
on the group in which they were stratified.
Secondary endpoints reviewed were initial
serum lactate levels, antibiotic administration

132 (101–146)
127 (111–167)

128 (119–139)
time, and whether or not they required intu-

103 (85–121)
initial SBP
Average
bation or vasopressor therapy within 72 hr of
admission. Descriptive statistics were utilized
to analyze the patient data. This study was
approved by the institutional review board at

Note. GCS = Glasgow Coma Scale; HR = heart rate; RR = respiratory rate; SBP = systolic blood pressure; WBC = white blood cell.
the study site.

17.5 (16–21)
20.5 (13–32)
24 (23–25)
28 (19–38)
initial RR
Average
RESULTS
A total of 206 patients were reviewed for in-
clusion into the study, with a total of 100
being included. Of the total 100 patients, 49

36.2 (35.1–37.8)
37.2 (36.2–38.1)
36.9 (35.8–38.2)
patients were stratified into Group 1, 37 into

temperature

37.0 (35.9–38)
Group 2, two into Group 3, and 12 into Group
Average
initial
4. Table 2 shows the baseline demographics
of patients. Of the 106 excluded, 34 patients
were designated trauma patients, 52 patients
were not admitted through the ED, and 21
patients did not receive antibiotics within the 100 (75–121)

100 (87–122)
designated inclusion time frame. With respect
80 (64–97)

69 (59–84)
initial HR
Average

to the primary endpoint (see Table 3), Group

1 had a total of seven patients (14.3%) who
received an ICD-10 code for sepsis or sep-
tic shock, Group 2 had 15 patients (40.5%),
Table 2. Patient demographics, WBC, and Vital Signs

15.2 (12.3–20.9)

15.8 (12.6–25.4)

Group 3 had one patient (50%), and Group

9.7 (7.7–11.1)

10.5 (5.7–13.1)
initial WBC

4 had nine patients (75%). In terms of ini-

Average

count

tial serum lactate levels, patients in Group 4,

who exhibited both SIRS and qSOFA criteria,
had higher initial mean serum lactate levels
(2.2 mmol/L) than the other groups and had
a higher percentage of patients who received
No. of males

antibiotics within 1 hr of admission (41.7%),

23 (47%)
17 (46%)
1 (50%)
3 (25%)

see Table 4. Eight patients in Group 4 required

vasopressor therapy (66.7%) and six required
intubation (50%), see Table 5. Interestingly,
the number of patients in Group 1 who re-
ceived antibiotics greater than 3 hours after
admission, yet received an ICD-10 code for
Group (n)

sepsis or septic shock.

1 (49)
2 (37)

4 (12)
3 (2)

DISCUSSION
Earlier identification and treatment of sepsis
have shown to reduce mortality, making this

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 April–June 2018 r Vol. 40, No. 2 SIRS vs. qSOFA in the ED 141

Table 3. ICD-10 Code

No. of patients with

No. of patients with ICD-10 ICD-10 code for septic
Group (n) code for sepsis (%) shock (%)

1 (49) 5 (10.2) 2 (4.1)

2 (37) 15 (40.5) 0
3 (2) 1 (50) 0
4 (12) 7 (58.3) 2 (16.7)

Note. ICD-10 = International Classification of Diseases, Tenth Revision.

Table 4. Antibiotic administration times by group

Patients who Patients who

Patients who received received
Average initial received antibiotics antibiotics in
serum lactate antibiotics in within 1–3 hr more than 3 hr
Group (n) level (mmol/L) 1 hr or less (%) (%) (%)

1 (49) 1.7 (1–2.1) 6 (12.2) 15 (30.6) 28 (57.1)

2 (37) 1.5 (1.2–2.3) 4 (10.3) 16 (43.2) 17 (45.9)
3 (2) 1.0 (0.8–1.2) 0 1 (50) 1 (50)
4 (12) 2.2 (1.8–4.3) 5 (41.7) 5 (41.7) 2 (16.6)

a priority for EDs across the country (Torsvik
et al., 2016). This study is fairly consistent
with previously reported data regard to the
utilization of SIRS criteria for screening pa-
tients for sepsis in the ED with it exhibiting
a low sensitivity (Calle, Cerro, Valencia, &
Jaimes, 2012; Macdonald, Arendts, Fatovich,
& Brown, 2014; McCormack et al., 2016;
Zhang et al., 2016). A smaller sample size
made evaluation of patients with solely qSOFA
criteria difficult. As sepsis is a dynamic pro-
cess, we hypothesize that it would be difficult
to screen for patients exhibiting only qSOFA
criteria without also meeting criteria for SIRS.
Other studies have evaluated the best
screening tool to utilize when screening pa-
tients for sepsis prior to ED arrival and in the
ED. A study by Dorsett et al. (2017) evaluated
the prehospital utilization of qSOFA for iden-
tification of severe sepsis and septic shock.

Table 5. Patients requiring vasopressors and/or intubation

Patients requiring
vasopressor therapy Patients requiring
within 72 hr of intubation within 72 hr
Group (n) admission (%) of admission (%)

1 (49) 4 (8.2) 3 (6.12)

2 (37) 9 (24.3) 6 (16.2)
3 (2) 2 (100) 1 (50)
4 (12) 8 (58.3) 6 (50)

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 142
They found that a prehospital qSOFA score of
2 or more showed 16.3% sensitivity while be-
ing 97.3% specific for patients who ultimately
were to be confirmed to have sepsis in the
ED. The authors concluded that the utiliza-
tion of qSOFA in the prehospital setting may
not be appropriate due to the dynamic nature
of sepsis.
A study by Freund et al. (2017) prospec-
tively evaluated the use of qSOFA in the ED as
a predictor of in-hospital mortality. Of 1,088
screened, 879 patients were included in the fi-
nal analysis and it was found that patients with
a qSOFA score of lower than 2 had an over-
all in-hospital mortality rate of 3% whereas
patients with a qSOFA score of greater than
2 had an overall in-hospital mortality rate of
24%. The authors concluded that the use of
qSOFA in the ED could be a useful tool for pre-
dicting in-hospital mortality when compared
with SIRS criteria.
Jouffroy et al. (2017) conducted a retro-
spective review study in which they com-
pared SIRS criteria versus qSOFA criteria as
it related to intensive care unit (ICU) admis-
sions. Their study found that of the 141 pa-
tients with sepsis included in their analysis,
both SIRS and qSOFA criteria were the same
with regard to predicting ICU admissions (p =
0.26). qSOFA criteria had a sensitivity of 75%
and a specificity of 68%, whereas SIRS criteria
had 87% sensitivity with 43% specificity. The
authors concluded that both scores have com-
parable, pertinent negative predictive values
at identifying patients who will be admitted
to the ICU.
Some strengths to our study include rele-
vant data points and consistency that is found
within the literature. Some of the limitations
of our study include our smaller sample size
and lack of comparative statistics, and the
utilization of ICD-10 codes as an identifica-
tion tool for sepsis or septic shock has not
been validated; however, because of data con-
straints, they were the most plausible for iden-
tification in a retrospective study.
Our study does however raise some inter-
esting questions on the utilization of qSOFA
and SIRS criteria. There was a relatively high
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Advanced Emergency Nursing Journal
rate of patients exhibiting both criteria who
were designated an ICD-10 code for sepsis,
and it would be interesting for larger random-
ized controlled trials to validate the sensitiv-
ity and specificity on the combination of both
criteria. Even more interestingly, the patients
who did not exhibit either criterion yet were
designated an ICD-10 code for sepsis might be
stratified further to identify certain traits that
could help screen patients at risk for delayed-
onset sepsis. We believe that the sample of
patients screened is generalizable to other in-
stitutions and raises thought-provoking ques-
tions on how institutions are screening their
patients for sepsis.
CONCLUSION
This pilot study showed that the utilization
of both qSOFA and SIRS criteria resulted in a
trend toward a higher percentage of patients
who were designated an ICD-10 code for
sepsis whereas patients who did not exhibit
either criterion still had roughly 15% of them
designated an ICD-10 code for sepsis. Larger
sample sizes would be needed to evaluate
the true validity of these preliminary findings.
As emergency providers, including advanced
nursing practitioners, are at the forefront for
the screening and identification of sepsis,
it is imperative we constantly evaluate our
screening processes. Early identification
of sepsis could correlate to more timely
treatment within the ED.
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