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Use of the qSOFA Score in the Emergency Department-Reply.

Dr Scheer and colleagues have 3 concerns about our study: questionable definitions, inconsistent methods, and a data set that includes missing values. The definition of “severe sepsis” that we used may not capture all patients in this category, particularly those with organ dysfunction and normal lactate levels. However, the definition of “organ dysfunction” in severe sepsis is equivocal.1 If we defined severe sepsis as any SOFA component of at least two, 127 more patients would have been classified as having severe sepsis, giving an area under the receiver operating curve (AUROC) for prediction of in-hospital mortality of 0.73. qSOFA still had better prognostic accuracy (incremental AUC, 0.07; 95% CI, 0.02-0.12). Scheer and colleagues suggest these 2 classifications performed equally because there was little difference in their positive and negative predictive values. Because our study was not powered to detect such differences, we do not believe this is a valid conclusion. Furthermore, the requirement for 2 elements of SIRS in severe sepsis resulted in poor sensitivity (47%), ie, in a substantial proportion of seriously ill patients misclassified as not having severe sepsis. This risk of misclassification has previously been reported.2 For these reasons, among others, the Sepsis-3 task force removed the SIRS criteria and focused only on organ dysfunction.3 Our results support these changes. What Scheer and colleagues suggest for severe sepsis is actually what was done with the new definition of sepsis that focuses on organ dysfunction, without the SIRS criteria.