Early identification of sepsis in the emergency setting is prudent for early intervention and mortality reduction. With sepsis accounting for extensive emergency presentations, efficacious emergency treatment is essential for reducing incidence and prevalence of ED and intensive care admissions, morbidity, and mortality [2]. To facilitate improved pre-hospital sepsis identification, the Australasian Journal of Paramedicine (now 'Paramedicine') recently supported the inclusion of sepsis screening tools such as qSOFA and SIRS in jurisdictional sepsis screening matrixes [5]. However, the review identified that shortages in high quality pre-hospital research and innovation have prevented validation of a ‘gold standard’ emergency sepsis screening tool [5]. The aim of this rapid review was to determine and recommend an emergency sepsis screening tool for validation, to empower clinicians to successfully identify and initiate sepsis management in the emergency settings. Despite a plethora of previous research, only a minor percentage incorporated the pre-hospital environment outside of, or preceding, the ED. Limited research integrated ambulance services with paramedic data or participation, and none identified a preferred tool for paramedic use, based on efficacy. These findings therefore confirm the unmet research need for further emergency out-of-hospital specific research in sepsis identification, and subsequently, treatment.

Previous literature has queried qSOFA as the preferred screening tool for emergency sepsis presentations [1, 5], therefore, forming the basis of this study’s review. From the evidence analysed within this review, qSOFA demonstrated the highest specificity in differentiating between sepsis and conventional infections without associated organ failure, as per current sepsis definitions [1, 4, 16, 17, 19, 21, 23, 25,26,27,28], and most successfully predicted mortality for at risk patients [4, 16, 22, 27, 28]. The authors note that there was a significant range in the specificity and more so, sensitivity in qSOFA results and suggest that is likely due to the heterogeneity of results recorded, particularly considering study designs and settings. The qSOFA low sensitivity was contrasted by SIRS high sensitivity for indicating potentially septic patients [3, 4, 19,20,21, 23, 26, 27, 29, 32], but with commonly low specificity [4, 23, 24, 26, 27, 29]. According to Feist [19], consequent employment of qSOFA as an emergency sepsis screening tool may reduce ED physician fatigue associated with increased false positives arising from the SIRS criteria. This finding is supported by the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) [1], and corroborated by Jiang et al. [26], who identified qSOFA as an effective mortality predictor, and Lane et al. [6], concluding qSOFA may be a beneficial sepsis screening tool for paramedics. However, Ortega et al. [22], found that NEWS had the highest combined sensitivity and specificity for predicting sepsis and adverse outcomes for patients within the emergency department, in comparison to qSOFA, based on receiver operator characteristic curves. It is also noted that similar disparities are seen in the in-hospital environment, and a single sepsis identification tool is yet to develop preference. Ortega et al. [22] further described the need for simple and sensitive tools for prompt pre-hospital identification of people at risk of sepsis. With NEWS and qSOFA demonstrating similar performance in identifying patients with sepsis [22], qSOFA requiring only three measures for screening may make it more rapid and favourable for employment in the pre-hospital environment over NEWS [8]. A plethora of evidence exists around sepsis identification in the in-hospital environment and generally suggests that a multi-faceted tiered approach is utilised for sepsis identification and management, including machine learning that includes vital signs and laboratory results aids in the rapid alert of potential sepsis [33]. The in-hospital evidence generally does not favour one specific identification tool [33, 34].

Accordingly, no one screening tool was identified to demonstrate both high sensitivity and specificity for the diagnosis of sepsis [6], rendering the evidence within this review insufficient for recommending a single preferential sepsis screening tool for use within the emergency environment, and more explicitly for paramedicine. As identified by Graham et al. [25], a combination of multiple screening tools employed throughout pre-hospital and ED sepsis presentations may be required to efficiently identify and confirm sepsis diagnosis [25]. Further research which integrates use of qSOFA for suspected sepsis presentations, or SIRS within the emergency environment, followed by qSOFA on ED presentation, is required before a single screening tool can be identified for validation.

The rapid review methodology lends itself to inherent limitations. Firstly, a very specific search was conducted to minimise irrelevant sources, and thus some potential studies may have been excluded simply due to an insufficient search. Exclusion of non-English language papers potentially excluded high quality studies, however due to the nature of a rapid review, the inclusion of said papers was not feasible regarding time and capacity limitations. Exclusion criteria regarding levels of evidence and studies of low quality were intended to increase the strength of the findings; hence a quality appraisal was undertaken. Finally, the review does not include any form of meta-analysis or in-depth quantitative review, in line with the rapid review methodology. The authors declare no conflicts of interest.