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Background We aimed to evaluate the clinical usefulness of qSOFA as a risk stratification tool for patients admitted with infection compared to traditional SIRS criteria or our triage system; the Rapid Emergency Triage and Treatment System (RETTS). Methods The study was an observational cohort study performed at one Emergency Department (ED) in an urban university teaching hospital in Norway, with approximately 20,000 visits per year. All patients >16 years presenting with symptoms or clinical signs suggesting an infection (n = 1535) were prospectively included in the study from January 1 to December 31, 2012. At arrival in the ED, vital signs were recorded and all patients were triaged according to RETTS vital signs, presenting infection, and sepsis symptoms. These admission data were also used to calculate qSOFA and SIRS. Treatment outcome was later retrieved from the patients’ electronic records (EPR) and mortality data from the Norwegian population registry. Results Of the 1535 admitted patients, 108 (7.0%) fulfilled the Sepsis2 criteria for severe sepsis. The qSOFA score ≥2 identified only 33 (sensitivity 0.32, specificity 0.98) of the patients with severe sepsis, whilst the RETTS-alert ≥ orange identified 92 patients (sensitivity 0.85, specificity 0.55). Twenty-six patients died within 7 days of admission; four (15.4%) of them had a qSOFA ≥2, and 16 (61.5%) had RETTS ≥ orange alert. Of the 68 patients that died within 30 days, only eight (11.9%) scored ≥2 on the qSOFA, and 45 (66.1%) had a RETTS ≥ orange alert. Discussion In order to achieve timely treatment for sepsis, a sensitive screening tool is more important than a specific one. Our study is the fourth study were qSOFA finds few of the sepsis cases in prehospital or at arrival to the ED. We add information on the RETTS triage system, the two highest acuity levels together had a high sensitivity (85%) for identifying sepsis at arrival to the ED - and thus, RETTS should not be replaced by qSOFA as a screening and trigger tool for sepsis at arrival. Conclusion In this observational cohort study, qSOFA failed to identify two thirds of the patients admitted to an ED with severe sepsis. Further, qSOFA failed to be a risk stratification tool as the sensitivity to predict 7-day and 30-day mortality was low. The sensitivity was poorer than the other warning scores already in use at the study site, RETTS-triage and the SIRS criteria. Electronic supplementary material The online version of this article (doi:10.1186/s13049-017-0399-4) contains supplementary material, which is available to authorized users.

Decision-making in an emergency department needs to be efficient. It does not allow observation of the patient for a prolonged period of time, especially if the patients harm themselves or others, or refuses treatment. This includes suicidal, violent, intentional self-inflicted or non-consenting to treatments patient. Clinicians have to quickly decide whether to call the police, admit the patient to the psychiatric ward, according to recommended, predefined procedures. Since, for different situations different laws are applicable, clinicians need to follow certain procedures and consider specific legal issues while also handling challenging patients at the emergency department. Finding the right information quickly and following the recommended procedure is essential since the repercussions for a doctor acting incorrectly could be severe. This paper presents a mobile decision support system (DSS) prototype designed for healthcare providers to identify and follow the correct procedure based on applicable laws to mitigate the chance of incorrect actions being taken, along with the associated risks and preserve both the patients and their own rights. We explored healthcare providers requirements and alternatives for visualizing information by conducting observation, semi structured interviews and a total of four co-design workshops. The resulting mobile DSS enables clinicians to quickly access the correct information regarding their power and authority while also protecting the safety and welfare of the patient. Usability evaluation of the prototype showed that the average time spent to complete a given task was about 12 seconds by a total of six medical interns. Participants of the evaluation described the system easy to use, intuitive and highly useful for everyday use.