Sepsis recognition in the emergency department - impact on quality of care and outcome?
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ABSTRACT: Background
Appropriate and timely recognition of sepsis is a prerequisite for starting goal-directed therapy bundles. We analyzed the appropriateness of sepsis recognition and documentation with regard to adequacy of therapy and outcome in an internal medicine emergency department (ED).Methods
This study included 487 consecutive patients ?18 years of age who presented to a university hospital ED during a 4-week period. Clinical, laboratory, and follow-up data were acquired independently from documentation by ED physicians. The study team independently rated quality of sepsis classification (American College of Chest Physicians/Society of Critical Care Medicine definitions), diagnostic workup, and guideline-adherent therapy in the ED.Results
Of 487 included patients, 110 presented because of infection. Of those, 54 patients matched sepsis criteria, including 20 with organ damage and thus severe sepsis, as rated by the study team. Sepsis was not recognized in 32 of these 54 cases (59%). Multivariate binary logistic regression analysis revealed that higher systolic blood pressure (p <0.05), the ability to stand (p <0.01) and a low number of documented vital signs in the ED discharge letter (p?ConclusionsNon-recognition of sepsis in ED patients with serious infections who formally meet organizational sepsis definitions seems to have no deleterious impact on initial therapy adequacy.
SUBMITTER: Morr M
PROVIDER: S-EPMC5363055 | biostudies-literature | 2017 Mar
REPOSITORIES: biostudies-literature
Publications
Sepsis recognition in the emergency department - impact on quality of care and outcome?
Morr Marius M Lukasz Alexander A Rübig Eva E Pavenstädt Hermann H Kümpers Philipp P
BMC emergency medicine 20170323 1
<h4>Background</h4>Appropriate and timely recognition of sepsis is a prerequisite for starting goal-directed therapy bundles. We analyzed the appropriateness of sepsis recognition and documentation with regard to adequacy of therapy and outcome in an internal medicine emergency department (ED).<h4>Methods</h4>This study included 487 consecutive patients ≥18 years of age who presented to a university hospital ED during a 4-week period. Clinical, laboratory, and follow-up data were acquired indepe ...[more]
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Project description:Around 42,000 children suffer from severe sepsis each year in the US alone, resulting in significant morbidity, mortality and billion dollar expenditures in the US healthcare system. Sepsis recognition is a clinical challenge in children. Biomarkers are needed to tailor appropriate antimicrobial therapies and improve risk stratification. The goal of this study was to determine if gene expression profiles from peripheral blood were associated with pathogen type and sepsis severity in children treated for suspected sepsis.
2020-01-01 | GSE119217 | GEO
Project description:ObjectivesThe objective was to compare the effectiveness of physician judgment and an electronic algorithmic alert to identify pediatric patients with severe sepsis/septic shock in a pediatric emergency department (ED).MethodsThis was an observational cohort study of patients older than 56 days with fever or hypothermia. All patients were evaluated for potential sepsis in real time by the ED clinical team. An electronic algorithmic alert was retrospectively applied to identify patients with potential sepsis independent of physician judgment. The primary outcome was the proportion of patients correctly identified with severe sepsis/septic shock defined by consensus criteria. Test characteristics were determined and receiver operating characteristic (ROC) curves were compared.ResultsOf 19,524 eligible patient visits, 88 patients developed consensus-confirmed severe sepsis or septic shock. Physician judgment identified 159 and the algorithmic alert identified 3,301 patients with potential sepsis. Physician judgment had sensitivity of 72.7% (95% confidence interval [CI] = 72.1% to 73.4%) and specificity of 99.5% (95% CI = 99.4% to 99.6%); the algorithmic alert had sensitivity of 92.1% (95% CI = 91.7% to 92.4%) and specificity of 83.4% (95% CI = 82.9% to 83.9%) for severe sepsis/septic shock. There was no significant difference in the area under the ROC curve for physician judgment (0.86, 95% CI = 0.81 to 0.91) or the algorithm (0.88, 95% CI = 0.85 to 0.91; p = 0.54). A combination method using either positive physician judgment or an algorithmic alert improved sensitivity to 96.6% and specificity to 83.3%. A sequential approach, in which positive identification by the algorithmic alert was then confirmed by physician judgment, achieved 68.2% sensitivity and 99.6% specificity. Positive and negative predictive values for physician judgment versus algorithmic alert were 40.3% versus 2.5% and 99.88% versus 99.96%, respectively.ConclusionsThe electronic algorithmic alert was more sensitive but less specific than physician judgment for recognition of pediatric severe sepsis and septic shock. These findings can help to guide institutions in selecting pediatric sepsis recognition methods based on institutional needs and priorities.
| S-EPMC4639443 | biostudies-literature
Project description:RationaleEarly antibiotics improve outcomes for patients with sepsis. Factors influencing antibiotic timing in emergency department (ED) sepsis remain unclear.ObjectivesDetermine the relationship between prehospital level of care of patients with sepsis and ED door-to-antibiotic time.MethodsThis retrospective cohort study comprised patients admitted from the community to an academic ED June 2009 to February 2015 with fluid-refractory sepsis or septic shock. Transfer patients and those whose antibiotics began before ED arrival or after ED discharge were excluded. We used multivariable regression to evaluate the association between the time from ED arrival to antibiotic initiation and prehospital level of care, defined as the highest level of emergency medical services received: none, basic life support (BLS) ambulance, or advanced life support (ALS) ambulance. We measured variation in this association when hypotension was or was not present by ED arrival.ResultsAmong 361 community-dwelling patients with sepsis, the level of prehospital care correlated with illness severity. ALS-treated patients received antibiotics faster than patients who did not receive prehospital care (median, 103 [interquartile range, 75 to 135] vs. 144 [98 to 251] minutes, respectively) or BLS-only patients (168 [100-250] minutes; P < 0.001 for each pairwise comparison with ALS). This pattern persisted after multivariable adjustment, where ALS care (-43 min; 95% confidence interval [CI], -84 to -2; P = 0.033) but not BLS-only care (-4 min; 95% CI, -41 to +34; P = 0.97) was associated with less antibiotic delay compared with no prehospital care. ALS-treated patients more frequently received antibiotics within 3 hours of ED arrival (91%) compared with walk-in patients (62%; adjusted odds ratio, 3.11; 95% CI, 1.20 to 8.03; P = 0.015) or BLS-treated patients (56%; adjusted odds ratio, 4.51; 95% CI, 1.89 to 11.35; P < 0.001). ALS-treated patients started antibiotics faster than walk-in patients in the absence of hypotension by ED arrival (-41 min; 95% CI, -110 to -13; P = 0.009) but not when hypotension was present (+25 min; 95% CI, -43 to +92; P = 0.66).ConclusionsPrehospital ALS but not BLS-only care was associated with faster antibiotic initiation for patients with sepsis without hypotension. Process redesign for non-ALS patients may improve antibiotic timeliness for ED sepsis.
| S-EPMC6322022 | biostudies-literature
Project description:Suboptimal communication during emergency department (ED) care transitions has been shown to contribute to medical errors, sometimes resulting in patient injury and litigation. The study objective was to determine whether a standardized checkout process would decrease the number of relevant missed clinical items (MCI).In this prospective pre- and post-intervention study conducted in an urban academic ED, we collected data on omitted or inaccurately conveyed medical information before and after the initiation of a standardized checkout process. The intervention included group checkout in an optimal location, review of electronic medical records, case discussion and assigned roles. MCI were considered relevant if they resulted in a delay or alteration in disposition or treatment plan. The primary outcome was the change in the number of MCI. Secondary outcomes were duration of checkout and physician satisfaction with the intervention.Pre-intervention, there were 94 relevant MCI during 164 care transitions. Post-intervention, there were 36 MCI in 157 transitions. The mean MCI per transition decreased by 58% from 0.57 (95% confidence interval [CI] [0.41, 0.73]) to 0.23 (95% CI [0.11-0.35]). Instituting the intervention did not lengthen checkout duration, which was 15 minutes (95% CI [13.81-16.19]) pre-intervention and 14 minutes (95% CI [12.99-15.01]) post-intervention. The majority of participants (73.4%) felt that the process decreased MCI, and 89.5% reported that the new process had a positive or neutral effect on their satisfaction with care transitions.The adoption of a standardized care transition process markedly decreased clinically relevant communication errors without lengthening checkout duration.
| S-EPMC5391896 | biostudies-other
Project description:PURPOSE:Sepsis is a common acute life-threatening condition that emergency physicians routinely face. Diagnostic options within the Emergency Department (ED) are limited due to lack of infrastructure, consequently limiting the use of invasive hemodynamic monitoring or imaging tests. The mortality rate due to sepsis can be assessed via multiple scoring systems, for example, mortality in emergency department sepsis (MEDS) score and sepsis patient evaluation in the emergency department (SPEED) score, both of which quantify the variation of mortality rates according to clinical findings, laboratory data, or therapeutic interventions. This study aims to improve the management processes of sepsis patients by comparing SPEED score and MEDS score for predicting the 28-day mortality in cases of emergency sepsis. METHODS:The study is a cross-sectional, prospective study including 61 sepsis patients in ED in Suez Canal University Hospital, Egypt, from August 2017 to June 2018. Patients were selected by two steps: (1) suspected septic patients presenting with at least one of the following abnormal clinical findings: (a) body temperature higher than 38 °C or lower than 36 °C, (b) heart rate higher than 90 beats/min, (c) hyperventilation evidenced by respiratory rate higher than 20 breaths/min or PaCO2 lower than 32 mmHg, and (d) white blood cell count higher than 12,000/?L or lower than 4000/?L; (2) confirmed septic patients with at least a 2-point increase from the baseline total sequential organ failure assessment (SOFA) score following infection. Other inclusion criteria included adult patients with an age ?18 years regardless of gender and those who had either systemic inflammatory response syndrome or suspected/confirmed infection. Patients were shortly follow-up for the 28-day mortality. Each patient was subject to SPEED score and MEDS score and then the results were compared to detect which of them was more effective in predicting outcome. The receiver operating characteristic curves were also done for MEDS and SPEED scores. RESULTS:Among the 61 patients, 41 died with the mortality rate of 67.2%. The mortality rate increased with a higher SPEED and MEDS scores. Both SPEED and MEDS scores revealed significant difference between the survivors and nonsurvivors (p = 0.004 and p < 0.001, respectively), indicating that both the two systems are effective in predicting the 28-day mortality of sepsis patients. Thereafter, the receiver operating characteristic curves were plotted, which showed that SPEED was better than the MEDS score when applied to the complete study population with an area under the curve being 0.87 (0.788-0.963) as compared with 0.75 (0.634-0.876) for MEDS. Logistic regression analysis revealed that the best fitting predictor of 28-day mortality for sepsis patients was the SPEED scoring system. For every one unit increase in SPEED score, the odds of 28-day mortality increased by 37%. CONCLUSION:SPEED score is more useful and accurate than MEDS score in predicting the 28-day mortality among sepsis patients. Therefore SPEED rather than MEDS should be more widely used in the ED for sepsis patients.
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Project description:RationaleSevere sepsis is common and highly morbid, yet the epidemiology of severe sepsis at the frontier of the health care system-pre-hospital emergency care-is unknown.ObjectivesWe examined the epidemiology of pre-hospital severe sepsis among emergency medical services (EMS) encounters, relative to acute myocardial infarction and stroke.MethodsRetrospective study using a community-based cohort of all nonarrest, nontrauma King County EMS encounters from 2000 to 2009 who were transported to a hospital.Measurements and main resultsOverall incidence rate of hospitalization with severe sepsis among EMS encounters, as well as pre-hospital characteristics, admission diagnosis, and outcomes. Among 407,176 EMS encounters, we identified 13,249 hospitalizations for severe sepsis, of whom 2,596 died in the hospital (19.6%). The crude incidence rate of severe sepsis was 3.3 per 100 EMS encounters, greater than for acute myocardial infarction or stroke (2.3 per 100 and 2.2 per 100 EMS encounters, respectively). More than 40% of all severe sepsis hospitalizations arrived at the emergency department after EMS transport, and 80% of cases were diagnosed on admission. Pre-hospital care intervals, on average, exceeded 45 minutes for those hospitalized with severe sepsis. One-half or fewer of patients with severe sepsis were transported by paramedics (n = 7,114; 54%) or received pre-hospital intravenous access (n = 4,842; 37%).ConclusionsEMS personnel care for a substantial and increasing number of patients with severe sepsis, and spend considerable time on scene and during transport. Given the emphasis on rapid diagnosis and intervention for sepsis, the pre-hospital interval may represent an important opportunity for recognition and care of sepsis.
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Project description:IntroductionIn many low-income countries, Emergency Medicine is underdeveloped and faces many operational challenges including emergency department (ED) overcrowding and prolonged patient length of stays (LOS). In high-resource settings, protocolized ED observation unit (EDOU) care reduces LOS while preserving care quality. EDOUs are untested in low-income countries. We evaluate the effect protocolized EDOU care for ischemic stroke on the quality and efficiency of care in Haiti.MethodsWe performed a prospective cohort study of protocolized observation care for ischemic stroke at a Haitian academic hospital between January 2014 and September 2015. We compared patients cared for in the EDOU using the ischemic stroke protocol (study group) to eligible patients cared for before protocol implementation (baseline group), as well as to eligible patients treated after protocol introduction but managed without the EDOU protocol (contemporary reference group). We analysed three quality of care measures: aspirin administration, physical therapy consultation, and swallow evaluation. We also analysed ED and hospital LOS as measures of efficiency.ResultsPatients receiving protocolized EDOU care achieved higher care quality compared to the baseline group, with higher rates of aspirin administration (91% v. 17%, p < 0.001), physical therapy consultation (50% v. 9.6%, p < 0.001), and swallow evaluation (36% v. 3.7%, p < 0.001). We observed similar improvements in the study group compared to the contemporary reference group. Most patients (92%) were managed entirely in the ED or EDOU. LOS for non-admitted patients was longer in the study group than the baseline group (28 v. 19 h, p = 0.023).ConclusionProtocolized EDOU care for patients with ischemic stroke in Haiti improved performance on key quality measures but increased LOS, likely due to more interventions. Future studies should examine the aspects of EDOU care are most effective at promoting higher care quality, and if similar results are achievable in patients with other conditions.
| S-EPMC7474244 | biostudies-literature
Project description:ObjectiveTo estimate the impact of urgent care centers on emergency department (ED) use.Data sourcesSecondary data from a novel urgent care center database, linked to the Healthcare Cost and Utilization Project State Emergency Department Databases (SEDD) from six states.Study designWe used a difference-in-differences design to examine ZIP code-level changes in the acuity mix of emergency department visits when local urgent care centers were open versus closed. ZIP codes with no urgent care centers served as a control group. We tested for differential impacts of urgent care centers according to ED wait time and patient insurance status.Data collection/extraction methodsUrgent care center daily operating times were determined via the urgent care center database. Emergency department visit acuity was assessed by applying the NYU ED algorithm to the SEDD data. Urgent care locations and nearby emergency department encounters were linked via zip code.Principal findingsWe found that having an open urgent care center in a ZIP code reduced the total number of ED visits by residents in that ZIP code by 17.2% (P < 0.05), due largely to decreases in visits for less emergent conditions. This effect was concentrated among visits to EDs with the longest wait times. We found that urgent care centers reduced the total number of uninsured and Medicaid visits to the ED by 21% (P < 0.05) and 29.1% (P < 0.05), respectively.ConclusionsDuring the hours they are open, urgent care centers appear to be treating patients who otherwise would have visited the ED. This suggests that urgent care centers have the potential to reduce health care expenditures, though questions remain about their net cost impact. Future work should assess whether urgent care centers can improve health care access among populations that often experience barriers to receiving timely care.
| S-EPMC8313962 | biostudies-literature
Project description:ObjectiveDue to atypical symptom presentation older patients are more prone to delayed sepsis recognition. We investigated whether initial disease severity before emergency department (ED) treatment (including treatable acute organ dysfunction), quality of ED sepsis care and the impact on mortality was different between patients older and younger than 70 years. If differences exist, improvements are needed for ED management of older patients at risk for sepsis.MethodsIn this observational multicenter study, ED patients who were hospitalized with a suspected infection were stratified by age <70 and ?70 years. The presence of treatable and potentially reversible acute organ dysfunction was measured by the RO components of the Predisposition, Infection, Response and Organ dysfunction (PIRO) score, reflecting acute sepsis-related organ dysfunction developed before ED presentation. Quality of care, as assessed by the full compliance with nine quality performance measures and the standardized mortality ratio (SMR: observed/expected in-hospital mortality), was compared between older and younger patients.ResultsThe RO-components of the PIRO score were 8 (interquartile range; 4-9) in the 833 older patients, twice as high as the 4 (2-8; P<0.001) in the 1537 younger patients. However, full compliance with all nine quality performance measures was achieved in 34.2 (31.0-37.4)% of the older patients, not higher than the 33.0 (30.7-35.4)% in younger patients (P = 0.640). In-hospital mortality was 9.2% (95%-CI, 7.3-11.2) in patients ?70, twice as high as the 4.6% (3.6-5.6) in patients <70 years, resulting in an SMR (in study period) of ~0.7 in both groups (P>0.05).ConclusionOlder sepsis patients are sicker at ED presentation but are not treated more expediently or reliably despite their extra acuity The presence of twice as much treatable acute organ dysfunction before ED treatment suggests that acute organ dysfunction is recognized relatively late by general practitioners or patients in the out of hospital setting.
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Project description:The Sepsis 6 is an internationally accepted management bundle that, when initiated within one hour of identifying sepsis, can reduce morbidity and mortality. This management bundle was advocated by the Scottish Patient Safety Programme as part of its Acute Adult campaign launched in 2008 and adopted by NHS Tayside in 2012. Despite this, the Emergency Department (ED) of Ninewells Hospital, a tertiary referral centre and major teaching hospital in Scotland, was displaying poor success in the Sepsis 6. We therefore set out to improve compliance by evaluating the application of all aspects of the NHS Tayside Sepsis 6 bundle within one hour of ED triage time, to identify what human factors may influence achieving the one hour The Sepsis 6 bundle. This allowed us to tailor a number of specific interventions including educational sessions, regular audit and personal feedback and check list Sepsis 6 sticker. These interventions promoted a steady increase in compliance from an initial rate of 51.0% to 74.3%. The project highlighted that undifferentiated patients create a challenge in initiating the Sepsis 6. Pyrexia is a key human factor-trigger for recognising sepsis with initial nursing assessment being vital in recognition and identifying the best area (resus) of the department to manage severely septic patients. EDs need to recognise these challenges and develop educational and feedback plans for staff and utilise available resources to maximise the Sepsis 6 compliance.
| S-EPMC4863434 | biostudies-other