Clinical performance of an automated systemic inflammatory response syndrome (sirs) / organ dysfunction alert: a system-based patient safety project

Abstract

Objective: We have employed our electronic medical record (EMR) in an effort to identify patients at the onset of severe sepsis through an automated analysis that identifies simultaneous occurrence of systemic inflammatory response syndrome (SIRS) and organ dysfunction. The purpose of this study was to determine the positive predictive value of this alert for severe sepsis and other important outcomes in hospitalized adults. Design: Prospective cohort. Setting: Banner Good Samaritan Medical Center, Phoenix AZ Patients: Forty adult inpatients who triggered alert logic within our EMR indicating simultaneous occurrence of SIRS and organ dysfunction. Interventions: Interview of bedside nurse and chart review within six hours of alert firing to determine the clinical event that triggered each alert. Results: Eleven of 40 patients (28%) had a major clinical event (immediately lifethreatening illness) associated with the alert firing. Severe sepsis or septic shock accounted for four of these-yielding a positive predictive value of 0.10 (95%CI: 0.04-0.23) of the alert for detection of severe sepsis. The positive predictive value of the alert for detection of major clinical events was 0.28 (95%CI: 0.16-0.43), and for detecting either a major or minor clinical event was 0.45 (95%CI: 0.31-0.60). Twenty-two of 40 patients (55%) experienced a false alert. Conclusions: Our first-generation SIRS/organ dysfunction alert has a low positive predictive value for severe sepsis, and generates many false alerts, but shows promise for the detection of acute clinical events that require immediate attention. We are currently investigating refinements of our automated alert system which we believe have potential to enhance patient safety.

Clinical performance of an interactive clinical decision support system for assessment of plasma lactate in hospitalized patients with organ dysfunction

“…Our lactate decision support system has a positive predictive value (PPV) for acute lifethreatening clinical events that is superior to that of our previous "sepsis alert" (27) and to those reported in several reviews of EWSs. One review of 39 EWSs reported PPVs ranging from 13.5-26.1% (34), and another review of 25 systems reported a median PPV of 36.7% with interquartile range 29.3-43.8% (34).…”

“…As stated in the new definition of sepsis, "Nonspecific SIRS criteria such as pyrexia or neutrophilia will continue to aid in the general diagnosis of infection" (7). Although these criteria are nonspecific, they appear to be relatively sensitive for sepsis (7,27). Our lactate DSS has excellent discriminant accuracy for predicting inpatient mortality (AUROC=0.80).…”

“…This likely represents the independent association between SIRS and organ dysfunction with the risk for mortality (27,31,32).…”

“…Although this system references SIRS it was found to be nonspecific for sepsis (27), and was subsequently employed in our healthcare system to identify patients deteriorating in real-time regardless of the cause. Subsequent research showed that our SIRS/OD alert system was triggered during the course of 19% of admissions, and that patients who triggered the alert had an odds ratio of 30.1 (95% CI: 26.1-34.5) for inpatient mortality (28).…”