Derivation and internal validation of the screening to enhance prehospital identification of sepsis (SEPSIS) score in adults on arrival at the emergency department

Abstract

Background Prehospital recognition of sepsis may inform case management by ambulance clinicians, as well as inform transport decisions. The objective of this study was to develop a prehospital sepsis screening tool for use by ambulance clinicians. Methods We derived and validated a sepsis screening tool, utilising univariable logistic regression models to identify predictors for inclusion, and multivariable logistic regression to generate the SEPSIS score. We utilised a retrospective cohort of adult patients transported by ambulance ( n = 38483) to hospital between 01 July 2013 and 30 June 2014. Records were linked using LinkPlus® software. Successful linkage was achieved in 33289 cases (86%). Eligible patients included adult, non-trauma, non-mental health, non-cardiac arrest cases. Of 33289 linked cases, 22945 cases were eligible. Eligible cases were divided into derivation ( n = 16063, 70%) and validation ( n = 6882, 30%) cohorts. The primary outcome measure was high risk of severe illness or death from sepsis, as defined by the National Institute for Health and Care Excellence Sepsis guideline. Results ‘High risk of severe illness or death from sepsis’ was present in 3.7% of derivation ( n = 593) and validation ( n = 254) cohorts. The SEPSIS score comprises the following variables: age, respiratory rate, peripheral oxygen saturations, heart rate, systolic blood pressure, temperature and level of consciousness ( p < 0.001 for all variables). Area under the curve was 0.87 (95%CI 0.85–0.88) for the derivation cohort, and 0.86 (95%CI 0.84–0.88) for the validation cohort. In an undifferentiated adult medical population, for a SEPSIS score ≥ 5, sensitivity was 0.37 (0.31–0.44), specificity was 0.96 (0.96–0.97), positive predictive value was 0.27 (0.23–0.32), negative predictive value was 0.97 (0.96–0.97), positive likelihood value was 13.5 (9.7–18.73) and the negative likelihood value was 0.83 (0.78–0.88). Conclusion This is the first screening tool developed to identify NICE high risk of severe illness or death from sepsis. The SEPSIS score is significantly associated with high risk of severe illness or death from sepsis on arrival at the Emergency Department. It may assist ambulance clinicians to identify those patients with sepsis in need of antibiotic therapy. However, it requires external validation, in clinical practice by ambulance clinicians, in an independent population. Electronic supplementary material The online version of this article (10.1186/s13049-019-0642-2) contains supplementary material, which is available to authorized users.

Supporting the ambulance service to safely convey fewer patients to hospital by developing a risk prediction tool: Risk of Adverse Outcomes after a Suspected Seizure (RADOSS)—protocol for the mixed-methods observational RADOSS project

“…104 123 124 ► Wider work also shows those who can and cannot have their records linked do not markedly differ. 22 ► CUREd+ could have even higher coverage due to more use of NHS numbers by ambulance services 125 (which supports linkage).…”

“…CUREd+ could have even higher coverage due to more use of NHS numbers by ambulance services 125 (which supports linkage).…”

Prehospital early warning scores for adults with suspected sepsis: the PHEWS observational cohort and decision-analytic modelling study

“…Smyth et al derived and validated the Screening to Enhance PrehoSpital Identification of Sepsis (SEPSIS) tool to identify patients with high risk of sepsis in medical cases attended by emergency ambulance with an area under the receiver operating characteristic (ROC) curve of 0.86, and sensitivity 0.80 and specificity 0.78 at the recommended threshold. 24 Bayer et al developed the PRESEP score to identify sepsis in prehospital patients with suspected sepsis with area under the ROC curve 0.93, sensitivity 0.85 and specificity 0.86. 25 Polito et al developed the PRESS score to identify severe sepsis in physiologically abnormal prehospital patients with suspected sepsis with sensitivity 0.86 and specificity 0.47.…”

“…We based our planned sample size estimate on data from Smyth et al reporting 3.7% prevalence of high-risk sepsis in adults transported to hospital with a non-specific emergency presentation, 24 and data from reviews of sepsis by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and the Intensive Care National Audit and Research Centre (ICNARC). 40,41 NCEPOD identified 3363 adults (≥ 16 years) seen by the Critical Care Outreach Team or admitted directly to critical care with a diagnosis of sepsis across 305 hospitals over a 2-week period.…”

Prehospital administration of antibiotics in addition to usual care versus usual care alone for patients with suspected sepsis – a systematic review

“…A growing body of research has investigated the effectiveness of screening by prehospital clinicians to improve early recognition and detection, and this has in most instances become the focus of prehospital care for sepsis. [6][7][8][9][10][11] However, more recently early pharmacological intervention, specifically the administration of antibiotics, has been proposed as a logical evolution of strategy aimed at reducing time to definitive care. Antibiotics are a core component of the sepsis 'bundle of care' and facilitating administration as early as possible has been argued to be the optimal approach.…”