Recognition and treatment of severe sepsis in the emergency department: retrospective study in two French teaching hospitals

Abstract

BackgroundSepsis management in the Emergency Department remains a daily challenge. The Surviving Sepsis Campaign (SSC) has released three-hour bundle. The implementation of these bundles in European Emergency Departments remains poorly described.The main objective was to assess the compliance with the Severe Sepsis Campaign 3-h bundle (blood culture, lactate dosage, first dose of antibiotics and 30 ml/kg fluid challenge). Secondary objectives were the analysis of the delay of severe sepsis recognition and description of the population.MethodsIn accordance with STROBE statement, we performed a retrospective study in two French University Hospital Emergency Departments from February to August 2015. Patients admitted during the study period were screened using the electronic files of the hospital databases. Patient’s files were reviewed and included in the study if they met severe sepsis criteria. Demographics, comorbities, treatments were recorded. Delays from admission to severe sepsis diagnosis, fluid loading onset and antibiotics administration were calculated.ResultsOne hundred thirty patients were included (76 men, mean age 71 ± 14 years). Blood culture, lactate dosage, antibiotics and 30 ml/kg fluid loading were performed within 3 hours in % [95% confidence interval] 100% [96–100%], 62% [54–70%], 49% [41–58%] and 19% [13–27%], respectively. 25 patients out of 130 (19% [13–27%]) fulfilled each criteria of the 3-h bundle. The mean fluid loading volume was 18 ± 11 ml/kg. Mean delay between presentation and severe sepsis diagnosis was 200 ± 263 min, from diagnosis to fluid challenge and first antibiotic dose, 10 ± 27 min and 20 ± 55 min, respectively.ConclusionCompliance with SSC 3-h bundle and delay between admission and sepsis recognition have to be improved. If confirmed by other studies, an improvement program might be deployed.

Early fluid bolus in adults with sepsis in the emergency department: a systematic review, meta-analysis and narrative synthesis

“…Most studies have reported non-patient related factors as barriers. Improper diagnosis of sepsis such as underestimating the severity of sepsis, difficulty and delay in recognising sepsis, and clinical reliance on development of hypotension to begin treatment have been repeatedly reported [ 32 , 34 , 38 ]. Experience of the treating healthcare professional has been identified as an inhibiting factor when inexperienced junior physicians and those without emergency training care for patients during the initial hours [ 30 , 31 , 34 ].…”

“…In contrast, Morr et al, report that correctness of the classification of sepsis and its severity had no impact on early initiation of fluid bolus [ 37 ]. Three studies have reported that overcrowding in the emergency department and its associated factors such as increased occupancy rate, increased patient hours and patients presenting between 0700 and 1900 h was strongly associated with delays in initiating fluid bolus [ 36 , 38 , 61 ]. However, the retrospective study by Kang et al, shows that over-crowding had no impact on the compliance rate [ 31 ].…”

“…Nine studies have suggested recommendations to improve compliance with early fluid administration. All nine studies recommend interventions specifically targeting the identified barriers which include 100% completion of triage vital signs data [ 30 ], pre-hospital sepsis screening [ 32 ], use of telemedicine [ 34 ], and use of assessment tools like qSOFA [ 38 ].Two studies have recommended appropriate staffing and bed flow to manage overcrowding [ 36 , 61 ]. Quality improvement projects involving multidisciplinary teams and electronic alerts along with professional development on sepsis management for nurses and physicians have also been suggested by five studies [ 30 , 31 , 38 , 39 , 61 ].…”

“… 27% (Control group) Faine (2015) [ 34 ] 193 Interhospital transfers from regional hospitals; inadequacy of emergency trained physicians in rural hospitals; clinical deterioration of patient during transfer. 54% (Patients transferred from regional hospitals) Use of telemedicine De Groot (2017) [ 35 ] 1732 Treatment commenced in ED patients in earlier stages of sepsis Emphasis on treatment in patients with and without organ failure in sepsis Gaieski (2017) [ 36 ] 2913 Time of presentation of patients to ED (between 07:00–19:00 less likely to receive fluids within 1 h compared to presenting after-hours); overcrowding, increased occupancy rate and patient hours in ED Appropriate staffing and patient flow in ED Morr (2017) [ 37 ] 487 Correctness of exact classification of sepsis- SIRS, severe sepsis, recognised or unrecognised sepsis Le Conte (2017) [ 38 ] 130 Advanced age; cardiac co-morbidities; delay in sepsis recognition; ED overcrowding; 25 (19%) received fluid challenge, Mean time to administration: 10 ± 27 min Multidisciplinary quality improvement programme with simple guidelines, electronic alerts; qSOFA score measurement Deis (2018) [ 39 ] 5631 Patients without an ICD sepsis diagnosis code despite similar baseline organ dysfunction 10.6% for patients without a sepsis diagnosis code; 19.6% for patients with a diagnosis code Education and quality improvement outcomes …”

Novel Approaches for Diagnosing Sepsis in the Critically Ill

“…For instance, patients may represent subgroups that could benefit from targeted interventions, if they have increased expression of genes associated with the adaptive and innate immune system, or alternatively, higher expression in specific coagulopathic pathways [42][43][44][45][46]. Other applications for host response transcription assays could be the identification of causative pathogens or prognostication of sepsis [42,[47][48][49][50][51][52]. However, in the present review we will focus exclusively on the diagnosis of infection in critically ill patients.…”