Sepsis recognition in the emergency department – impact on quality of care and outcome?

Abstract

BackgroundAppropriate 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).MethodsThis 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.ResultsOf 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 < 0.05) were independent predictors of missed sepsis. Surprisingly, adequate detection of the septic focus (81 vs. 93%, p = 0.17), appropriate fluid administration (86 vs. 87%, p = 0.39), and guideline-adherent antibiotic regimen (95 vs. 100%, p = 0.42) did not differ between cases of recognized and unrecognized sepsis, respectively. Non-recognition affected neither death-censored length of hospital stay (median 7.63 d vs. 7.13 d, p = 0.42) nor a combined endpoint of death or ICU admission to (9 vs. 12%, p = 0.55).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.Electronic supplementary materialThe online version of this article (doi:10.1186/s12873-017-0122-9) contains supplementary material, which is available to authorized users.

Early diagnosis of sepsis in emergency departments, time to treatment, and association with mortality: An observational study

“…The delays we identified in diagnostic procedures are consistent with previous research findings of delay in time to triage [24], recording of vital signs [5,7], measurement of blood lactate [25,26], and delays in recognition of sepsis in general [7]. The processes we found to be lacking are essential for reaching an accurate diagnosis and institution of treatment in a timely manner [27].…”

“…Sepsis is a major challenge, being present in a large proportion of hospitalizations that culminate in death [1][2][3]. Most sepsis cases seem to arise outside hospital settings [4], and these patients present to emergency departments with heterogeneous signs and symptoms, making detection and diagnosis challenging [5]. New sepsis criteria and early antibiotic treatment has been a major focus of research and debate over the last years [6] but factors associated with delayed treatment in the emergency departments have received less attention.…”

“…Previous research, mostly based on single case studies and smaller patient cohorts, suggests that systematic screening and diagnostic procedures for recognizing sepsis are not consistently carried out according to current guidelines [5,7] and that sepsis is not recognized early enough [7]. Early recognition of sepsis is of critical importance for timely treatment [8][9][10], and compliance with sepsis guidelines is associated with improved outcomes [11][12][13].…”

Implantação do Protocolo de Manejo de Sepse no Pronto Atendimento do Hospital Universitário Regional dos Campos Gerais

“…9,13 Além disso, o que o prognóstico poderia ser diferente em termos de gravidade se a terapêutica adotada pudesse ocorrer logo no primeiro atendimento, ainda fora do ambiente de UTI, conforme ocorreu com a implantação do 'Protocolo de Manejo de Sepse' no HURCG. 10 No que se concerne às características dos pacientes investigados, a maioria era idosos e apresentavam algum tipo de doença crônica, sendo as mais prevalentes, hipertensão arterial sistêmica e diabetes mellitus. Estes achados, coadunam com a literatura ao demostrar que idosos dispõem de um sistema imunológico mais vulnerável aos processos infecciosos e quando associado as doenças crônicas aumentam a susceptibilidade do desenvolvimento de outras enfermidades, como sepse, além do risco do óbito.…”

“…2 Desta forma, o desenvolvimento e implantação de protocolos que facilitem a correta detecção e tratamento precoce da infecção sistêmica é de fundamental importância para subsidiar atenção em saúde mais eficaz e de qualidade, principalmente nas unidades de Pronto Atendimento (PA) prestado nos primeiros cuidados e que por inúmeras vezes são locais de permanência dos pacientes devido falta de leitos de internação. 6,10,11 Especificamente no PA do Hospital Universitário Regional dos Campos Gerais (HURCG) em Ponta Grossa-PR, existia grande dificuldade por parte dos profissionais de saúde em manejar o paciente em sepse, devido à estrutura física que dificultava a visualização contínua dos pacientes (sala de emergência distante do posto de…”