The effect of sepsis recognition on telemedicine use and bundle completion in rural emergency department sepsis treatment

Abstract

Objective: Sepsis has high mortality, but it is often not recognized due to varied and vague presentations. Provider-to-provider emergency department telehealth (tele-ED) has been proposed to improve rural sepsis care, but we hypothesized that its use and effectiveness is dependent on local sepsis recognition. The objective of this study was to measure the association between sepsis documentation and tele-ED use, treatment guideline adherence, and mortality. Methods: This analysis was a multicenter (n=23) cohort study of sepsis patients treated in rural emergency departments (EDs) that participated in a tele-ED network between August 2016 and June 2019. The primary exposure was whether sepsis was recognized in the local ED, and the primary outcome was rural tele-ED use, with secondary outcomes of time to tele-ED use, 3-hour guideline adherence, and in-hospital mortality. We used multivariable generalized estimating equation models for our analysis. Results: Data from 1,146 rural sepsis patients were included, 315 (27%) had tele-ED used, and 415 (36%) had sepsis recognized in the rural ED. Sepsis recognition was not independently associated with higher rates of tele-ED use (adjusted odds ratio [aOR] 1.23, 95% CI 0.90-1.67). Sepsis recognition was associated with earlier tele-ED activation (adjusted hazard ratio [aHR] 1.69, 95% CI 1.34-2.13), lower 3-hour guideline adherence (aOR 0.73, 95% CI: 0.55-0.97), and lower in-hospital mortality (aOR 0.72, 95% CI: 0.54-0.97). Conclusions: Sepsis recognition in rural EDs participating in a tele-ED network was not associated with tele-ED use. Future work will focus on how telehealth can be used to improve diagnostic accuracy and sepsis recognition.

The Role of Sepsis Care in Rural Emergency Departments: A Qualitative Study of Emergency Department User Perspectives

“…20, 21 An early study showed that telehealth in rural EDs was associated with higher sepsis bundle adherence (adjusted odds ratio [aOR] 17.3, 95% confidence interval [CI] 6.6 to 44.9) 22 , but we subsequently found that one significant barrier to telehealth use was sepsis diagnosis and recognition. 23 In another multicenter study in telehealth-capable hospitals with contemporary controls (n=1,191), we found telehealth consultation was not associated with improved outcomes, but the subgroup of patients treated in the most remote hospitals by advanced practice providers may have had reduced mortality (aOR 0.11, 95% CI 0.02 to 0.73). 24 Since these findings were unexpected, we conducted a qualitative study of rural hospital and hub healthcare staff to better understand and interpret the findings from our quantitative studies.…”

Provider‐to‐provider telehealth for sepsis patients in a cohort of rural emergency departments

“…5 We have previously shown that rural sepsis is underdiagnosed, however, and the failure to recognize sepsis was associated with decreased tele-ED use and higher mortality. 44,45 Filbin et al 6 identified that sepsis patients with atypical presentations were more likely to have delays in antibiotics and sepsis treatments, and they correspondingly had higher mortality. The participating tele-ED network in this study cannot screen patients for sepsis from the tele-ED hub without a telehealth consult request, so it requires local staff to recognize sepsis and request tele-ED consultation.…”