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Abstract

Introduction: There is limited data regarding the triage of patients admitted through the emergency room (ER) with severe sepsis. We examined the triage of these patients to three levels of care. Hypothesis: Patients with severe sepsis that are appropriately identified and treated in the ER by the time of triage can be safely admitted to a non-ICU setting. Methods: As part of an ongoing quality improvement initiative at our institution, data is collected on all patients meeting criteria for severe sepsis(Surviving Sepsis Campaign) admitted through the ER. Patients reviewed had evidence of hypoperfusionand did not require vasopressor support. At our institution, triage decisions are made by a Critical Care attending.We reviewed data for a six month interval; January through June, 2012. Results: Sixty-one patients met criteria for severe sepsis. Twenty-four patients were triaged to the general floors, 30 to an intermediate care unit and 7 tothe ICU. Of the general floor admissions, 54%(13/24) had initial hypotension and 54%(13/24) had an initial serum lactate?4mmol/L. Sixteen percent(4/24) of the general floor patients were transferred to the ICU. One transfer, a patient with terminal malignancy, died. The in-hospital mortality rate was 16%(4/24). In each case, the level of care was limited in the ER. For intermediate care unit patients, 63%(19/30) had initial hypotension and 47%(14/30) had an initial serum lactate?4 mmol/L. Thirteen percent(4/30) of these patients were transferred to the ICU with no mortality. For the group, the in-hospital mortality was 13%(4/30). Of patients initially triaged to the ICU, 57%(4/7) had initial hypotension and 57%(4/7) had an initial serum lactate?4 mmol/L. There were no mortalities in this group. Taken together, all of the patients initially hypotensive in the ER responded to fluid resuscitation with an increase in their blood pressure. Ninety-three percent of the patients demonstrated a decrease in lactate of > 10% following initial resuscitation. Conclusions: This data suggests that patients meeting criteria for severe sepsis can be triaged to general floors and/or intermediate care units with good clinical outcomes based on their initial response to fluid infusion.