Abstract
IntroductionMany patients meeting criteria for severe sepsis are not given a sepsis-related diagnosis by emergency physicians (EP). This study 1) compares emergency department (ED) interventions and in-hospital outcomes among patients with severe sepsis, based on the presence or absence of sepsis-related diagnosis, and 2) assesses how adverse outcomes relate to three-hour sepsis bundle completion among patients fulfilling severe sepsis criteria but not given a sepsis-related diagnosis.MethodsWe performed a retrospective cohort study using patients meeting criteria for severe sepsis at two urban, academic tertiary care centers from March 2015 through May 2015. We included all ED patients with the following: 1) the 1992 Consensus definition of severe sepsis, including two or more systemic inflammatory response syndrome criteria and evidence of organ dysfunction; or 2) physician diagnosis of severe sepsis or septic shock. We excluded patients transferred to or from another hospital and those <18 years old. Patients with an EP-assigned sepsis diagnosis created the “Physician Diagnosis” group; the remaining patients composed the “Consensus Criteria” group. The primary outcome was in-hospital mortality. Secondary outcomes included completed elements of the current three-hour sepsis bundle; non-elective intubation; vasopressor administration; intensive care unit (ICU) admission from the ED; and transfer to the ICU in < 24 hours. We compared proportions of each outcome between groups using the chi-square test, and we also performed a stratified analysis using chi square to assess the association between failure to complete the three-hour bundle and adverse outcomes in each group.ResultsOf 418 patients identified with severe sepsis we excluded 54, leaving 364 patients for analysis: 121 “Physician Diagnosis” and 243 “Consensus Criteria.” The “Physician Diagnosis” group had a higher in-hospital mortality (12.4% vs 3.3%, P < 0.01) and compliance with the three-hour sepsis bundle (52.1% vs 20.2%, P < 0.01) compared with the “Consensus Criteria” group. An incomplete three-hour sepsis bundle was not associated with a higher incidence of death, intubation, vasopressor use, ICU admission or transfer to the ICU in <24 hours in patients without a sepsis diagnosis.Conclusion“Physician Diagnosis” patients more frequently received sepsis-specific interventions and had a higher incidence of mortality. “Consensus Criteria” patients had infrequent adverse outcomes regardless of three-hour bundle compliance. EPs’ sepsis diagnoses reflect risk-stratification beyond the severe sepsis criteria.
Highlights
Many patients meeting criteria for severe sepsis are not given a sepsis-related diagnosis by emergency physicians (EP)
This study 1) compares emergency department (ED) interventions and in-hospital outcomes among patients with severe sepsis, based on the presence or absence of sepsis-related diagnosis, and 2) assesses how adverse outcomes relate to three-hour sepsis bundle completion among patients fulfilling severe sepsis criteria but not given a sepsisrelated diagnosis
Of 418 patients identified with severe sepsis we excluded 54, leaving 364 patients for analysis: 121 “Physician Diagnosis” and 243 “Consensus Criteria.”
Summary
Many patients meeting criteria for severe sepsis are not given a sepsis-related diagnosis by emergency physicians (EP). Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.[1] In response to the high morbidity, mortality,[2,3] and cost[1,4] associated with sepsis, clinical recommendations have been developed to promote the early recognition and aggressive treatment of sepsis.[5] In 2015 these recommendations were integrated into the Center for Medicare and Medicaid Services (CMS) sepsis quality measure, NQF# 0500, which mandates three- and six-hour care bundles for patients with severe sepsis This measure includes all patients with an International Classification of Diseases, Tenth Revision, Clinical Management (ICD-10) diagnosis of “severe sepsis” or “septic shock,” as well as “sepsis,” if patients demonstrate two or more systemic inflammatory response syndrome (SIRS) criteria, new sepsis-related organ dysfunction, and suspected infection—the definition of severe sepsis in the 1992 Consensus guidelines.[6,7]. It is possible that these under-identified patients compose a lower risk strata within the cohort of severe sepsis patients, mitigating the benefits of aggressive care
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