Abstract
BackgroundSepsis is the focus of national quality improvement programs and a recent public reporting measure from the Centers for Medicare and Medicaid Services. However, diagnosing sepsis requires interpreting nonspecific signs and can therefore be subjective. We sought to quantify interobserver variability in diagnosing sepsis.MethodsWe distributed five case vignettes of patients with suspected or confirmed infection and organ dysfunction to a sample of practicing intensivists. Respondents classified cases as systemic inflammatory response syndrome, sepsis, severe sepsis, septic shock, or none of the above. Interobserver variability was calculated using Fleiss’ κ for the five-level classification, and for answers dichotomized as severe sepsis/septic shock versus not-severe sepsis/septic shock and any sepsis category (sepsis, severe sepsis, or septic shock) versus not-sepsis.ResultsNinety-four physicians completed the survey. Most respondents (88 %) identified as critical care specialists; other specialties included pulmonology (39 %), anesthesia (19 %), surgery (9 %), and emergency medicine (9 %). Respondents had been in practice for a median of 8 years, and 90 % practiced at academic hospitals. Almost all respondents (83 %) felt strongly or somewhat confident in their ability to apply the traditional consensus sepsis definitions. However, overall interrater agreement in sepsis diagnoses was poor (Fleiss’ κ 0.29). When responses were dichotomized into severe sepsis/septic shock versus not-severe sepsis/septic shock or any sepsis category versus not-sepsis, agreement was still poor (Fleiss’ κ 0.23 and 0.18, respectively). Seventeen percent of respondents classified one of the five cases as severe sepsis/septic shock, 27.7 % rated two cases, 33.0 % respondents rated three cases, 19.2 % rated four cases, and 3.2 % rated all five cases as severe sepsis/septic shock. Among respondents who felt strongly confident in their ability to use sepsis definitions (n = 45), agreement was no better (Fleiss’ κ 0.28 for the five-category classification, and Fleiss’ κ 0.21 for the dichotomized severe sepsis/septic shock classification). Cases were felt to be extremely or very realistic in 74 % of responses; only 3 % were deemed unrealistic.ConclusionsDiagnosing sepsis is extremely subjective and variable. Objective criteria and standardized methodology are needed to enhance consistency and comparability in sepsis research, surveillance, benchmarking, and reporting.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1266-9) contains supplementary material, which is available to authorized users.
Highlights
Sepsis is the focus of national quality improvement programs and a recent public reporting measure from the Centers for Medicare and Medicaid Services
Survey and case vignette description We designed a survey that began with several background questions aimed at gaining an understanding of the characteristics of the responding clinician, including years of clinical experience, specialty, volume of intensive care unit (ICU) patients seen on a regular basis, type of hospital practice, and baseline level of confidence in the clinician’s knowledge and ability to apply the international consensus clinical definitions of sepsis
Case E was designed to be an unequivocal case of septic shock with gram-negative rod bacteremia leading to shock, multiorgan failure, and death, so as to serve as a “control” case to ensure respondents were attentive to the cases and reasonably knowledgeable about sepsis definitions
Summary
Sepsis is the focus of national quality improvement programs and a recent public reporting measure from the Centers for Medicare and Medicaid Services. Diagnosing sepsis requires interpreting nonspecific signs and can be subjective. To make the diagnosis of severe sepsis, clinicians must decide whether a patient has an infection, whether acute organ dysfunction is present, and whether acute organ dysfunction (when present) is attributable to infection. These determinations can be subjective and it is highly conceivable that thoughtful clinicians might differ substantially in their judgments
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