Sepsis In Emergency Department Research Articles

Effectiveness and Safety of an Emergency Department Code Sepsis Protocol: A Pragmatic Clinical Trial.

Rationale: Sepsis care delivery-including the initiation of prompt, appropriate antimicrobials-remains suboptimal. Objectives: This study was conducted to determine direct and off-target effects of emergency department (ED) sepsis care reorganization. Methods: This pragmatic pilot trial enrolled adult patients who presented from November 2019 to February 2021 to an ED in Utah before and after implementation of a multimodal, team-based "Code Sepsis" protocol. Patients who presented to two other EDs where usual care was continued served as contemporaneous control subjects. The primary outcome was door-to-antimicrobial time among patients meeting Sepsis-3 criteria before ED departure. Secondary and safety outcomes included all-cause 30-day mortality, antimicrobial utilization and overtreatment, and antimicrobial-associated adverse events. Multivariable regression analyses used difference-in-differences methods to account for trends in outcomes unrelated to the studied intervention. Results: Code Sepsis protocol activation (N = 307) exhibited 8.5% sensitivity and 66% positive predictive value for patients meeting sepsis criteria before ED departure. Among 10,151 patients who met sepsis criteria during the study, adjusted difference-in-differences analysis demonstrated a 13-minute (95% confidence interval = 7-19) decrease in door-to-antimicrobial time associated with Code Sepsis implementation (P < 0.001). Mortality and clinical safety outcomes were unchanged, but Code Sepsis implementation was associated with increased false-positive presumptive infection diagnoses among patients who met sepsis criteria in the ED and increased antimicrobial utilization. Conclusions: Implementation of a team-based protocol for rapid sepsis evaluation and treatment during the coronavirus disease (COVID-19) pandemic's first year was associated with decreased ED door-to-antimicrobial time but also increased antimicrobial utilization. Measurement of both patient-centered and off-target effects of sepsis care improvement interventions is essential to comprehensive assessment of their value. Clinical trial registered with www.clinicaltrials.gov (NCT04148989).

Development and validation of an early acute kidney injury risk prediction model for patients with sepsis in emergency departments

In this study, we aimed to develop and validate a nomogram to predicting the risk of sepsis-associated acute kidney injury (SA-AKI) in patients admitted to emergency departments (EDs). We randomly divided a retrospective dataset of 391 patients with sepsis into a 294-person training cohort and a 97-person validation cohort, and developed three predictive models using multivariate logistic regression analysis and clinical insight. No difference was observed between the three models using the DeLong test and Model 3 was selected as the risk prediction model based on the principle of least inclusion indicators. The use of vasopressor drugs, patient age, platelet count, procalcitonin, and D-dimer levels were included. The training and validation cohorts had a consistency index of 0.832 and 0.866, respectively, indicating high accuracy and stability in predicting SA-AKI risk. The area under the receiver operating characteristic curve was 0.832, showing excellent discrimination. The calibration curves for the training and validation cohorts showed excellent calibration. The decision curve and clinical impact curve analyses showed that the net clinical benefit of using the nomogram was greatest over a probability threshold of 0.05–0.90. In addition, the model showed moderate validity in predicting the 30-day survival and the incidence of major adverse renal events within 30 days. The nomogram developed for SA-AKI risk assessment in patients in EDs showed good discriminability and clinical utility. It can provide a theoretical basis for emergency physicians to prevent SA-AKI.

Clinical impact of the implementation of monocyte distribution width (MDW) measurement on time to anti-infective administration in sepsis patients in the emergency department: a before/after cohort study

BackgroundTimely recognition of sepsis in emergency department (ED) is challenging. We evaluated the impact of implementing the biomarker monocyte distribution width (MDW) at bedside, on the time to anti-infective administration.MethodsWe conducted a before-and-after cohort study in the ED of an academic hospital in Paris, to compare sepsis patients care and outcomes, before and after the implementation of point of care (POC) MDW measurement in the ED. During post-implementation period (period-2), MDW was measured with complete blood count by ED nurses with results given in 2 min: if above 21.5 units, ED physicians were asked to consider sepsis and to start an anti-infectious as soon as possible. Primary endpoint was time to anti-infectious administration (TTA) from ED arrival, and secondary endpoints were TTA from sepsis onset (TTAS), length of stay, mortality, and hospitalization rates.ResultsIn total, 255 patients (period-1) and 180 patients (period-2) with sepsis were included. The TTA was 5.4 h (3.5–7.7) period-1 and 4.9 h (IQR 2.5–7.1) in period-2 (p = 0.06). MDW implementation significantly reduced the median TTAS from to 3.7 h (IQR 1.5–5.8) in period-1, to 2.2 h (IQR 0.5–4.5) in period-2 (p < 0.001). Mortality rates remained similar between the two periods (18% vs. 16% respectively, p = 0.4), as did hospitalization rates (93% vs. 91%, p = 0.4) and ED length of stay (7.2 h (5.3–9.8) vs 7.0 (5.4–9.4), p = 0.7).ConclusionImplementing POC MDW measurement in the ED protocols enhances the timeliness of anti-infective administration from sepsis onset, meeting current sepsis management guidelines.

Characteristics, clinical care, and outcomes of sepsis among patients boarding in the emergency department.

Patients who first meet clinical criteria for sepsis while boarding in the emergency department (ED) may not receive optimal sepsis care. Assess the association between ED boarding status and sepsis quality of care and outcomes. We conducted a retrospective cohort study of adult patients admitted to a large academic hospital from July 2021 to October 2023 who had clinical features consistent with sepsis present while physically in the ED. We compared outcomes for patients who experienced time zero (T-0; the time clinical features of sepsis were first present) while boarding in the ED (physically in the ED but admitted to a different service) to those experiencing T-0 while still under the care of the ED provider team. We used logistic regression to estimate the association between ED boarding status at T-0 and compliance with the US Centers for Medicare & Medicaid Services (CMS) Severe Sepsis and Septic Shock: Management Bundle (SEP-1) core measure, individual bundle element compliance, and hospital mortality adjusting for prespecified covariates. In a subgroup analysis among patients who had not already received antibiotics before T-0, we conducted a Cox proportional hazards model to estimate the association between boarding status on time-to-antibiotics. Among 4795 patients meeting a clinical definition of sepsis in the ED, 422 (8.8%) experienced T-0 as ED boarders. These patients were similar in age, sex, and comorbidities compared with patients experiencing T-0 while still under ED care. Fewer patients with T-0 as an ED boarder received SEP-1 compliant care (25% vs. 38%, p < .001), including a lower proportion of fluid resuscitation (15% vs. 26%, p = .004) and lactate assessment (62% vs. 94%, p < .001). Overall, more patients in the ED boarder group received antibiotics within 3 hours, but one-third of patients had already received antibiotics prior to T-0. Among patients who had not already received antibiotics prior to T-0, experiencing T-0 as an ED boarder was associated with a decreased likelihood of receiving antibiotics (hazard ratio [HR]: 0.67 [95% confidence interval [CI], 0.54-0.84]) and longer time to antibiotics from T-0 (142 min vs. 100 min, p = .007). Sepsis patients experiencing T-0 as a boarder in the ED have a lower likelihood of receiving SEP-1 compliant care compared to patients who experience T-0 while still under ED care.

A-165 Value Of Monocyte Distribution Width In Bacteremia Assessment In Emergency Department Patients

Abstract Background Monocyte distribution width (MDW) is an immune response biomarker and part of a CBC differential. MDW is derived from the distribution of monocyte volumes and elevated MDW values correlate with severe infections and sepsis in Emergency Department (ED) adult patients. Neutrophil to lymphocyte ratio (NLR) is predictive of infections and inflammatory stress. Evaluating these biomarkers could be valuable in bacteremia risk assessment. Bacteremia is the presence of viable bacteria in the bloodstream and is present in up to 20% of septic patients. Blood cultures establish pathogen identity but require culture time, potentially delaying appropriate treatment. Our goal was to characterize MDW and NLR clinical performance in ED patients with suspected bacteremia. Methods This was an observational cohort study of ED patients 18 years and older with CBC differential and blood cultures obtained. MDW values ≥20 is the published cut-off for increased infection risk. Clinical literature suggests that NLR ≥3 is abnormal. We assessed the diagnostic performance of MDW and NLR for positive blood cultures using SPSS Version 25. Results From 07/2021-09/2023, 9,400 blood cultures were ordered and 5174 patients had differential CBCs. The overall blood culture positivity rate was 14.4%. MDW and NLR performance for positive blood cultures is shown in Table 1. Conclusions Our analysis provides evidence that MDW and NLR may be useful for early recognition of bacteremia in ED patients. CBC differential results are reported sooner than culture results. MDW is directly reported, NLR can be readily calculated from the differential. Therefore both could contribute to earlier risk stratification and our findings suggest potentially distinct information from MDW and NLR. Combining MDW with other CBC parameters may provide additional diagnostic advantage. Further analysis will incorporate added clinical data for enhanced decision support in interpreting MDW values in the context of pending blood culture results.

26 BMI Is Negatively Related to Initial Serum Lactate but Not Mortality in Emergency Department Sepsis Patients

26 BMI Is Negatively Related to Initial Serum Lactate but Not Mortality in Emergency Department Sepsis Patients

442 The ICED-SODA Initiative: Improving Compliance With Emergency Department Sepsis OrDer Set Application

442 The ICED-SODA Initiative: Improving Compliance With Emergency Department Sepsis OrDer Set Application

Can We Improve Mortality Prediction in Patients with Sepsis in the Emergency Department?

Background and Objectives: Sepsis represents a global health challenge and requires advanced diagnostic and prognostic approaches due to its elevated rate of morbidity and fatality. Our study aimed to assess the value of a novel set of six biomarkers combined with severity scores in predicting 28 day mortality among patients presenting with sepsis in the Emergency Department (ED). Materials and Methods: This single-center, observational, prospective cohort included sixty-seven consecutive patients with septic shock and sepsis enrolled from November 2020 to December 2022, categorized into survival and non-survival groups based on outcomes. The following were assessed: procalcitonin (PCT), soluble Triggering Receptor Expressed on Myeloid Cells-1 (sTREM-1), the soluble form of the urokinase plasminogen activator receptor (suPAR), high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), and azurocidin 1 (AZU1), alongside clinical scores such as the Quick Sequential Organ Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome (SIRS), the Sequential Organ Failure Assessment (SOFA), the Acute Physiology and Chronic Health Evaluation II (APACHE II), the Simplified Acute Physiology Score II and III (SAPS II/III), the National Early Warning Score (NEWS), Mortality in Emergency Department Sepsis (MEDS), the Charlson Comorbidity Index (CCI), and the Glasgow Coma Scale (GCS). The ability of each biomarker and clinical score and their combinations to predict 28 day mortality were evaluated. Results: The overall mortality was 49.25%. Mechanical ventilation was associated with a higher mortality rate. The levels of IL-6 were significantly higher in the non-survival group and had higher AUC values compared to the other biomarkers. The GCS, SOFA, APACHEII, and SAPS II/III showed superior predictive ability. Combining IL-6 with suPAR, AZU1, and clinical scores SOFA, APACHE II, and SAPS II enhanced prediction accuracy compared with individual biomarkers. Conclusion: In our study, IL-6 and SAPS II/III were the most accurate predictors of 28 day mortality for sepsis patients in the ED.

Quality Initiative to Improve Emergency Department Sepsis Bundle Compliance Through Resident Education and Awareness

Introduction: Timely recognition of sepsis is important for physicians as each hour of delay before sepsis is treated is associated with a 4-9% increase in mortality. In order to monitor the care provided in critically ill patients, the Centers for Medicare &amp; Medicaid Services (CzMS) designed Hospital Quality Initiatives which include The Severe Sepsis and Septic Shock Management Bundle (SEP-1). A prior study conducted by Alexander et al at McLaren Oakland Hospital’s Emergency Department (ED) demonstrated improvement in bundle compliance with standardization in documentation and order entry in EMR in the form of Sepsis Macros. Subsequently, the compliance rates with the SEP-1 bundle at McLaren Oakland were found to have fluctuated monthly. This fluctuation affects both patient outcomes and reimbursement for the care provided. Therefore, we hypothesized further education needed to be provided to ensure quality care of septic patients. Objectives: Our project aimed to improve sepsis bundle compliance at McLaren Oakland by providing education to the PGY-1 class and off-service residents on how to accurately utilize the pre-populated sepsis macro and order sets in EMR in order to recognize and treat sepsis in a timely manner. Methods: We developed a Sepsis Education sheet sent in the form of a monthly educational email. This initiative targeted PGY-1s, instructing them on how to appropriately use the new sepsis macro to have timely recognition of sepsis and appropriate orders placed to meet compliance guidelines. Our monthly educational email was sent from August 2022 to February 2023. Results: Sepsis Compliance data was analyzed from August 2022 to February 2023 and compared to August 2021 to February 2022. After implementation of the Sepsis Education sheet, the mean of compliance rates actually decreased from 64% (SD= 0.101 95% CI: 0.575 to 0.719) to 47% (SD= 0.116 95% CI: 0.388 to 0.560) during intervention (p-value = 0.0101). Conclusion: Our intervention was not successful in increasing compliance with SEP-1 bundle requirements. We therefore determined that PGY-1 awareness of sepsis and use of macros is not the limiting factor in sepsis compliance for McLaren Oakland Hospital’s ED. Further investigation regarding limiting factors in sepsis bundle compliance at our institution will need to be conducted.

The six scoring systems' prognostic value in predicting 24-hour mortality in septic patients.

The use of scoring systems contributes to the faster identification of septic patients, especially those at a high risk of a fatal outcome. The best scoring system does not exist, so the search for the optimal one is always current. The aim of this study is to estimate the prognostic value of the six scoring systems in predicting 24-hour mortality among septic patients presented at the emergency department. An observational retrospective study was conducted in the Emergency Triage Room (ETR) of the Emergency Center (EC) at the University Clinical Center of Serbia (UCCS) in Belgrade. Consecutive septic patients, according to the Sepsis-3 definition, with or without shock, presented to the ETR and then hospitalized in Intensive Care Units were included in the study. Mortality data within 24 h and on the 28th day were extracted from the Hospital information system or the National mortality database. Scoring systems including sequential organ failure assessment (SOFA), quick sequential organ failure assessment (qSOFA), systemic inflammatory response syndrome (SIRS), National early warning score (NEWS), sepsis patient evaluation in the emergency department (SPEED), and mortality in emergency department sepsis (MEDS) were analyzed for all patients utilizing the available data. The primary outcome of this study was death within 24 hours of triage. Receiver operating characteristic (ROC) analysis was used to determine the most effective scoring system. Lactate was then added to this system to enhance its predictive accuracy. Nineteen out of 120 patients included in the study (15.8%) experienced death within 24 hours of triage. The twenty-eight-day mortality rate was 55%. SOFA score demonstrated the highest predictive value for 24-hour mortality but was only moderately predictive overall, with an area under the receiver operating curve (AUC) of 0.755 (95% CI 0.625-0.885). SPEED, MEDS, and NEVS exhibited modest discriminatory power [0.673 (95% CI 0.543-0.803), 0.665 (95% CI 0.536-0.794), 0.630 (95% CI 0.528-0.724)], while SIRS and qSOFA remained insignificant in predicting 24-hour mortality. The predictive value of the SOFA score was increased by the addition of lactate (AUC 0.865, 95% CI 0.736-0.995; p=0.0081). All scores demonstrated better and satisfactory predictive power for 28-day mortality. SOFA, with the addition of lactate, is a complex but reliable tool for the early stratification of septic patients who are presenting at an emergency department.

Effects of Preoperative Glucocorticoid Use on Patients Undergoing Single-Level Lumbar Fusions: A Retrospective Propensity Score-Matched Registry Study.

Objective Spinal fusions are gaining popularity as a means of treating spinal deformity and instability from a range of pathologies. The prevalence of glucocorticoid use has also increased in recent decades, and their systemic effects are well-documented. Although commonly used in the preoperative period, the effects of steroids on outcomes amongpatients undergoing spinal fusions are inadequately described. This study compares the oddsof developing complications amongpatients who underwent single-level lumbar fusions with and without preoperative glucocorticoid use in hopes of establishing more evidence-based parameters for guiding preoperative steroid use. Methods The TriNetX multi-institutional electronic health record database was used to perform a retrospective, propensity score-matched analysis of clinical outcomes of two cohorts of patients who underwent posterior or posterolateral single-level lumbar fusions with and without interbody fusion, those who used glucocorticoids for at least one week within a year of fusion and those who did not. The outcomes of interest were examined within 30 days of the operation and included death, reoperation, deep or superficial surgical site infection (SSI), pneumonia, reintubation, ventilator dependence, tracheostomy, acute kidney injury (AKI), renal insufficiency, pulmonary embolism (PE) or deep venous thrombosis (DVT), urinary tract infection (UTI), emergency department (ED) visit, sepsis, and myocardial infarction (MI). Results The odds of developing pneumonia within 30 days of spinal fusion in the cohort that used glucocorticoids within one year of operation compared to the cohort without glucocorticoid use was 0.67 (p≤0.001, 95% CI: 0.59-0.69). The odds of requiring a tracheostomy within 30 days of spinal fusion in the cohort that used glucocorticoids within one year of operation compared to the cohort without glucocorticoid use was 0.39 (p≤0.001, 95% CI: 0.26-0.60).The odds of reoperation, deep and superficial SSI, and ED visits within 30 days of operation were significantly higher for the same glucocorticoid-receiving cohort, with odds ratios of 1.4 (p=0.003, 95% CI: 1.11-1.65), 1.86 (p≤0.001, 95% CI: 1.31-2.63), 2.28 (p≤0.001, 95% CI: 1.57-3.31), and 1.25 (p≤0.001, 95% CI: 1.17-1.33), respectively. After propensity score-matching, there was no significant difference between the odds of death, DVT, PE, MI, UTI, AKI, sepsis, reintubation, and ventilator dependence between the two cohorts. Conclusion In support of much of the current literature regarding preoperative glucocorticoid use and rates of complications, patients who underwent a single-level lumbar fusion and have used glucocorticoids for at least a week within a year of operation experienced significantly higher odds of reoperation, deep and superficial SSI, and ED visits. However, these patients using glucocorticoids were also found to have lower odds of developing pneumonia, renal insufficiency, and tracheostomy requirement than those who did not use steroids within a year of surgery.

Emergency Department Sepsis Triage Scoring Tool Elements Associated With Hypotension Within 24 Hours in Children With Fever and Tachycardia.

Pediatric sepsis screening is becoming the standard of care for children presenting to the emergency department (ED) and has been shown to improve recognition of severe sepsis, but it is unknown if these screening tools can predict progression of disease. The objective of this study was to determine if any elements of a sepsis triage trigger tool were predictive of progression to hypotensive shock in children presenting to the ED with fever and tachycardia. This study is a retrospective case-control study of children ≤18 years presenting to an ED with fever and tachycardia, comparing those who went on to develop hypotensive shock in the subsequent 24 hours (case) to those who did not (control). Primary outcome was the proportion of encounters where the patient had specific abnormal vital signs or clinical signs as components of the sepsis triage score. The secondary outcomes were the proportion of encounters where the patient had a sepsis risk factor. During the study period, there were 94 patients who met case criteria and 186 controls selected. In the adjusted multivariable model, the 2 components of the sepsis triage score that were more common in case patients were the presence of severe cerebral palsy (adjusted odds ratio, 9.4 [3.7, 23.9]) and abnormal capillary refill at triage (adjusted odds ratio, 3.1 [1.4, 6.9]). Among children who present to a pediatric ED with fever and tachycardia, those with prolonged capillary refill at triage or severe cerebral palsy were more likely to progress to decompensated septic shock, despite routine ED care.

Impact of a Coordinated Sepsis Response on Time to Treatment in a Pediatric Emergency Department.

Sepsis is responsible for 75 000 pediatric hospitalizations annually, with an associated mortality rate estimated between 11% and 19%. Evidence supports the use of timely fluid resuscitation and antibiotics to decrease morbidity and mortality. Our emergency department did not meet the timeliness goals for fluid and antibiotic administration suggested by the 2012 Surviving Sepsis Campaign. In November 2018, we implemented a sepsis response team utilizing a scripted communication tool and a dedicated sepsis supply cart to address timeliness barriers. Performance was evaluated using statistical process control charts. We conducted observations to evaluate adherence to the new process. Our aim was to meet the Surviving Sepsis Campaign's timeliness goals for first fluid and antibiotic administration (20 and 60 minutes, respectively) within 8 months of our intervention. We observed sustained decreases in mean time to fluids. We also observed a shift in the proportion of patients receiving fluids within 20 minutes. No shifts were observed for timely antibiotic administration. The implementation of a dedicated emergency department sepsis response team with designated roles and responsibilities, directed communication, and easily accessible supplies can lead to improvements in the timeliness of fluid administration in the pediatric population.

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

Telehealth has been proposed as one strategy to improve the quality of time-sensitive sepsis care in rural emergency departments (EDs). The purpose of this study was to measure the association between telehealth-supplemented ED (tele-ED) care, health care costs, and clinical outcomes among patients with sepsis in rural EDs. Cohort study using Medicare fee-for-service claims data for beneficiaries treated for sepsis in rural EDs between February 1, 2017, and September 30, 2019. Our primary hospital-level analysis used multivariable generalized estimating equations to measure the association between treatment in a tele-ED-capable hospital and 30-day total costs of care. In our supporting secondary analysis, we conducted a propensity-matched analysis of patients who used tele-ED with matched controls from non-tele-ED-capable hospitals. Our primary outcome was total health care payments among index hospitalized patients between the index ED visit and 30 days after hospital discharge, and our secondary outcomes included hospital mortality, hospital length of stay, 90-day mortality, 28-day hospital-free days, and 30-day inpatient readmissions. In our primary analysis, sepsis patients in tele-ED-capable hospitals had 6.7% higher (95% confidence interval [CI] 2.1%-11.5%) total health care costs compared to those in non-tele-ED-capable hospitals. In our propensity-matched patient-level analysis, total health care costs were 23% higher (95% CI 16.5%-30.4%) in tele-ED cases than matched non-tele-ED controls. Clinical outcomes were similar. Tele-ED capability in a mature rural tele-ED network was not associated with decreased health care costs or improved clinical outcomes. Future work is needed to reduce rural-urban sepsis care disparities and formalize systems of regionalized care.

Immediate vs latent antibiotic administration for septic shock or severe sepsis in Emergency department – a systematic review

Background: Sepsis is a time-dependent, host response to infection that is linked to an unacceptable high death rate, making it a medical emergency and potentially fatal illness. Therefore, during the first hour of sepsis diagnosis, doctors treating suspected or confirmed cases must start treating patients with broad-spectrum antibiotics. In order to examine research on the effect of early (1 to 3 hours) vs immediate (0 to 1 hours) antibiotic administration on mortality in septic shock or severe sepsis patients, we conducted this systematic review. Method: The PRISMA guidelines were followed in this review. Grey literature and databases including Web of Science, PubMed, EMBASE, and the Cochrane Library were searched. We considered studies included mortality data from consecutive adult patients with septic shock or severe sepsis who were treated with antibiotics within each time frame. All writers extracted the data. Result: Following screening, eight papers were included in the final evaluation. Seven trials were carried out in the ED, and one research was done in the ICU and ED. The ED triage in three studies, ED arrival in three studies, period of organ failure in one research, and the ED registration in one study were all considered the zero time for sepsis start. Ferrer et al. and Alan et al. carried out the two largest investigations, involving 34 and 144 hospitals, respectively. Seven studies classified mortality as occurring in the hospital during the index visit, while one research defined it as occurring within 28 days following admission. Conclusion: The study found that patients with septic shock or severe sepsis who received their first antibiotic later had higher in-hospital mortality.

Comparison of qSOFA, MEDS, and APACHE II Scores in Early Identification of Sepsis for Patients with 28 days Mortality and ICU Admission: A cross-sectional Study

Introduction: Sepsis is a life-threatening infection that results in organ dysfunction due to an increased pathogen load, necessitating urgent intervention. There is a gap in clinicians’ ability to identify septic patients at high-risk with poor outcomes, highlighting the need for validated predictive scores for early intervention, favourable outcomes, and prompt recovery. Aim: To validate the predictive capacity of the Sequential Organ Failure Assessment (qSOFA), Mortality in Emergency Department Sepsis (MEDS), and Acute Physiology and Chronic Health Evaluation (APACHE 2) scores in patients with 28- day mortality and in Intensive Care Unit (ICU) patients due to sepsis. Materials and Methods: This cross-sectional study was conducted on 150 septic patients at the Department of Emergency Medicine, Sri Ramachandra Institute of Higher Education and Research in Chennai, India, between June and December 2022. Parameters assessed included Respiratory Rate (RR), Systolic Blood Pressure (SBP), Mean Arterial Pressure (MAP), temperature, White Blood Cell (WBC) count, platelet count, bilirubin, and creatinine. Descriptive analysis of age, gender, source, RR, GCS, SBP, qSOFA, MEDS, APACHE 2 in 28-day mortality, and ICU patients. Positive correlation and good predictivity of predictive scores (qSOFA, MEDS, APACHE 2) were analysed using Spearman’s Rank Correlation Coefficient (SRCCRs) statistical test in 28-day mortality and ICU patients. Results: A total of 150 septic patients (male: female-93:57) with an average age of 57.07±14.4 years were included. Urosepsis was the most common (n=51), followed by respiratory sepsis (n=48). Of these, 96 patients were admitted to the ICU, and 54 patients experienced 28-day mortality. The average and median values of RR were 27.1±7.64 breaths/minute (b/m) and 26 b/m, respectively. SBP values were 106.13±30.47 mmHg and 110 mmHg, respectively. Diastolic Blood Pressure (DBP) values were 66±16.51 mmHg and 60 mmHg, respectively. The average and median values of GCS were 12.75±3.92 and 15, respectively. The average for qSOFA was 29.1±0.025, with a median of 28; for MEDS, the average was 7.99±5.89, with a median of 7; and for APACHE 2, the average was 16.74±9.64, with a median of 15. Spearman’s Rank Correlation Coefficient (SRCCRs) demonstrated a strong positive correlation and good predictive validity between qSOFA, MEDS, and APACHE 2 scores in 28- day mortality and ICU patients (&lt;0.001). Receiver Operating Characteristic Curve (ROC) analysis indicated good predictive validity for qSOFA in 28-day mortality and ICU patients. Conclusion: qSOFA exhibited a positive correlation and good predictive validity compared to MEDS and APACHE 2 in both 28-day mortality and ICU patients (&lt;0.001). This study highlights the utility and applicability of qSOFA at the bedside for initial triage, as it can be quickly employed with minimal information.

Pulmonary embolism and risk factors of ICU admission: systematic review

To forecast mortality and identify adult patients who required admission to an intensive care unit (ICU), we compared the efficacy of the most widely used early warning scores. The present review assessed the pulmonary embolism and risk factors of ICU admission; systematic review. A search of the literature was conducted in the bibliographic databases PubMed and EMBASE between 2009 and 2022. Each reviewer verified independently that each possibly relevant title and abstract qualified. There were nine studies that were included in the review. National early warning score (NEWS) was the best indicator of ICU admission; however, the modified early warning score (MEWS) performed better in sepsis patients. According to emergency department (ED) Mortality, the NEWS was the most accurate score for predicting mortality in the entire ED population, and the mortality in emergency department sepsis score was the most accurate measure for patients with sepsis. For all endpoints, NEWS and MEWS had good outcomes in the ICU and ED. Numerous investigations should be conducted utilizing various prognostic scores on ED and ICU patients. Anemia in patients with venous thrombosis was associated with a higher risk of ICU admission and mortality.

Appropriateness of antibiotic prescribing for patients with sepsis in rural hospital emergency departments.

This was a multicentre retrospective cohort study of adult patients (≥18 years) presenting with a process associated International Classification of Diseases code (ICD-AM-10) pertaining to sepsis between January 2017 and July 2020 to rural Emergency Departments. Our primary outcome was antibiotic appropriateness as defined by the Australian Therapeutic Guidelines (for antibiotic selection relative to infecting source) and the National Antimicrobial Prescribing Survey tool. Our secondary outcome was in-hospital mortality. Relevant clinical and non-clinical, physiological and laboratory data were collected retrospectively. Multivariate logistic regression was used to estimate the odds of both inappropriate antibiotic prescribing and in-hospital mortality based on clinical and non-clinical factors. A total of 378 patients were included who primarily presented with sepsis of unknown origin (36.8%), a genitourinary (22.22%) or respiratory (18.78%) source. Antibiotics were appropriately prescribed in 59% of patients. A positive Quick Sequential Organ Failure Assessment score (qSOFA) (odds ratio [OR] = 0.49; 95% confidence interval [CI], 0.29-0.83), a respiratory infection source (OR = 0.5; 95% CI, 0.29-0.86) and documented allergy (OR = 0.42; 95% CI, 0.25-0.72) were associated with a lower risk of appropriate prescribing in multivariate analysis. Forty-one percent of patients received antibiotics within 1 h of presentation. Inappropriate antibiotic prescribing was not associated with in-hospital mortality. The rates of appropriate antibiotic prescribing in rural Emergency Departments for patients presenting with sepsis is low, but comparable to other referral metropolitan centres.

Pediatric Sepsis in General Emergency Departments: Association Between Pediatric Sepsis Case Volume, Care Quality, and Outcome

To assess whether a general emergency department's (ED) annual pediatric sepsis volume increases the odds of delivering care concordant with Surviving Sepsis pediatric guidelines. A retrospective cohort study of children <18 years with sepsis presenting to 29 general EDs. Emergency department and hospital data were abstracted from the medical records of 2 large health care systems, including all hospitals to which children were transferred. Guideline-concordant care was defined as intravenous antibiotics within 3 hours, intravenous fluid bolus within 3 hours, and lactate measured. The association between annual ED pediatric sepsis encounters and the probability of receiving guideline-concordant care was assessed. We included 1,527 ED encounters between January 1, 2015, and September 30, 2021. Three hundred and one (19%) occurred in 25 EDs with <10 pediatric sepsis encounters annually, 466 (31%) in 3 EDs with 11 to 100 pediatric sepsis encounters annually, and 760 (50%) in an ED with more than 100 pediatric sepsis encounters annually. Care was concordant in 627 (41.1%) encounters. In multivariable analysis, annual pediatric sepsis volume was minimally associated with the probability of guideline-concordant care (odds ratio 1.002 [95% confidence interval 1.001 to 1.00]). Care concordance increased from 23.1% in 2015 to 52.8% in2021. Guideline-concordant sepsis care was delivered in 41% of pediatric sepsis cases in general EDs, and annual ED pediatric sepsis encounters had minimal association with the odds of concordant care. Care concordance improved over time. This study suggests that factors other than pediatric sepsis volume are important in driving care quality and identifying drivers of improvement is important for children first treated in general EDs.

879. Host Response Classifiers Identify Infection and Illness Severity and Improve Antibiotic Decision-Making in Patients with Suspected Infections Presenting to the Emergency Department

Abstract Background Nonspecific presentation and limited diagnostic solutions of acute infections and sepsis in emergency departments (EDs) result in early antimicrobial administration at a cost to antimicrobial stewardship. We validated the host response classifiers, IMX-BVN-3b and SEV-3b, to determine bacterial and viral infection status and illness severity. We also assessed antibiotic over- and underuse. Methods We prospectively enrolled adult ED patients with suspected acute infections or sepsis with ≥1 vital sign abnormal across 7 sites. At enrollment, we surveyed treating physicians on infection probability and antibiotic prescribing. BVN/SEV-3b were calculated using NanoString nCounter® on PAXgene® blood samples. We compared BVN-3b likelihood of bacterial and viral infection to post-hoc clinical adjudication infection status and SEV-3b likelihood of severe outcomes to 7-day need for ICU care and 30-day mortality. Results Of 568 enrolled patients, 346 had consensus adjudications (131 bacterial, 52 viral, 1 coinfection, 162 noninfected). The BVN-3b area under the receiver operating curve (AUROC) for bacterial infections was 0.82 (95%CI 0.77-0.87), compared to 0.76 (95%CI 0.71-0.81) for procalcitonin (p = 0.011). BVN-3b AUROC for viral infections was 0.89 (95%CI 0.84-0.95). SEV-3b AUROC was 0.78 (95%CI 0.69-0.86) and 0.88 (95%CI 0.73-1) for 7-day ICU care and 30-day mortality, respectively. Of the 346, 226 patients had a pre-lab result physician questionnaire; of these, 110 patients received antibiotics. Of these, BVN-3b would have corrected 71% of antibiotic prescribing errors (34/48 overprescriptions and 13/18 underprescriptions). Conclusion BVN-3b and SEV-3b accurately identified bacterial and viral infections and risk status. If implemented in a rapid workflow, these tests may improve patient management and antibiotic prescribing, reducing healthcare costs in the ED. Disclosures Arianna Beltran, BS, Inflammatix: Internship Uan-I Chen, MS, Inflammatix: Stocks/Bonds Edward A. Michelson, MD, Inflamatix: Research expense reimbursement for sponsored clinical trial Alexandra Weissman, MD, Inflammatix Inc: Advisor/Consultant Evangelos J. Giamarellos-Bourboulis, PhD, D(ABMM), Abbot Product Operations AG: Grant/Research Support|Abbot Product Operations AG: Honoraria|bioMerieux: Grant/Research Support|bioMerieux: Honoraria|Horizon 2020 European Program: Grant/Research Support|Horizon Health European Program: Grant/Research Support|Sobi AB: Advisor/Consultant|Sobi AB: Grant/Research Support|Sobi AB: Honoraria Oliver Liesenfeld, MD, Inflammatix Inc.: Ownership Interest Natalie N. Whitfield, PhD, D(ABMM), GenMark Dx/Roche: Employee|GenMark Dx/Roche: Stocks/Bonds|Inflammatix: Employee|Inflammatix: Stocks/Bonds