Sepsis Screening Tool Research Articles

The predictive value of variables measurable in the ambulance and the development of the Predict Sepsis screening tools: a prospective cohort study

BackgroundDespite sepsis being a time critical condition with a high mortality, it is often not identified in a timely fashion. The aim of the current study was to create a screening tool based on bedside measurable variables predictive of sepsis among ambulance patients with infection according to clinical judgment by ambulance personnel.MethodsProspective cohort study of 551 adult patients presenting with suspected infection, performed in the ambulance setting of Stockholm during 2017–2018. 18 variables were measured in the ambulance (8 keywords related to medical history, 6 vital signs, 4 point-of-care blood tests, in addition to age, gender, and comorbidity. Logistic regression, area under the curve (AUC) and classification trees were used to study the association with sepsis. The AUC, sensitivity, specificity, predictive values and likelihood ratios were used to evaluate the predictive ability of sepsis screening models.ResultsThe six variables with the strongest association with sepsis were: systolic blood pressure ≤ 100 mmHg, temperature > 38.5 °C, GCS < 15, lactate > 4 mmol/L, gastrointestinal symptoms, and a history of acute altered mental status. These were combined into the Predict Sepsis screening tool 1, with a sensitivity of 0.90, specificity 0.41, AUC 0.77; 95% confidence interval [CI] 0.73–0.81, PPV 0.52, and NPV 0.86. Combining a history of acute altered mental status with GCS < 15 and excluding lactate in the Predict Sepsis screening tool 2 did not noticeably affect the AUC. In addition, the AUCs of these models did not differ noticeably when compared to a model including vital signs alone, with novel calculated cut-offs; the Predict Sepsis screening tool 3.ConclusionsSystolic blood pressure ≤ 100 mmHg, temperature > 38.5 °C, GCS < 15, lactate > 4 mmol/L, gastrointestinal symptoms, and a history of acute altered mental status demonstrated the strongest association with sepsis. We present three screening tools to predict sepsis with similar sensitivity. The results indicated no noticeable increase of predictive ability by including symptom-variables and blood tests to a sepsis screening tool in the current study population.Trial registrationNCT03249597.

Role of Hematological Score in Early Diagnosis of Neonatal Sepsis

Background: Neonatal sepsis is one of the major causes of morbidity &amp; mortality in the newborn, more so in the developing countries.&#x0D; Objective: The objective of this study was to evaluate the applicability of Haematological Scoring System (HSS) in early diagnosis of sepsis and its compatibility with C-reactive protein (CRP) and blood culture.&#x0D; Materials and methods: This prospective study consisted of 205 neonates admitted at neonatal intensive care unit of Chattogram Maa-shishu-o General Hospital with clinical suspicion of neonatal sepsis, from July 2017 to December 2017. The neonatal hematological parameter was measured in all cases. Blood culture and CRP estimation were also performed. Blood culture is considered as gold standard for diagnosis of sepsis. Score 3 and more was considered as positive&#x0D; Results: Out of 205 neonates of our study population, forty one (20%) had proven sepsis according to culture. Total leukocyte count showed high sensitivity &amp; least specificity, immature to mature neutrophil ratio showed high sensitivity and high specificity. Platelet count showed high negative predictive value and least positive predictive value. The HSS was found to have a sensitivity of 82.9%, specificity of 79.8%, positive predictive value was 50.74% and negative predictive value was 94.92%. Considering the high sensitivity and negative predictive value, this study implies that score ³3 were more reliable as a screening tool for sepsis than any of the individual hematological parameter.&#x0D; Conclusion: HSS is a simple, easy and rapid adjunct for the diagnosis of clinically suspected cases of neonatal sepsis. It also provides an effective guideline to make decisions regarding judicious use of antibiotic therapy.&#x0D; Chatt Maa Shi Hosp Med Coll J; Vol.18 (2); July 2019; Page 45-48

Point-of-care lactate measurement for suspected sepsis in the prehospital environment: are we missing the point at the sharp end?

Expecting ambulance clinicians to dependably differentiate the life-threatening organ dysfunction caused by sepsis from an inflammatory response to a non-infectious aetiology, relying upon vital signs and a physical examination of the patient alone, must be considered unrealistic. Although lactate measurement has been integrated into numerous prehospital sepsis screening tools, it is not yet measured routinely within UK ambulance services. Research has generally focused on whether handheld point-of-care lactate measurement devices are as accurate as laboratory analysis of venous or arterial samples. The weight of literature has concluded negatively in relation to this. However, there is potential for handheld devices to be used independently to monitor trends in lactate elimination or accumulation to inform decisions on the efficacy of prehospital interventions, or simply to report categorical data in terms of whether lactate levels are elevated or not. This offers UK paramedics the opportunity to improve sepsis care through the enhanced assessment of risk and acuity, the identification of patients with cryptic shock, more aggressive fluid resuscitation and advanced notification to receiving units.

Predictive Accuracy of the Quick Sepsis-related Organ Failure Assessment Score in Brazil. A Prospective Multicenter Study.

Rationale: Although proposed as a clinical prompt to sepsis based on predictive validity for mortality, the Quick Sepsis-related Organ Failure Assessment (qSOFA) score is often used as a screening tool, which requires high sensitivity.Objectives: To assess the predictive accuracy of qSOFA for mortality in Brazil, focusing on sensitivity.Methods: We prospectively collected data from two cohorts of emergency department and ward patients. Cohort 1 included patients with suspected infection but without organ dysfunction or sepsis (22 hospitals: 3 public and 19 private). Cohort 2 included patients with sepsis (54 hospitals: 24 public and 28 private). The primary outcome was in-hospital mortality. The predictive accuracy of qSOFA was examined considering only the worst values before the suspicion of infection or sepsis.Measurements and Main Results: Cohort 1 contained 5,460 patients (mortality rate, 14.0%; 95% confidence interval [CI], 13.1–15.0), among whom 78.3% had a qSOFA score less than or equal to 1 (mortality rate, 8.3%; 95% CI, 7.5–9.1). The sensitivity of a qSOFA score greater than or equal to 2 for predicting mortality was 53.9% and the 95% CI was 50.3 to 57.5. The sensitivity was higher for a qSOFA greater than or equal to 1 (84.9%; 95% CI, 82.1–87.3), a qSOFA score greater than or equal to 1 or lactate greater than 2 mmol/L (91.3%; 95% CI, 89.0–93.2), and systemic inflammatory response syndrome plus organ dysfunction (68.7%; 95% CI, 65.2–71.9). Cohort 2 contained 4,711 patients, among whom 62.3% had a qSOFA score less than or equal to 1 (mortality rate, 17.3%; 95% CI, 15.9–18.7), whereas in public hospitals the mortality rate was 39.3% (95% CI, 35.5–43.3).Conclusions: A qSOFA score greater than or equal to 2 has low sensitivity for predicting death in patients with suspected infection in a developing country. Using a qSOFA score greater than or equal to 2 as a screening tool for sepsis may miss patients who ultimately die. Using a qSOFA score greater than or equal to 1 or adding lactate to a qSOFA score greater than or equal to 1 may improve sensitivity.Clinical trial registered with www.clinicaltrials.gov (NCT03158493).

A Sepsis Screening Tool for Hematopoietic Cell Transplant Recipients Remains Elusive.

A Sepsis Screening Tool for Hematopoietic Cell Transplant Recipients Remains Elusive.

Assessing the Relationship between Glasgow Coma Scale Scores and MS Documentation in Allogeneic Hematopoietic Cell Transplant Recipients with Suspected Infection

Topic Significance & Study Purpose/Background/Rationale Sepsis leads to physiologic shock, organ dysfunction and death. Mental status (MS) changes are known indicators of sepsis, so clinical criteria that measure awareness and mentation have been incorporated in sepsis screening tools such as the quick Sequential Organ Failure Assessment (qSOFA). To evaluate the utility of GCS as a MS assessment tool, we examined the relationship between GCS scores and MS clinical record documentation in allogeneic hematopoietic cell transplant (aHCT) recipients with suspected infections (SI). Methods, Intervention, & Analysis We retrospectively examined aHCT recipients with SI who were transplanted between September 2010 and July 2017. We assessed data from the first 100-days post-HCT using clinical databases and medical records. We defined SI as an antibiotic and a culture within a specific time epoch. We randomly selected a cohort of inpatient detected SIs (n=100) based on presence of GCS availability: 30 SIs with and 70 SIs without a GCS score recorded 24 hrs after SI onset. Using a selection of search terms associated with MS changes, chart-review was done to ascertain clinical MS assessments conducted by healthcare staff within 24 hours of SI onset. Findings & Interpretation A total of 773/1170 (66.1%) patients had 1 or more SIs. The 773 recipients experienced 1,655 SIs during follow-up, of which, 625 (37.8%) had a documented GCS score within 24 hours of onset. Of the selected cohort, those with GCS scores had a median of 3 current MS notes, compared to 2 among those without GCS scores. Among patients with SIs and GCS scores, 8 had documented altered MS, including 3 with GCS scores of 15 and 5 with scores of Discussion & Implications GCS scores are often used in sepsis screening tools, yet the frequency and accuracy of documentation among aHCT recipients has not been assessed. We found that the majority of aHCT recipients did not have GCS score within 24 hours of a suspected infection. Additionally, GCS scores did not always correlate with healthcare staff documentation of post-transplant altered MS.

Risk Factors, Etiologies, and Screening Tools for Sepsis in Pregnant Women: A Multicenter Case-Control Study.

Given the significant morbidity and mortality of maternal sepsis, early identification is key to improve outcomes. This study aims to evaluate the performance characteristics of the systemic inflammatory response syndrome (SIRS), quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA), and maternal early warning (MEW) criteria for identifying cases of impending sepsis in parturients. The secondary objective of this study is to identify etiologies and risk factors for maternal sepsis and to assess timing of antibiotics in patients diagnosed with sepsis. Validated maternal sepsis cases during the delivery hospitalization from 1995 to 2012 were retrospectively identified at 7 academic medical centers in the United States and Israel. Control patients were matched by date of delivery in a 1:4 ratio. The sensitivity and specificity of SIRS, qSOFA, and MEW criteria for identifying sepsis were calculated. Data including potential risk factors, vital signs, laboratory values, and clinical management were collected for cases and controls. Eighty-two sepsis cases during the delivery hospitalization were identified and matched to 328 controls. The most common causes of sepsis were the following: chorioamnionitis 20 (24.4%), endometritis 19 (23.2%), and pneumonia 9 (11.0%). Escherichia coli 12 (14.6%), other Gram-negative rods 8 (9.8%), and group A Streptococcus 6 (7.3%) were the most commonly found pathogens. The sensitivities and specificities for meeting criteria for screening tools were as follows: (1) SIRS (0.93, 0.63); (2) qSOFA (0.50, 0.95); and (3) MEW criteria for identifying sepsis (0.82, 0.87). Of 82 women with sepsis, 10 (12.2%) died. The mortality rate for those who received antibiotics within 1 hour of diagnosis was 8.3%. The mortality rate was 20% for the patients who received antibiotics after >1 hour. Chorioamnionitis and endometritis were the most common causes of sepsis, together accounting for about half of cases. Notable differences were observed in the sensitivity and specificity of sepsis screening tools with the highest to lowest sensitivity being SIRS, MEW, and qSOFA criteria, and the highest to lowest specificity being qSOFA, MEW, and SIRS. Mortality was doubled in the cohort of patients who received antibiotics after >1 hour. Clinicians need to be vigilant to identify cases of peripartum sepsis early in its course and prioritize timely antibiotic therapy.

The use of screening tools in the early recognition of sepsis in the prehospital adult patient: a review of the literature

Background: Sepsis has been identified as a time critical and life-threatening condition resulting from the body's own systemic response to infection leading to multi-organ dysfunction and failure, and remains a major frontrunner in the morbidity and mortality of critically ill patients1–3. The 2016 Surviving Sepsis Campaign1 identified that similar to patients with polytrauma, stroke and acute myocardial infarction, the early identification and timeous delivery of appropriate treatment for patients with sepsis could improve patient outcomes and decrease mortality rates1,4. Prehospital sepsis screening tools could provide a systematic approach to critically ill patients in order to identify those patients with a high index of suspicion for sepsis and allow for early and aggressive management.Methods: A literature review was conducted for the period January 2011 to September 2017. A database search was conducted via the electronic databases Ovid MEDLINE (without revisions), CINAHL and The Cochrane Library. The websites ScienceDirect, Wiley Online Library, British Medical Journal (BMJ) and Google Scholar were also used in the search for literature. Full search strategies are detailed in Table 1. The selection and rejection of all articles can be reviewed in Figure 1.Results: All articles identified for full review (n = 13) were between the period January 2011 and September 2017. The three most common methodologies identified were systematic review (n = 3), prospective cohort study (n = 3) and prospective observational study (n = 3). Other methodologies included literature review (n = 1), retrospective cohort study (n = 1), retrospective analysis (n = 1), and retrospective cross-sectional study (n = 1). Through literature analysis, three main areas of interest were identified in which articles were reviewed: the early recognition of sepsis by Emergency Medical Services (EMS) staff (n = 2), the early recognition of sepsis using a prehospital sepsis screening tool by EMS (n = 6), and the impact of EMS sepsis recognition and management on patient outcomes (n = 4). A comparison summary of the various sepsis screening tools can be viewed in Table 2.Conclusion: Previous literature has described EMS transport rates of approximately 3.3 sepsis patients per 100 and approximately 40% of septic patients admitted having been transported by EMS5. Despite this relatively high prevalence, the review identified that recognition of sepsis by EMS personnel was poor. The use of various sepsis screening tools showed improved recognition by EMS but validation studies on the accuracy of these tools is required. In patients in whom a screening tool was used and early pre-notification given to receiving facilities, a decrease time to definitive management of these patients was identified. These varied findings in outcomes of septic patients transported by EMS identifies the need for further studies on EMS recognition of sepsis and the impact it has on the outcomes of these patients. A specific prehospital sepsis screening tool could possibly assist in the early recognition of sepsis. Pre-notification to receiving facilities could allow the facility to prepare for EMS arrival and continue aggressive early goal directed therapy (EGDT) as required.The author acknowledges the possibility of publication and selection bias within this review due to single author selection and only English studies being included.

Mortality Prediction of Septic Patients in the Emergency Department Based on Machine Learning.

In emergency departments, the most common cause of death associated with suspected infected patients is sepsis. In this study, deep learning algorithms were used to predict the mortality of suspected infected patients in a hospital emergency department. During January 2007 and December 2013, 42,220 patients considered in this study were admitted to the emergency department due to suspected infection. In the present study, a deep learning structure for mortality prediction of septic patients was developed and compared with several machine learning methods as well as two sepsis screening tools: the systemic inflammatory response syndrome (SIRS) and quick sepsis-related organ failure assessment (qSOFA). The mortality predictions were explored for septic patients who died within 72 h and 28 days. Results demonstrated that the accuracy rate of deep learning methods, especially Convolutional Neural Network plus SoftMax (87.01% in 72 h and 81.59% in 28 d), exceeds that of the other machine learning methods, SIRS, and qSOFA. We expect that deep learning can effectively assist medical staff in early identification of critical patients.

781. Nurse-Driven Time-of-Triage Sepsis Screening Tool Improves Timely Intervention in Ambulatory Emergency Department (ED) Patients with Suspected Sepsis

BackgroundSepsis is a potentially life-threatening, systemic complication of infection. Rapid intervention is critical to reduce morbidity and mortality; however, early recognition of sepsis is challenging due to a highly variable and nonspecific presentation. Recognition is particularly problematic in ambulatory (walk-in) patients who receive minimal to no medical attention prior to ED presentation. There is limited literature addressing sepsis intervention among the ambulatory population in the ED. Our organization has employed an electronic, nurse-driven sepsis screening tool into the triage process for all ambulatory patients who present to the ED.MethodsThis was a retrospective, quasi-experimental study conducted from November 2015 to May 2018 in three consecutive timeframes: pre-implementation (12 months), implementation (7 months), and post-implementation (12 months). Adult ambulatory ED patients were included if they had a coded diagnosis of sepsis, septic shock, or an infectious syndrome, had fever or hypothermia and systemic inflammatory response syndrome signs on presentation. The primary outcome measure was hourly time interval to antibiotic administration from time of ED registration.ResultsA total of 902 patients were included with 286, 208, and 408 patients in the pre-implementation, implementation and post-implementation cohorts, respectively. Baseline characteristics including comorbid conditions and infection source were similar between cohorts. The primary outcome of hourly time interval to antibiotic administration was significantly different (P = 0.044) between the three cohorts with the most substantial increase in administration specifically in the less than 1-hour interval. Between the pre-implementation, implementation, and post-implementation cohorts, significant decreases were observed in mean time to fluids (3.6, 3.0, and 2.5 hours, respectively, P = 0.003) and average length of stay (5.5, 5.8, and 4.2 days, respectively, P < 0.001) and a significant increase was observed in ED sepsis alert activations (26%, 48%, 51%, respectively, P < 0.001).ConclusionA nurse-driven electronic time-of-triage sepsis screening tool improved timely recognition and intervention in ambulatory ED patients with suspected sepsis. Disclosures All authors: No reported disclosures.

Performance of a quick sofa-65 score as a rapid sepsis screening tool during initial emergency department assessment: A propensity score matching study

PurposeWe sought to elucidate the performance of a Quick Sequential Organ Function Assessment-65 (qSOFA-65) score in recognizing sepsis and to compare the qSOFA-65 score to systemic inflammatory response syndrome (SIRS) and qSOFA scores. MethodsWe performed a matched case-control study using propensity score matching. The number of patients meeting qSOFA-65, qSOFA, and SIRS positive criteria were calculated between the sepsis and non-sepsis groups. We compared the diagnostic performance of the three scoring systems in predicting sepsis. ResultsA total of 2441 patients were included in the study. In propensity matched cohorts, the percentage of patients who met qSOFA-65, qSOFA, and SIRS positive criteria were 46.7%, 14.3%, and 55.6%, respectively. The sensitivity and specificity scores for the qSOFA-65, qSOFA, and SIRS positive criteria for sepsis were 0.66 and 0.73, 0.28 and 0.97, and 0.66 and 0.55, respectively. The AUC value of qSOFA-65 positive criteria in predicting sepsis was significantly higher than that of qSOFA and SIRS positive criteria (adjusted AUC 0.688 vs. 0.630 vs. 0.596, respectively). ConclusionsWe found that qSOFA-65 was more likely to identify patients with sepsis on the initial ED visit relative to qSOFA or SIRS. This may have quality improvement implications in predicting sepsis.

194 The Performance of Sepsis Screening Tools in an Urban Emergency Department in Belize

There is limited data on the burden and treatment of sepsis in low and middle-income countries (LMICs), especially in Central America and the Caribbean. We sought to characterize the burden of sepsis among patients admitted to the largest public referral hospital in Belize and the generalizability of the quick Sequential Organ Function Assessment (qSOFA) score and Emergency Triage and Treatment (ETAT) emergency signs as sepsis screening tools. We performed a single-site retrospective review of patients admitted from the emergency department (ED) at Karl Heusner Memorial Hospital, a tertiary government facility in Belize City, Belize with approximately 25,000 annual ED visits. We reviewed paper and electronic medical records for patients admitted from October 2017 to September 2018 with a diagnosis suggestive of infection. Of the total of 3,703 admissions during the review period, 1,693 (46%) had a diagnosis suggestive of infection. Only 21 (1.2%) patients had sepsis documented as an admission diagnosis. We conducted a selective chart review of 590 of these admissions during the review period. For the overall cohort, 367 (62%) patients were adults, median age was 33, 53% were male, 14% were HIV positive and 11% were transferred from a referring facility. Utilizing the Sepsis-3 recommended criteria of a change of ≥2 in the SOFA/pSOFA score, 123 (21%) patients met the definition of sepsis. The 30-day mortality rate was 20% and the 90-day mortality rate was 28% in the sepsis cohort, compared with 5.1% and 7.8% in the overall cohort. The rate of ICU admission was higher in the sepsis cohort (9% versus 4.7% overall). HIV positive patients and transfers made up 15% and 19% of the sepsis cohort respectively. In the pediatric population, a positive ETAT emergency sign was poorly sensitive for sepsis (39.0%) as was pediatric Systemic Inflammatory Response Syndrome (pSIRS) criteria ≥2 (36.6%). There was only one pediatric sepsis death so mortality prediction was not assessed. In the adult population, both SIRS and qSOFA were poorly sensitive for sepsis (SIRS ≥ 2 55.3%, qSOFA≥2 32.5%) however a qSOFA score ≥1 had a sensitivity of 80.7%. A high qSOFA score was associated with an increased risk of death (qSOFA 2 RR 2.7, 95% CI, 1.3 to 5.7; p<0.01 and qSOFA 3 RR 5.8, 95% CI, 2.6 to 12.7; p<0.01). Only when all four SIRS criteria were present was it associated with an increased risk of death (RR 4.5, 95% CI, 1.4 to 14.9; p<0.01). There was no significant discriminatory ability between qSOFA or SIRS in predicting 30-day mortality; however, SOFA was superior to qSOFA or SIRS in predicting 90-day mortality (AUROC 0.68, 0.64, and 0.52 respectively, p <0.01). Likewise, a SOFA score of ≥2 was associated with an increased risk of death (RR 4.1, 95% CI 2.5-6.6; p<0.01). We observed a trend of under-diagnosis of patients with sepsis at this public hospital in Belize. Existing screening tools utilized in high-income countries (qSOFA and SIRS) as well as pediatric screening tools utilized in LMICs (ETAT) were poorly sensitive for sepsis. There was an increased risk of death with a high qSOFA or SIRS score; however, neither demonstrated significant discrimination for mortality. This demonstrates the need for the development of novel sepsis screening tools for LMIC settings to improve the diagnosis and treatment of sepsis.

Screening for sepsis: SIRS or qSOFA? A literature review.

In 2016, definitions of sepsis and septic shock were updated to focus on organ dysfunction rather than systemic inflammatory response as the identifying trait. This article aims to compare and evaluate the effectiveness of systemic inflammatory response syndrome (SIRS) and quick Sequential Organ Failure Assessment (qSOFA) in detecting sepsis in emergency department (ED) patients. A systematic search of the literature was undertaken using four databases. A total of 307 articles was identified. After the selection process, 13 articles met the inclusion criteria for the review. Five themes emerged from the meta-analysis: SIRS; qSOFA; timeliness and simplicity; sensitivity versus specificity; and adding lacate. SIRS offered users greater sensitivity when assessing for sepsis. However, qSOFA is a simple bedside tool with greater specificity, which does not require any blood test results. The author created a new qSOFA screening tool, which incorporated the use of point-of-care serum lactate measurement. He found that qSOFA outperforms SIRS as an ED sepsis screening tool with its strengths of efficacy, efficiency and ease. It was also found to differentiate better between uncomplicated infection and sepsis, which can commonly cause trigger fatigue in EDs.

Clinical Scores and Formal Triage for Screening of Sepsis and Adverse Outcomes on Arrival in an Emergency Department All-Comer Cohort.

Early recognition of sepsis remains a major challenge. The clinical utility of the Quick Sepsis-Related Organ Failure Assessment (qSOFA) score is still undefined. Several studies have tested its prognostic value. However, its ability to diagnose sepsis is still unknown. Our aim was to compare the performance of qSOFA, systemic inflammatory response syndrome (SIRS) criteria, National Early Warning Score (NEWS), and formal triage with the Emergency Severity Index (ESI) algorithm to identify patients with sepsis and predict adverse outcomes on arrival in an emergency department (ED) all-comer cohort. We included all patients presenting consecutively to the ED during a 3-week period. We used vital signs recorded at triage to calculate the study scores. Two independent assessors retrospectively assigned the primary outcome of sepsis according to Third International Consensus Definitions for Sepsis and Septic Shock criteria in a chart review process. There were 2523 cases included in the analysis and 39 (1.6%) had the primary outcome of sepsis. The area under the curve for sepsis was 0.79 (95% confidence interval [CI] 0.71-0.86) for qSOFA, 0.81 (95% CI 0.73-0.87) for SIRS, 0.85 (95% CI 0.77-0.92) for NEWS, and 0.77 (95% CI 0.70-0.83) for ESI. qSOFA offered high specificity for the prediction of sepsis and adverse outcomes. However, its low sensitivity does not support widespread use as a screening tool for sepsis. NEWS outperformed qSOFA for prediction of adverse outcomes and screening for sepsis.

Real World Patterns of Antimicrobial Use and Microbiology Investigations in Patients with Sepsis outside the Critical Care Unit: Secondary Analysis of Three Nation-Wide Point Prevalence Studies.

Recent description of the microbiology of sepsis on the wards or information on the real-life antibiotic choices used in sepsis is lacking. There is growing concern of the indiscriminate use of antibiotics and omission of microbiological investigations in the management of septic patients. We performed a secondary analysis of three annual 24-h point-prevalence studies on the general wards across all Welsh acute hospitals in years 2016–2018. Data were collected on patient demographics, as well as radiological, laboratory and microbiological data within 48-h of the study. We screened 19,453 patients over the three 24 h study periods and recruited 1252 patients who fulfilled the entry criteria. 775 (64.9%) patients were treated with intravenous antibiotics. Only in 33.65% (421/1252) of all recruited patients did healthcare providers obtain blood cultures; in 25.64% (321/1252) urine cultures; in 8.63% (108/1252) sputum cultures; in 6.79% (85/1252) wound cultures; in 15.25% (191/1252) other cultures. Out of the recruited patients, 59.1% (740/1252) fulfilled SEPSIS-3 criteria. Patients with SEPSIS-3 criteria were significantly more likely to receive antibiotics than the non-septic cohort (p < 0.0001). In a multivariable regression analysis increase in SOFA score, increased number of SIRS criteria and the use of the official sepsis screening tool were associated with antibiotic administration, however obtaining microbiology cultures was not. Our study shows that antibiotics prescription practice is not accompanied by microbiological investigations. A significant proportion of sepsis patients are still at risk of not receiving appropriate antibiotics treatment and microbiological investigations; this may be improved by a more thorough implementation of sepsis screening tools.

Prehospital Capture of Variables Commonly Used in ED Sepsis Screening Tools

Prehospital Capture of Variables Commonly Used in ED Sepsis Screening Tools

Using modified sepsis criteria to improve specificity of standardized triage screening for pediatric severe sepsis and septic shock

Background: Effective triage for patients with severe sepsis is critical first step for timely recognition and management. We implemented a standardized pediatric sepsis screening tool based on Goldstein SIRS criteria to streamline our ED triage process in 2013. Although the baseline cohort (N=259) had no patients missed, specificity of our screening tool was only 0.270 for severe sepsis. Implementation of this tool raised concerns for over triage, misappropriation of resources and alert fatigue. We set a goal to …

Diagnosis accuracy of quick sequential organ failure assessment score for adult sepsis patient with soft tissue infection

To assess the diagnosis accuracy of the quick sequential organ failure assessment (qSOFA) score for adult sepsis patient with soft tissue infection, and to assess the prognostic accuracy of the qSOFA score for septic shock. A retrospective study was conducted. The patients with soft tissue infection admitted to the general surgery department of Beijing Hospital and the burns and plastic surgery department of Fourth Medical Center of PLA General Hospital from January 2012 to December 2018 were enrolled. Patients were divided into the sepsis group and the non-sepsis group according to whether sepsis occurred within 48 hours after diagnosis of infection. The baseline data, prognosis, and qSOFA, the change of sequential organ failure assessment (ΔSOFA), systemic inflammatory response syndrome (SIRS) scores were compared between the two groups, and the receiver operating characteristic (ROC) curves were also drawn to assess the diagnosis accuracy of the qSOFA and SIRS scores for adult sepsis patients with soft tissue infection and to assess the prognostic accuracy of the qSOFA, ΔSOFA and SIRS scores for septic shock of these patients. 192 patients were included in the study. Sepsis occurred in 79 patients (41.1%) within 48 hours after diagnosis of infection. Septic shock occurred in 28 patients (14.6%) during 28-day hospitalization and 6 patients (3.1%) died. Compared with non-sepsis group, more proportion of necrotizing fasciitis, septic shock and patients received mechanical ventilation (21.5% vs. 4.4%, 31.6% vs. 2.7%, 16.5% vs. 4.4%, all P < 0.01), with higher mortality (7.6% vs. 0%, P = 0.003) in sepsis group. ROC curve analysis showed that when the cut-off value of qSOFA ≥ 2, the sensitivity, specificity, positive predictive value, negative predictive value and area under ROC curve (AUC) were 48.1%, 92.0%, 80.8%, 71.7% and 0.824 [95% confidence interval (95%CI) = 0.764-0.884, P < 0.01] respectively for diagnosis of sepsis caused by soft tissue infection. When the cut-off value of SIRS score ≥ 3, the sensitivity, specificity, positive predictive value, negative predictive value and AUC were 89.8%, 48.6%, 55.0%, 87.3% and 0.721 (95%CI = 0.677-0.765, P < 0.01) respectively for diagnosis of sepsis caused by soft tissue infection. All scores of qSOFA ≥ 2, ΔSOFA ≥ 2 and SIRS score ≥ 3 could be used to predict septic shock (all P < 0.01). The AUC of ΔSOFA, qSOFA and SIRS scores were 0.767 (95%CI = 0.665-0.869), 0.840 (95%CI = 0.757-0.923) and 0.716 (95%CI = 0.596-0.835) respectively. qSOFA ≥ 2 can be used as a rapid sepsis screening tool for adult patients with soft tissue infection. It is suggested that qSOFA or SIRS scores can be used to predict septic shock of adult patients with soft tissue infection initially.

Derivation and internal validation of the screening to enhance prehospital identification of sepsis (SEPSIS) score in adults on arrival at the emergency department

BackgroundPrehospital recognition of sepsis may inform case management by ambulance clinicians, as well as inform transport decisions. The objective of this study was to develop a prehospital sepsis screening tool for use by ambulance clinicians.MethodsWe derived and validated a sepsis screening tool, utilising univariable logistic regression models to identify predictors for inclusion, and multivariable logistic regression to generate the SEPSIS score. We utilised a retrospective cohort of adult patients transported by ambulance (n = 38483) to hospital between 01 July 2013 and 30 June 2014. Records were linked using LinkPlus® software. Successful linkage was achieved in 33289 cases (86%). Eligible patients included adult, non-trauma, non-mental health, non-cardiac arrest cases. Of 33289 linked cases, 22945 cases were eligible. Eligible cases were divided into derivation (n = 16063, 70%) and validation (n = 6882, 30%) cohorts. The primary outcome measure was high risk of severe illness or death from sepsis, as defined by the National Institute for Health and Care Excellence Sepsis guideline.Results‘High risk of severe illness or death from sepsis’ was present in 3.7% of derivation (n = 593) and validation (n = 254) cohorts. The SEPSIS score comprises the following variables: age, respiratory rate, peripheral oxygen saturations, heart rate, systolic blood pressure, temperature and level of consciousness (p < 0.001 for all variables). Area under the curve was 0.87 (95%CI 0.85–0.88) for the derivation cohort, and 0.86 (95%CI 0.84–0.88) for the validation cohort. In an undifferentiated adult medical population, for a SEPSIS score ≥ 5, sensitivity was 0.37 (0.31–0.44), specificity was 0.96 (0.96–0.97), positive predictive value was 0.27 (0.23–0.32), negative predictive value was 0.97 (0.96–0.97), positive likelihood value was 13.5 (9.7–18.73) and the negative likelihood value was 0.83 (0.78–0.88).ConclusionThis is the first screening tool developed to identify NICE high risk of severe illness or death from sepsis. The SEPSIS score is significantly associated with high risk of severe illness or death from sepsis on arrival at the Emergency Department. It may assist ambulance clinicians to identify those patients with sepsis in need of antibiotic therapy. However, it requires external validation, in clinical practice by ambulance clinicians, in an independent population.

SOFA and qSOFA at admission to the emergency department: Diagnostic sensitivity and relation with prognosis in patients with suspected infection

ObjectiveTo evaluate the adequacy of SOFA and qSOFA for predicting unfavorable outcomes, and of qSOFA as a screening tool for sepsis in patients admitted to the emergency department (ED) of a Brazilian public hospital. MethodsThis was a single-center retrospective study conducted on a cohort of patients admitted to a Brazilian public hospital between August 2016 and November 2017 due to suspected infection. Exclusion criteria were: age <18 years, admission to the ED after 24 h of hospitalization, lack of information in the medical records, advanced comorbidities, or request of limited invasive care. ResultsA total of 184 patients were included; 84.24% had a SOFA score of 2 or higher. The relative risk of death, need for intensive care unit (ICU) and mechanical ventilation (MV) related to a positive SOFA on admission were: 5.17 (2.11–12.87), 1.45 (1.09–2.15) and 2.74 (1.63–5.16), respectively; sensitivity was 93.7% for death, 88.5% for ICU need and 93.6% for undergoing MV. The mean length of hospital stay was 38.83 days for patients with a positive SOFA score and 8.95 days for patients with a negative score (p = 0.02). The median SOFA value was higher for the patients who died; 41% of the patients had a positive qSOFA and its sensitivity for a positive SOFA was 46.4%. The relative risk of death, ICU and MV need related to qSOFA at admission were 1.83 (1.39–2.44), 0.98 (0.82–1.16) and 1.60 (1.23–1.97), respectively, and its sensitivity was 56.8% for death, 41.4% for ICU need and 53.6% for MV. ConclusionqSOFA did not perform well as a screening tool for sepsis and for predicting a poor prognosis in the ED. SOFA, on the other hand, showed reasonable sensitivity for predicting unfavorable outcomes and scores ≥2 were related to a poor prognosis.