Clinical Review

Early Recognition: The Rate-Limiting Step to Quality Care for Severe Sepsis Patients in the Emergency Department

Journal of Clinical Outcomes Management. 2015 May;22(5)

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Operational processes to screen for sepsis in the ED will need to account for ED organizational flow (eg, average time from registration to triage, average time from triage to being seen by a physician, average length of stay in the ED, number of hospital beds) and hand-off practices (eg, care transition from ED team to floor or ICU team, or within ED at shift change). For ED organizations with shorter ED lengths of stay (eg, < 2 hours), screening practices at ED triage will serve as the focal point to identify cases of sepsis. Boarding, defined as caring for a patient in the ED pending transfer, is common, increasing as a result of ED closures [30,31], and associated with prolonged hospital length of stay and increased in-hospital mortality when ICU transfer is delayed [32]. Sepsis patients in particular appear to be a vulnerable group of patients. While many explanations exist to account for the relationship between delayed transfer and adverse outcomes, timely recognition and management of the septic patient could be compromised with prolonged boarding. To combat this potential effect, continual assessment during the entire ED stay may unmask an initially unclear presentation of sepsis.

One strategy to identify sepsis in ED organizations with prolonged ED lengths of stay is through the use of a track-and-trigger system, or early warning system. Traditionally, track-and-trigger systems were implemented on the hospital wards, as means to identify physiological deterioration in a timely manner to prevent clinical deterioration [33]. More recently, early warning systems have been used to identify patients with sepsis on the hospital wards and within EDs, as these systems rely on physiological parameters such as SIRS that are cardinal features of sepsis [34]. However, given the potential for alert fatigue, designing a system that operates with high accuracy is imperative.

Efforts are underway to redefine sepsis, using a simplified approach and readily available physiological variables, with the main goal of targeting those most at-risk of an adverse outcome during the hospitalization. Simultaneously, an understanding of the overt and more occult manifestations are essential to incorporate into the clinical decision-making and pattern recognition required to identify sepsis in a timely and accurate manner. In Table 2, the signs and symptoms that may serve as flags for severe sepsis are presented.

Mature early warning systems, designed to leverage the electronic medical record (EMR) by capturing vital signs, laboratory measures, (eg, elevated serum creatinine compared to a recent hospitalization) and symptoms (eg, altered mental status), are well-positioned to herald clinical deterioration (eg, cardiac arrest) with improved accuracy [35] and to be applied to sepsis specifically [34]. While sophisticated analytical strategies, such as machine learning, are being used to improve the test characteristics of these early warning systems, iterative, prospective chart review is an essential and complementary performance improvement step to refine the process. Further, chart review affords the opportunity to ensure compliance with sepsis care bundles.

Knowledge of the risk factors associated with development of sepsis is critical for the front-line emergency physician and nurse. Additionally, as many of these risk factors are associated with adverse outcomes, including unplanned ICU transfer and in-hospital mortality, which occur in as many as one out of 8 patients admitted directly to the ward, they have utility for early risk-stratification and triaging purposes in the ED. Advanced age and pre-existing comorbid conditions, particularly an oncologic diagnosis and/or chronic organ dysfunction, are major risk factors for sepsis and worse outcomes result in those who develop sepsis [2]. Further, illness severity, including an elevated serum lactate level, is associated with adverse outcomes. These factors can be incorporated into triage decisions and/or close monitoring for patients admitted to the general ward [36]. Conversely, because patients admitted to the ICU setting and subsequently stepped down through their hospitalization may experience better outcomes compared to patients admitted to the general ward who then require step-up to an ICU setting (37,38), attention to triage practices is critical.