Validation of sepsis screening tool using StO2 in emergency department patients

Sepsis Awareness to Enhance Early Identification of Sepsis in Emergency Departments

BACKGROUND

Early identification of sepsis continues to be a challenge for nurses in the acute care setting. Often, a gap exists between existing policies for sepsis identification and structured education to support these policies.

METHOD

Using quantitative methodology and descriptive correlational design, this project explored the differences between emergency department nurses who received education on the early identification and treatment of sepsis and emergency department nurses who did not receive this education.

RESULTS

Descriptive statistics and independent t test were used to analyze and compare data between the control and implementation group. The p value was .018, which was statistically significant. The mean time to identify sepsis was decreased by 33 minutes.

CONCLUSION

Using a sepsis standing order set combined with education helped to identify and elevate the care of sepsis patients. Resources such as the Surviving Sepsis Campaign screening tool to identify sepsis helped emergency department nurses to identify sepsis in a timely manner. [J Contin Educ Nurs. 2021;52(1):39-42.].

Near-infrared spectroscopy to predict organ failure and outcome in sepsis: the Assessing Risk in Sepsis using a Tissue Oxygen Saturation (ARISTOS) study

OBJECTIVES

Sepsis is acute organ dysfunction in the setting of infection. An accurate diagnosis is important to guide treatment and disposition. Tissue oxygen saturation (StO2) can be estimated noninvasively by near-infrared spectroscopy (NIRS), and may be an indicator of microcirculatory dysfunction in early sepsis. We aimed to determine the utility of StO2 for sepsis recognition and outcome prediction among patients presenting to the emergency department (ED) with infection.

PATIENTS AND METHODS

A multicentre, prospective, observational cohort study recruited patients who were being admitted to hospital with infection. StO2 was measured in the ED using a handheld NIRS device, Inspectra 300. Outcomes were sepsis, defined as an increase in sequential organ failure assessment score of at least 2 points within 72 h, and composite in-hospital mortality/ICU admission at least 3 days.

RESULTS

A cohort of 323 participants, median age 64 (interquartile range: 47-77) years, was recruited at three Australian hospitals. 143 (44%) fulfilled the criteria for sepsis and 22 (7%) died within 30 days. The mean ± SD StO2 was 74 ± 8% in sepsis and 78 ± 7% in nonsepsis (P < 0.0001). StO2 correlated with the peak sequential organ failure assessment score (Spearman's ρ -0.27, P  <  0.0001). Area under the receiver operating characteristic curve was 0.66 (95% confidence interval: 0.60-0.72) for sepsis and 0.66 (0.58-0.75) for the composite outcome. StO2 less than 75% had an odds ratio of 2.67 (1.45-4.94; P = 0.002), for the composite outcome compared with StO2 at least 75%.

CONCLUSION

NIRS-derived StO2 correlates with organ failure and is associated with outcome in sepsis. However, its ability to differentiate sepsis among ED patients with infection is limited. NIRS cannot be recommended for this purpose.

Sepsis now a priority: a quality improvement initiative for early sepsis recognition and care

Objective

To develop a triage-based screening algorithm and treatment order-sets aimed at improving the quality of care of all patients with sepsis presenting to our emergency department (ED).

Design

Retrospective cohort study conducted during a pre-intervention period from 1 April 2010 to 31 March 2011 and a post-intervention period from 1 September 2014 to 30 April 2015.

Setting

A large teaching hospital located in Toronto, Ontario, Canada with a 35-bed ED.

Participants

All patients meeting pre-specified sepsis criteria during the ED encounter.

Main Outcome Measures

Process of care measures included time to assessment by emergency physician, lactate measurement, blood culture collection, fluid and antibiotic administration. Intensive care unit (ICU) outcomes including admissions, length of stay (LOS) and deaths were reviewed.

Results

There were 346 patients pre-intervention, and 270 patients post-intervention. We significantly improved all process measures including mean time to antibiotics by 60 min (P = 0.003) and proportion of patients receiving fluid resuscitation (64.7% vs. 94.4%, P < 0.001). There was no significant difference in the number of patients admitted to ICU (P = 0.14). The median ICU LOS was shorter in the post-intervention group [2.0 days (interquartile range (IQR) 1.0-4.5 days) vs. 5.0 days (IQR 1.5-10.8 days), P = 0.04], and there was no difference in in-hospital mortality between groups (P = 0.27).

Conclusions

We have demonstrated that a triage-based sepsis screening tool results in expedited and consistent delivery of care, with a significant improvement in initial resuscitation measures.

Evaluation for occult sepsis incorporating NIRS and emergency sonography

PURPOSE

We aim to determine whether the combination of regional tissue oxygen saturation (StO₂) measurement using near-infrared spectroscopy (NIRS), inferior vena cava (IVC) collapsibility and ejection fraction (EF) is able to detect occult sepsis.

METHODS

We included adult patients in the emergency department with at least one of the following: fever; any one component of the quick sepsis-related organ function assessment (SOFA) score; heart rate≥100 beats per minute; or white cell count <4.0×10⁹/L or >12.0×10⁹/L. StO₂ parameters, IVC collapsibility and EF were assessed. Primary outcome was composite of admission to intensive care unit, hypotension requiring fluid resuscitation or vasopressor use, and antibiotic escalation.

RESULTS

We included 184 patients with mean age of 55.4years and slight male predominance (51.6%). Increase in temperature (adjusted odds ratio [aOR] 3.05; 95% confidence interval [CI] 1.16 to 8.02), higher white cell counts (aOR 1.10; 95% CI 1.03 to 1.19), increase in time taken to new StO₂ baseline (aOR 1.03; 95% CI 1.01 to 1.06) and reduced EF (aOR 33.9; 95% CI 2.19 to 523.64) had higher odds of achieving the primary outcome.

CONCLUSION

Change in StO₂ and time taken to reach new StO₂ baseline, combined with EF could potentially predict sepsis among patients with infection.

Sepsis Screening: Current Evidence and Available Tools

BACKGROUND

Early recognition of sepsis is challenging, especially in the surgical patient. Because of the non-specific nature of the initial signs and symptoms, delays in recognition are all too common. To improve the early identification of sepsis, screening tools have been developed, and several papers have described their results. This article reviews the available sepsis screening tools.

METHODS

A PubMed search was performed using the search terms "sepsis" and "shock," "electronic alert," "clinical decision support," and "early warning systems." The papers found were reviewed to determine their relevance to the topic of sepsis screening, and outcome data were extracted from appropriate papers.

RESULTS

Multiple sepsis screening tools were identified with differing performance characteristics. These tools are reviewed individually along with a summary of their sensitivity, specificity, and positive and negative predictive values.

CONCLUSIONS

Clearly, sepsis screening has the potential to improve patient outcomes by aiding clinicians in the early recognition of the condition, enabling early implementation of evidence-based therapies. However, significant challenges remain, including identifying an optimal screening tool. Continued research is needed into the development and integration of automated screening tools that will be effective in a variety of clinical settings.

Correlations between pulmonary artery pressures and inferior vena cava collapsibility in critically ill surgical patients: An exploratory study

INTRODUCTION

As pulmonary artery catheter (PAC) use declines, search continues for reliable and readily accessible minimally invasive hemodynamic monitoring alternatives. Although the correlation between inferior vena cava collapsibility index (IVC-CI) and central venous pressures (CVP) has been described previously, little information exists regarding the relationship between IVC-CI and pulmonary artery pressures (PAPs). The goal of this study is to bridge this important knowledge gap. We hypothesized that there would be an inverse correlation between IVC-CI and PAPs.

METHODS

A post hoc analysis of prospectively collected hemodynamic data was performed, examining correlations between IVC-CI and PAPs in a convenience sample of adult Surgical Intensive Care Unit patients. Concurrent measurements of IVC-CI and pulmonary arterial systolic (PAS), pulmonary arterial diastolic (PAD), and pulmonary arterial mean (PAM) pressures were performed. IVC-CI was calculated as ([IVCmax - IVCmin]/IVCmax) × 100%. Vena cava measurements were obtained by ultrasound-credentialed providers. For the purpose of correlative analysis, PAP measurements (PAS, PAD, and PAM) were grouped by terciles while the IVC-CI spectrum was divided into thirds (<33, 33-65, ≥66).

RESULTS

Data from 34 patients (12 women, 22 men, with median age of 59.5 years) were analyzed. Median Acute Physiologic Assessment and Chronic Health Evaluation II score was 9. A total of 76 measurement pairs were recorded, with 57% (43/76) obtained in mechanically ventilated patients. Correlations between IVC-CI and PAS (rs = -0.334), PAD (rs = -0.305), and PAM (rs = -0.329) were poor. Correlations were higher between CVP and PAS (R2 = 0.61), PAD (R2 = 0.68), and PAM (R2 = 0.70). High IVC-CI values (≥66%) consistently correlated with measurements in the lowest PAP ranges. Across all PAP groups (PAS, PAD, and PAM), there were no differences between the mean measurement values for the lower and middle IVC-CI ranges (0%-65%). However, all three groups had significantly lower mean measurement values for the ≥66% IVC-CI group.

CONCLUSIONS

Low PAS, PAD, and PAM measurements show a reasonable correlation with high IVC-CI (≥66%). These findings are consistent with previous descriptions of the relationship between IVC-CI and CVP. Additional research in this area is warranted to better describe the hemodynamic relationship between IVC-CI and PAPs, with the goal of further reduction in the reliance on the use of PACs.

AME evidence series 001-The Society for Translational Medicine: clinical practice guidelines for diagnosis and early identification of sepsis in the hospital

Sepsis is a heterogeneous disease caused by an infection stimulus that triggers several complex local and systemic immuno-inflammatory reactions, which results in multiple organ dysfunction and significant morbidity and mortality. The diagnosis of sepsis is challenging because there is no gold standard for diagnosis. As a result, the clinical diagnosis of sepsis is ever changing to meet the clinical and research requirements. Moreover, although there are many novel biomarkers and screening tools for predicting the risk of sepsis, the diagnostic performance and effectiveness of these measures are less than satisfactory, and there is insufficient evidence to recommend clinical use of these new techniques. As a consequence, diagnostic criteria for sepsis need regular revision to cope with emerging evidence. This review aims to present the most updated information on diagnosis and early recognition of sepsis. Recommendations for clinical use of different diagnostic tools rely on the Grades of Recommendation Assessment, Development and Evaluation (GRADE) framework. Because most of the studies were observational and did not allow a reliable assessment of these tools, a two-step inference approach was employed. Future trials need to confirm or refute a particular index test and should directly explore relevant patient outcome parameters.

Longer time to antibiotics and higher mortality among septic patients with non-specific presentations--a cross sectional study of Emergency Department patients indicating that a screening tool may improve identification

Background

The presentation of sepsis is varied and our hypotheses were that septic patients with non-specific presentations such as decreased general condition (DGC) have a less favourable outcome, and that a screening tool could increase identification of these patients. We aimed to: 1) assess time to antibiotics and in-hospital mortality among septic patients with ED chief complaint DGC, as compared with septic patients with other ED chief complaints, and 2) determine whether a screening tool could improve identification of septic patients with non-specific presentations such as DGC.

Methods

Cross sectional study comparing time to antibiotics (Mann Whitney and Kaplan-Meier tests), and in-hospital mortality (logistic regression), between 61 septic patients with ED chief complaint DGC and 516 septic patients with other ED chief complaints. The sensitivity and specificity of the modified Robson screening tool was compared with that of ED doctor clinical judgment (McNemar’s two related samples test) among 122 patients presenting to the ED with chief complaint DGC, of which 61 were discharged with ICD code sepsis.

Results

Septic patients presenting to the ED with the chief complaint DGC had a longer median time to antibiotics (05:26 h:minutes; IQR 4:00–10:40, vs. 03:56 h:minutes; IQR 2:21–7:32) and an increased in-hospital mortality (crude OR = 4.01; 95 % CI, 2.19–7.32), compared to septic patients with other ED chief complaints. This association remained significant when adjusting for sex, age, priority, comorbidity and fulfilment of the Robson score (OR 4.31; 95 % CI, 2.12–8.77). The modified Robson screening tool had a higher sensitivity (63.0 vs. 24.6 %, p < 0.001), but a lower specificity (68.3 vs. 100.0 %, p < 0.001), as compared to clinical judgment.

Discussion

This is, to the best of our knowledge, the first study comparing outcome of septic patients according to ED chief complaint. Septic patients presenting with a non-specific ED presentation, here exemplified as the chief complaint DGC, have a less favourable outcome. Our results indicate that implementation of a screening tool may increase the identification of septic patients.

Conclusions

The results indicate that septic patients presenting with ED chief complaint DGC constitute a vulnerable patient group with delayed time to antibiotics and high in-hospital mortality. Furthermore, the results support that implementation of a screening tool may be beneficial to improve identification of these patients.