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Biebelberg B, Kehoe IE, Zheng H, O'Connell A, Filbin MR, Heldt T, Reisner AT. Atypical symptoms in emergency department patients with urosepsis challenge current urinary tract infection management guidelines. Acad Emerg Med 2024. [PMID: 38661262 DOI: 10.1111/acem.14914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Brett Biebelberg
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Iain E Kehoe
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hui Zheng
- Massachusetts General Hospital Biostatistics Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Abigail O'Connell
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thomas Heldt
- Institute for Medical Engineering and Science and Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Andrew T Reisner
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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2
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Prasad V, Aydemir B, Kehoe IE, Kotturesh C, O’Connell A, Biebelberg B, Wang Y, Lynch JC, Pepino JA, Filbin MR, Heldt T, Reisner AT. Diagnostic suspicion bias and machine learning: Breaking the awareness deadlock for sepsis detection. PLOS DIGITAL HEALTH 2023; 2:e0000365. [PMID: 37910497 PMCID: PMC10619833 DOI: 10.1371/journal.pdig.0000365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 09/11/2023] [Indexed: 11/03/2023]
Abstract
Many early warning algorithms are downstream of clinical evaluation and diagnostic testing, which means that they may not be useful when clinicians fail to suspect illness and fail to order appropriate tests. Depending on how such algorithms handle missing data, they could even indicate "low risk" simply because the testing data were never ordered. We considered predictive methodologies to identify sepsis at triage, before diagnostic tests are ordered, in a busy Emergency Department (ED). One algorithm used "bland clinical data" (data available at triage for nearly every patient). The second algorithm added three yes/no questions to be answered after the triage interview. Retrospectively, we studied adult patients from a single ED between 2014-16, separated into training (70%) and testing (30%) cohorts, and a final validation cohort of patients from four EDs between 2016-2018. Sepsis was defined per the Rhee criteria. Investigational predictors were demographics and triage vital signs (downloaded from the hospital EMR); past medical history; and the auxiliary queries (answered by chart reviewers who were blinded to all data except the triage note and initial HPI). We developed L2-regularized logistic regression models using a greedy forward feature selection. There were 1164, 499, and 784 patients in the training, testing, and validation cohorts, respectively. The bland clinical data model yielded ROC AUC's 0.78 (0.76-0.81) and 0.77 (0.73-0.81), for training and testing, respectively, and ranged from 0.74-0.79 in four hospital validation. The second model which included auxiliary queries yielded 0.84 (0.82-0.87) and 0.83 (0.79-0.86), and ranged from 0.78-0.83 in four hospital validation. The first algorithm did not require clinician input but yielded middling performance. The second showed a trend towards superior performance, though required additional user effort. These methods are alternatives to predictive algorithms downstream of clinical evaluation and diagnostic testing. For hospital early warning algorithms, consideration should be given to bias and usability of various methods.
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Affiliation(s)
- Varesh Prasad
- Harvard-MIT Program in Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
| | - Baturay Aydemir
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Iain E. Kehoe
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Chaya Kotturesh
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Abigail O’Connell
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Brett Biebelberg
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Yang Wang
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - James C. Lynch
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
| | - Jeremy A. Pepino
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Michael R. Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Thomas Heldt
- Harvard-MIT Program in Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
| | - Andrew T. Reisner
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Barry L, Tighe SM, Griffin A, Ryan D, O'Connor M, Fitzgerald C, Egan S, Galvin R, Meskell P. A qualitative evidence synthesis (QES) exploring the barriers and facilitators to screening in emergency departments using the theoretical domains framework. BMC Health Serv Res 2023; 23:1090. [PMID: 37821877 PMCID: PMC10568862 DOI: 10.1186/s12913-023-10027-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/12/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Validated screening tools can be utilised to detect early disease processes and risk factors for disease and adverse outcomes. Consequently, identifying individuals in need of early intervention and targeted assessment can be achieved through the implementation of screening in the ED. Successful implementation can be impacted by a lack of resources and ineffective integration of screening into the clinical workflow. Tailored implementation processes and staff training, which are contextually specific to the ED setting, are facilitators to effective implementation. This review will assist in the identification of barriers and facilitators to screening in the ED using a QES to underpin implementation processes. Healthcare workers engage in screening in the ED routinely. Consequently, this review focused on synthesizing the experience of healthcare workers (HCWs) who are involved in this process. This synthesis is informed by a QES protocol published by the lead author in 2021 (Barry et al., HRB Open Res 3:50, 2021). METHODOLOGY A comprehensive literature search, inclusive of grey literature sources, was undertaken. Initially, an a priori framework of themes was formed to facilitate the interpretation and organisation of search results. A context specific conceptual model was then formulated using "Best fit" framework synthesis which further assisted in the interpretation of data that was extracted from relevant studies. Dual blind screening of search results was undertaken using RAYYAN as a platform. Thirty studies were identified that met the inclusion criteria. Dual appraisal of full text articles was undertaken using CASP, GRADE CERQual assessed confidence of findings and data extraction was performed by two reviewers collaboratively. FINDINGS This is the first known synthesis of qualitative research on HCW's experiences of screening in the ED. Predominantly, the findings illustrate that staff experience screening in the ED as a complex challenging process. The barriers and facilitators identified can be broadly categorised under preconditions to screen, motivations to screen and knowledge and skills to screen. Competing interests in the ED, environmental stressors such as overcrowding and an organisational culture that resists screening were clear barriers. Adequate resources and tailored education to underpin the screening process were clear facilitators. TRIAL REGISTRATION PROSPERO: CRD42020188712 05/07/20.
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Affiliation(s)
- Louise Barry
- Department of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Castletroy, Limerick, Ireland.
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland.
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Castletroy, Limerick, Ireland.
| | - Sylvia Murphy Tighe
- Department of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Castletroy, Limerick, Ireland
| | - Anne Griffin
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Castletroy, Limerick, Ireland
| | - Damien Ryan
- Emergency Department, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Margaret O'Connor
- Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Christine Fitzgerald
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Castletroy, Limerick, Ireland
| | - Siobhan Egan
- Clinical Research Support Unit, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Rose Galvin
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Castletroy, Limerick, Ireland
| | - Pauline Meskell
- Department of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Castletroy, Limerick, Ireland
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
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Hansen M, Gillespie J, Riddick T, Samatham R, Baker S, Filer S, Xin H, Sheridan D. Evaluation of electronic measurement of capillary refill for Sepsis screening at ED triage. Am J Emerg Med 2023; 70:61-65. [PMID: 37201452 DOI: 10.1016/j.ajem.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/03/2023] [Accepted: 05/08/2023] [Indexed: 05/20/2023] Open
Abstract
OBJECTIVE To evaluate the association between capillary refill time (CRT) measured by a medical device and sepsis among patients presenting to the Emergency Department (ED). METHODS This prospective observational study enrolled adult and pediatric patients during ED triage when sepsis was considered a potential diagnosis by the triage nurse. Patients were enrolled at an academic medical center between December 2020 and June 2022. CRT was measured by a research assistant using an investigational medical device. The outcomes included sepsis and septic shock defined using sep-3 criteria, septic shock defined as IV antibiotics and a vasopressor requirement, ICU admission, and hospital mortality. Other measures included patient demographics and vital signs at ED triage. We evaluated univariate associations between CRT and sepsis outcomes. RESULTS We enrolled 563 patients in the study, 48 met Sep-3 criteria, 5 met Sep-3 shock criteria, and 11 met prior septic shock criteria (IV antibiotics and vasopressors to maintain mean arterial pressure of 65). Sixteen patients were admitted to the ICU. The mean age was 49.1 years, and 51% of the cohort was female. The device measured CRT was significantly associated with the diagnosis of sepsis by sep-3 criteria (OR 1.23, 95% CI 1.06-1-43), septic shock by sep-3 criteria (OR 1.57, 95% CI 1.02-2.40), and septic shock defined as receipt of IV antibiotics and a vasopressor requirement (OR 1.37, 95% CI 1.03-1.82). Patients with CRT >3.5 s measured by the DCR device had an odds ratio of 4.67 (95%CI 1.31-16.1) of septic shock (prior definition), and an odds ratio of 3.97 (95% CI 1.99-7.92) of ICU admission, supporting the potential for the 3.5-s cutoff of the DCR measurement. CONCLUSIONS CRT measured by a medical device at ED triage was associated with the diagnosis of sepsis. Objective CRT measurement using a medical device may be a relatively simple way to improve sepsis diagnosis during ED triage.
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Affiliation(s)
- Matthew Hansen
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland, OR, United States of America; School of Medicine, Oregon Health & Science University, Portland, OR, United States of America; Promedix Inc, Portland, OR.
| | - Jordan Gillespie
- School of Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Tyne Riddick
- School of Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Ravi Samatham
- Department of Dermatology, Oregon Health & Science University, Portland, OR, United States of America
| | | | | | - Haichang Xin
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - David Sheridan
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland, OR, United States of America; School of Medicine, Oregon Health & Science University, Portland, OR, United States of America; Promedix Inc, Portland, OR
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Moorthy GS, Pung JS, Subramanian N, Theiling BJ, Sterrett EC. Causal Association of Physician-in-Triage with Improved Pediatric Sepsis Care: A Single-Center, Emergency Department Experience. Pediatr Qual Saf 2023; 8:e651. [PMID: 37250616 PMCID: PMC10219727 DOI: 10.1097/pq9.0000000000000651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 04/04/2023] [Indexed: 05/31/2023] Open
Abstract
Approximately 75,000 children are hospitalized for sepsis yearly in the United States, with 5%-20% mortality estimates. Outcomes are closely related to the timeliness of sepsis recognition and antibiotic administration. Methods A multidisciplinary sepsis task force formed in the Spring of 2020 aimed to assess and improve pediatric sepsis care in the pediatric emergency department (ED). The electronic medical record identified pediatric sepsis patients from September 2015 to July 2021. Data for time to sepsis recognition and antibiotic delivery were analyzed using statistical process control charts (X̄-S charts). We identified special cause variation, and Bradford-Hill Criteria guided multidisciplinary discussions to identify the most probable cause. Results In the fall of 2018, the average time from ED arrival to blood culture orders decreased by 1.1 hours, and the time from arrival to antibiotic administration decreased by 1.5 hours. After qualitative review, the task force hypothesized that initiation of attending-level pediatric physician-in-triage (P-PIT) as a part of ED triage was temporally associated with the observed improved sepsis care. P-PIT reduced the average time to the first provider exam by 14 minutes and introduced a process for physician evaluation before ED room assignment. Conclusions Timely assessment by an attending-level physician improves time to sepsis recognition and antibiotic delivery in children who present to the ED with sepsis. Implementing a P-PIT program with early attending-level physician evaluation is a potential strategy for other institutions.
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Affiliation(s)
- Ganga S. Moorthy
- From the Division of Pediatric Infectious Diseases, Department of Pediatrics, Duke University Medical Center; Durham, North Carolina
| | - Jordan S. Pung
- Division of Pediatric Critical Care, Department of Pediatrics, Duke University Medical Center; Durham, North Carolina
| | - Neel Subramanian
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Duke University Medical Center; Durham, North Carolina
| | - B. Jason Theiling
- Department of Emergency Medicine, Duke University Medical Center; Durham, North Carolina
| | - Emily C. Sterrett
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Duke University Medical Center; Durham, North Carolina
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Jouffroy R, Parfait PA, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye PN. Relationship between prehospital modified Charlson Comorbidity Index and septic shock 30-day mortality. Am J Emerg Med 2022; 60:128-133. [DOI: 10.1016/j.ajem.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/31/2022] [Accepted: 08/02/2022] [Indexed: 10/15/2022] Open
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Malhotra C, Kumar A, Sahu AK, Ramaswami A, Bhoi S, Aggarwal P, Lodha R, Kapil A, Vaid S, Joshi N. Strengthening sepsis care at a tertiary care teaching hospital in New Delhi, India. BMJ Open Qual 2021; 10:bmjoq-2020-001335. [PMID: 34344745 PMCID: PMC8336124 DOI: 10.1136/bmjoq-2020-001335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 05/16/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Failure of early identification of sepsis in the emergency department (ED) leads to significant delays in antibiotic administration which adversely affects patient outcomes. Aim The primary objective of our Quality Improvement (QI) project was to reduce the door-to-antibiotic time (DTAT) by 30% from the preintervention in patients with suspected sepsis. Secondary objectives were to increase the blood culture collection rate by 30% from preintervention, investigate the predictors of improving DTAT and study the effect of these interventions on 24-hour in-hospital mortality. Methods This QI project was conducted in the ED of a tertiary care teaching hospital of North India; the ED receives approximately 400 patients per day. Adult patients with suspected sepsis presenting to our ED were included in the study, between January 2019 and December 2020. The study was divided into three phases; preintervention phase (100 patients), intervention phase (100 patients) and postintervention phase (93 patients). DTAT and blood cultures prior to antibiotic administration was recorded for all patients. Blood culture yield and 24-hour in-hospital mortality were also recorded using standard data templates. Change ideas planned by the Sepsis QI Team were implemented after conducting plan-do-study-act cycles. Results The median DTAT reduced from 155 min in preintervention phase to 78 min in postintervention phase. Drawing of blood cultures prior to antibiotic administration improved by 67%. Application of novel screening tool at triage was found to be an independent predictor of reduced DTAT. Conclusion Our QI project identified the existing lacunae in implementation of the sepsis bundle which were dealt with in a stepwise manner. The sepsis screening tool and on-site training improved care of patients with sepsis. A similar approach can be used to deal with complex quality issues in other high-volume low-resource settings.
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Affiliation(s)
- Charu Malhotra
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Akshay Kumar
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ankit Kumar Sahu
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Akshaya Ramaswami
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Bhoi
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Praveen Aggarwal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Aarti Kapil
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Nitesh Joshi
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
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Perman SM, Mikkelsen ME, Goyal M, Ginde A, Bhardwaj A, Drumheller B, Sante SC, Agarwal AK, Gaieski DF. The sensitivity of qSOFA calculated at triage and during emergency department treatment to rapidly identify sepsis patients. Sci Rep 2020; 10:20395. [PMID: 33230117 PMCID: PMC7683594 DOI: 10.1038/s41598-020-77438-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 11/11/2020] [Indexed: 12/12/2022] Open
Abstract
The quick sequential organ failure assessment (qSOFA) score has been proposed as a means to rapidly identify adult patients with suspected infection, in pre-hospital, Emergency Department (ED), or general hospital ward locations, who are in a high-risk category with increased likelihood of "poor outcomes:" a greater than 10% chance of dying or an increased likelihood of spending 3 or more days in the ICU. This score is intended to replace the use of systemic inflammatory response syndrome (SIRS) criteria as a screening tool; however, its role in ED screening and identification has yet to be fully elucidated. In this retrospective observational study, we explored the performance of triage qSOFA (tqSOFA), maximum qSOFA, and first initial serum lactate (> 3 mmol/L) at predicting in-hospital mortality and compared these results to those for the initial SIRS criteria obtained in triage. A total of 2859 sepsis cases were included and the in-hospital mortality rate was 14.4%. The sensitivity of tqSOFA ≥ 2 and maximum qSOFA ≥ 2 to predict in-hospital mortality were 33% and 69%, respectively. For comparison, the triage SIRS criteria and the initial lactate > 3 mmol/L had sensitivities of 82% and 65%, respectively. These results demonstrate that in a large ED sepsis database the earliest measurement of end organ impairment, tqSOFA, performed poorly at identifying patients at increased risk of mortality and maximum qSOFA did not significantly outperform initial serum lactate levels.
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Affiliation(s)
- Sarah M Perman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, USA
| | - Mark E Mikkelsen
- Division of Pulmonary and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Munish Goyal
- Departments of Emergency and Critical Care Medicine, MedSTAR Washington Hospital Centre, Washington, USA
| | - Adit Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, USA
| | - Abhishek Bhardwaj
- Division of Critical Care Medicine, Cleveland Clinic Department of Internal Medicine, Cleveland, USA
| | - Byron Drumheller
- Department of Emergency Medicine, Albert Einstein Medical Center, Philadelphia, USA
| | - S Cham Sante
- Department of Emergency Medicine, University of New Mexico School of Medicine, Philadelphia, USA
| | - Anish K Agarwal
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - David F Gaieski
- Department of Emergency Medicine, Vice Chair for Resuscitation Services, Director of Emergency Critical Care, Enterprise Physician Lead for Sepsis Care, Sidney Kimmel Medical College at Thomas Jefferson University, 1025 Walnut Street; 300 College Building, Philadelphia, PA, 19107, USA.
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Spoto S, Nobile E, Carnà EPR, Fogolari M, Caputo D, De Florio L, Valeriani E, Benvenuto D, Costantino S, Ciccozzi M, Angeletti S. Best diagnostic accuracy of sepsis combining SIRS criteria or qSOFA score with Procalcitonin and Mid-Regional pro-Adrenomedullin outside ICU. Sci Rep 2020; 10:16605. [PMID: 33024218 PMCID: PMC7538435 DOI: 10.1038/s41598-020-73676-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 09/03/2020] [Indexed: 12/17/2022] Open
Abstract
Early diagnosis and treatment significantly reduce sepsis mortality. Currently, no gold standard has been yet established to diagnose sepsis outside the ICU. The aim of the study was to evaluate the diagnostic accuracy of sepsis defined by SIRS Criteria of 1991, Second Consensus Conference Criteria of 2001, modified Second Consensus Conference Criteria of 2001 (obtaining SIRS Criteria and SOFA score), Third Consensus Conference of 2016, in addition to the dosage of Procalcitonin (PCT) and MR-pro-Adrenomedullin (MR-proADM). In this prospective study, 209 consecutive patients with clinical diagnosis of sepsis were enrolled (May 2014-June 2018) outside intensive care unit (ICU) setting. A diagnostic protocol could include SIRS criteria or qSOFA score evaluation, rapid testing of PCT and MR-proADM, and SOFA score calculation for organ failure definition. Using this approach outside the ICU, a rapid diagnostic and prognostic evaluation could be achieved, also in the case of negative SIRS, qSOFA or SOFA scores with high post-test probability to reduce mortality and improve outcomes.
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Affiliation(s)
- Silvia Spoto
- Diagnostic and Therapeutic Medicine Department, University Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy.
| | - Edoardo Nobile
- Diagnostic and Therapeutic Medicine Department, University Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Emanuele Paolo Rafano Carnà
- Diagnostic and Therapeutic Medicine Department, University Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Marta Fogolari
- Unit of Clinical Laboratory Science, University Campus Bio-Medico, Rome, Italy
| | - Damiano Caputo
- Department of Surgery, University Campus Bio-Medico, Rome, Italy
| | - Lucia De Florio
- Unit of Clinical Laboratory Science, University Campus Bio-Medico, Rome, Italy
| | - Emanuele Valeriani
- Diagnostic and Therapeutic Medicine Department, University Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Domenico Benvenuto
- Unit of Medical Statistics and Molecular Epidemiology, University Campus Bio-Medico, Rome, Italy
| | - Sebastiano Costantino
- Diagnostic and Therapeutic Medicine Department, University Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Massimo Ciccozzi
- Unit of Medical Statistics and Molecular Epidemiology, University Campus Bio-Medico, Rome, Italy
| | - Silvia Angeletti
- Unit of Clinical Laboratory Science, University Campus Bio-Medico, Rome, Italy
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Belsky JB, Filbin MR, Rivers EP, Bobbitt KR, Jaehne AK, Wisnik CA, Maciejewski KR, Li F, Morris DC. F-Actin is associated with a worsening qSOFA score and intensive care unit admission in emergency department patients at risk for sepsis. Biomarkers 2020; 25:391-396. [PMID: 32421363 DOI: 10.1080/1354750x.2020.1771419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Objective: We previously demonstrated that plasma levels of F-actin and Thymosin Beta 4 differs among patients with septic shock, non-infectious systemic inflammatory syndrome and healthy controls and may serve as biomarkers for the diagnosis of sepsis. The current study aims to determine if these proteins are associated with or predictive of illness severity in patients at risk for sepsis in the Emergency Department (ED).Methods: Prospective, biomarker study enrolling patients (>18 years) who met the Shock Precautions on Triage Sepsis rule placing them at-risk for sepsis.Results: In this study of 203 ED patients, F-actin plasma levels had a linear trend of increase when the quick Sequential Organ Failure Assessment (qSOFA) score increased. F-actin was also increased in patients who were admitted to the Intensive Care Unit (ICU) from the ED, and in those with positive urine cultures. Thymosin Beta 4 was not associated with or predictive of any significant outcome measures.Conclusion: Increased levels of plasma F-actin measured in the ED were associated with incremental illness severity as measured by the qSOFA score and need for ICU admission. F-actin may have utility in risk stratification of undifferentiated patients in the ED presenting with signs and symptoms of sepsis.
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Affiliation(s)
- Justin B Belsky
- Department of Emergency Medicine, Yale University, New Haven, CT, USA
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Emanuel P Rivers
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI, USA
| | - Kevin R Bobbitt
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI, USA
| | - Anja K Jaehne
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI, USA
| | - Christopher A Wisnik
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kaitlin R Maciejewski
- School of Public Health, Yale Center for Analytical Sciences, Yale University, New Haven, CT, USA
| | - Fangyong Li
- School of Public Health, Yale Center for Analytical Sciences, Yale University, New Haven, CT, USA
| | - Daniel C Morris
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI, USA
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Loritz M, Busch HJ, Helbing T, Fink K. Prospective evaluation of the quickSOFA score as a screening for sepsis in the emergency department. Intern Emerg Med 2020; 15:685-693. [PMID: 32036543 DOI: 10.1007/s11739-019-02258-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 12/09/2019] [Indexed: 12/29/2022]
Abstract
In 2016, the new bedside tool quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) was presented to identify patients at high risk of developing sepsis or adverse outcome. The aim of this study was to investigate the diagnostic performance of the qSOFA scoring system as a screening in patients presenting at an emergency department (ED) of any cause. Therefore, we compared qSOFA with the systemic inflammatory response syndrome (SIRS) criteria and two modifications of qSOFA score. This is a prospective single-center study including patients presenting to the ED of any non-traumatic cause. Primary outcome was development of sepsis within 48 h, secondary outcomes were 30-day mortality and ICU stay for > 3 days. Data were collected within one hour after arrival to indicate an impression of initial medical contact. Among 1,668 patients, 105 sepsis cases were identified. 8.4% presented with qSOFA ≥ 2, 27.2% with SIRS ≥ 2 within one hour. Sensitivity of qSOFA in predicting sepsis was lower compared to the SIRS criteria. qSOFA showed better prognostic accuracy for 30-day mortality compared to SIRS (p < 0.05), but not for prolonged ICU stay (p = 0.56). Modification of qSOFA in replacing GCS by other scoring systems recording altered mental status did not improve its sensitivity. The qSOFA score has poor sensitivity to identify patients at risk of developing sepsis and can therefore not be considered as an adequate screening for sepsis in patients presenting to the ED. Furthermore, a positive qSOFA at arrival at the ED showed no sufficient reliability in detecting patients with adverse clinical course.
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Affiliation(s)
- Monika Loritz
- Department of Emergency Medicine, Medical Center, University Hospital of Freiburg, Faculty of Medicine, University of Freiburg, Sir-Hans-A.-Krebs-Str., 79106, Freiburg im Breisgau, Germany
| | - Hans-Jörg Busch
- Department of Emergency Medicine, Medical Center, University Hospital of Freiburg, Faculty of Medicine, University of Freiburg, Sir-Hans-A.-Krebs-Str., 79106, Freiburg im Breisgau, Germany
| | - Thomas Helbing
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg im Breisgau, Germany
| | - Katrin Fink
- Department of Emergency Medicine, Medical Center, University Hospital of Freiburg, Faculty of Medicine, University of Freiburg, Sir-Hans-A.-Krebs-Str., 79106, Freiburg im Breisgau, Germany.
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Jouffroy R, Tourtier JP, Philippe P, Bloch-Laine E, Bounes V, Gueye-Ngalgou P, Vivien B. Prehospital Shock Precautions on Triage (PSPoT) score to assess in-hospital mortality for septic shock. Am J Emerg Med 2020; 44:230-234. [PMID: 32591305 DOI: 10.1016/j.ajem.2020.03.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/15/2020] [Accepted: 03/21/2020] [Indexed: 10/24/2022] Open
Abstract
CONTEXT In the prehospital setting, early identification of septic shock (SS) with high risk of poor outcome is a daily issue. There is a need for a simple tool aiming to early assess outcome in order to decide delivery unit (emergency department (ED) or intensive care unit (ICU)). In France, prehospital emergencies are managed by the Service d'Aide Médicale d'Urgence (SAMU). The SAMU physician decides the destination ward either to the ICU or to the ED after on scene severity assessment. We report the association between The Prehospital Shock Precautions on Triage (PSPoT) score, and in-hospital mortality of SS patients initially cared for in the prehospital setting by a mobile ICU (MICU). METHODS SS patients cared for by MICU were prospectively included between February 2017 and July 2019. The PSPoT score was established by adding shock index>1 and criterion based on past medical history: age >65 years and at least 1 previous comorbidity (chronic cardiac failure, chronic renal failure, chronic obstructive pulmonary disease, previous or actual history of cancer, institutionalization, hospitalisation within previous 3 months. A threshold of ≥2, was arbitrarily chosen for clinical relevance and usefulness in clinical practice. RESULTS One-hundred and sixty-nine with a median age of 72 [20-93] years were analysed. SS origin was mainly pulmonary (54%), abdominal (19%) and urinary (15%). The median PSPoT score was 2 [1-2]. PSPoT score and PSPoT score ≥ 2 were associated with in-hospital mortality: OR = 1.24 [0.77-2.05] and OR = 2.19 [1.09-4.59] respectively. CONCLUSION We report an association between PSPoT score, and in-hospital mortality of SS patients cared for by a MICU. A PSPoT score ≥ 2 early identifies poorer outcome.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Anesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; Department of Anesthesia, Clinical Epidemiology and Biostatistics, Michael De Groote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Perioperative Medicine and Surgical Research Unit, Hamilton, Ontario, Canada; Fire Brigade of Paris, Paris, France.
| | | | - Pascal Philippe
- Intensive Care Unit, Anesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Emmanuel Bloch-Laine
- Emergency department, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | - Papa Gueye-Ngalgou
- SAMU 972 CHU de Martinique Pierre Zobda -Quitman Hospital, 97261 Fort-de-France Martinique, France
| | - Benoit Vivien
- Intensive Care Unit, Anesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
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Kemp K, Mertanen R, Lääperi M, Niemi-Murola L, Lehtonen L, Castren M. Nonspecific complaints in the emergency department - a systematic review. Scand J Trauma Resusc Emerg Med 2020; 28:6. [PMID: 31992333 PMCID: PMC6986144 DOI: 10.1186/s13049-020-0699-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nonspecific complaint (NSC) is a common presenting complaint in the emergency setting, especially in the elderly population. Individual studies have shown that it is associated with significant morbidity and mortality. This prognostic systematic review draws a synthesis of reported outcomes for patients presenting with NSC and compares them with outcomes for patients presenting with a specific complaint. METHODS We conducted a literature search for publications, abstracts and conference presentations from Ovid, Scopus and Web of Science for the past 20 years. Studies were included which treated adult patients presenting to the Emergency Medical Services or Emergency Department with NSC. 2599 studies were screened for eligibility and quality was assessed using the SIGN assessment for bias tool. We excluded any low-quality studies, resulting in nine studies for quantitative analysis. We analysed the included studies for in-hospital mortality, triage category, emergency department length of stay, admission rate, hospital length of stay, intensive care admissions and re-visitation rate and compared outcomes to patients presenting with specific complaints (SC), where data were available. We grouped discharge diagnoses by ICD-10 category. RESULTS We found that patients presenting with NSC were mostly older adults. Mortality for patients with NSC was significantly increased compared to patients presenting with SC [OR 2.50 (95% CI 1.40-4.47)]. They were triaged as urgent less often than SC patients [OR 2.12 (95% CI 1.08-4.16)]. Emergency department length of stay was increased in two out of three studies. Hospital length of stay was increased by 1-3 days. Admission rates were high in most studies, 55 to 84%, and increased in comparison to patients with SC [OR 3.86 (95% CI 1.76-8.47)]. These patients seemed to require more resources than patients with SC. The number for intensive care admissions did not seem to be increased. Data were insufficient to make conclusions regarding re-visitation rates. Discharge diagnoses were spread throughout the ICD-10 main chapters, infections being the most prevalent. CONCLUSIONS Patients with NSC have a high risk of mortality and their care in the Emergency Department requires more time and resources than for patients with SC. We suggest that NSC should be considered a major emergency presentation.
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Affiliation(s)
- Kirsi Kemp
- Department of Emergency Medicine and Services, Helsinki University Hospital, and Emergency Medicine, Helsinki University, Helsinki, Finland.
| | - Reija Mertanen
- Department of Emergency Medicine and Services, Helsinki University Hospital, and Emergency Medicine, Helsinki University, Helsinki, Finland
| | - Mitja Lääperi
- Department of Emergency Medicine and Services, Helsinki University Hospital, and Emergency Medicine, Helsinki University, Helsinki, Finland
| | - Leila Niemi-Murola
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Lasse Lehtonen
- Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maaret Castren
- Department of Emergency Medicine and Services, Helsinki University Hospital, and Emergency Medicine, Helsinki University, Helsinki, Finland
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Levin N, Horton D, Sanford M, Horne B, Saseendran M, Graves K, White M, Tonna JE. Failure of vital sign normalization is more strongly associated than single measures with mortality and outcomes. Am J Emerg Med 2019; 38:2516-2523. [PMID: 31864869 DOI: 10.1016/j.ajem.2019.12.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/05/2019] [Accepted: 12/13/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Modified Early Warning Systems (MEWS) scores offer proxies for morbidity and mortality that are easily acquired, but there are limited data on what changing MEWS scores within the ED indicate. We examined the correlation of changing MEWS scores during resuscitation in the ED and in-hospital morbidity and mortality. METHODS We conducted a retrospective analysis on medical ED patients with simplified MEWS scores (without urine output or mental status) admitted to a single academic tertiary care center over one year. Triage-to-Last delta MEWS score and Triage-to-Max delta MEWS scores were calculated and correlated to in-hospital mortality, ICU admission, length of stay (LOS) and diagnosis of sepsis. RESULTS Our analysis included 8322 ED patients with an ICU admission rate of 17% and a mortality rate of 2%. Every point of worsened MEWS after triage was more strongly associated with all-cause mortality (OR 2.41, 95% CI 1.96-2.97) than triage MEWS alone (OR 1.33, 95% CI 1.23-1.44; p < 0.001). Likewise, each point of worsened MEWS was associated with increased odds of ICU admission (Triage-to-Last: OR 2.12, 95% CI 1.92-2.33 and Triage-to-Max: OR 1.52, 95% CI 1.45-1.60, respectively). Among patients with suspected infection, similar associations are found. CONCLUSIONS Dynamic vital signs in the emergency department, as categorized by delta MEWS, and failure to normalize abnormalities, were associated with increased mortality, ICU admission, LOS, and the diagnosis of sepsis. Our results suggest that MEWS scores that do not normalize, from triage onward, are more strongly associated with outcome than any single score.
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Affiliation(s)
- Nicholas Levin
- Division of Emergency Medicine, University of Utah Health, United States of America
| | - Devin Horton
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah Health, United States of America
| | - Matthew Sanford
- Value Engineering, University of Utah Health, United States of America
| | - Benjamin Horne
- Department of Surgery, Department of Biomedical Informatics, University of Utah Health, United States of America
| | - Mahima Saseendran
- System Quality Department, University of Utah Health, United States of America
| | - Kencee Graves
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah Health, United States of America
| | | | - Joseph E Tonna
- Division of Emergency Medicine, University of Utah Health, United States of America; Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, United States of America.
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16
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Filbin MR, Thorsen JE, Zachary TM, Lynch JC, Matsushima M, Belsky JB, Heldt T, Reisner AT. Antibiotic Delays and Feasibility of a 1-Hour-From-Triage Antibiotic Requirement: Analysis of an Emergency Department Sepsis Quality Improvement Database. Ann Emerg Med 2019; 75:93-99. [PMID: 31561998 DOI: 10.1016/j.annemergmed.2019.07.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/19/2019] [Accepted: 07/09/2019] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE We identify factors associated with delayed emergency department (ED) antibiotics and determine feasibility of a 1-hour-from-triage antibiotic requirement in sepsis. METHODS We studied all ED adult septic patients in accordance with Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock National Quality Measures in 2 consecutive 12-month intervals. During the second interval, a quality improvement intervention was conducted: a sepsis screening protocol plus case-specific feedback to clinicians. Data were abstracted retrospectively through electronic query and chart review. Primary outcomes were antibiotic delay greater than 3 hours from documented onset of hypoperfusion (per Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock National Quality Measures) and antibiotic delay greater than 1 hour from triage (per 2018 Surviving Sepsis Campaign recommendations). RESULTS We identified 297 and 357 septic patients before and during the quality improvement intervention, respectively. Before and during quality improvement intervention, antibiotic delay in accordance with Centers for Medicare & Medicaid Services measures occurred in 30% and 21% of cases (-9% [95% confidence interval -16% to -2%]); and in accordance with 2018 Surviving Sepsis Campaign recommendations, 85% and 71% (-14% [95% confidence interval -20% to -8%]). Four factors were independently associated with both definitions of antibiotic delay: vague (ie, nonexplicitly infectious) presenting symptoms, triage location to nonacute areas, care before the quality improvement intervention, and lower Sequential [Sepsis-related] Organ Failure Assessment scores. Most patients did not receive antibiotics within 1 hour of triage, with the exception of a small subset post-quality improvement intervention who presented with explicit infectious symptoms and triage hypotension. CONCLUSION The quality improvement intervention significantly reduced antibiotic delays, yet most septic patients did not receive antibiotics within 1 hour of triage. Compliance with the 2018 Surviving Sepsis Campaign would require a wholesale alteration in the management of ED patients with either vague symptoms or absence of triage hypotension.
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Affiliation(s)
- Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
| | - Jill E Thorsen
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Tracey M Zachary
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - James C Lynch
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
| | - Minoru Matsushima
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA; Nihon Kohden Innovation Center, Cambridge, MA
| | - Justin B Belsky
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, CT
| | - Thomas Heldt
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
| | - Andrew T Reisner
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
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Weiner SG, Hoppe JA, Finkelman MD. Techniques to Shorten a Screening Tool for Emergency Department Patients. West J Emerg Med 2019; 20:804-809. [PMID: 31539338 PMCID: PMC6754189 DOI: 10.5811/westjem.2019.7.42938] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 07/09/2019] [Indexed: 02/06/2023] Open
Abstract
Introduction Screening of patients for opioid risk has been recommended prior to opioid prescribing. Opioids are prescribed frequently in the emergency department (ED) setting, but screening tools are often of significant length and therefore limited in their utility. We describe and evaluate three approaches to shortening a screening tool: creation of a short form; curtailment; and stochastic curtailment. Methods To demonstrate the various shortening techniques, this retrospective study used data from two studies of ED patients for whom the provider was considering providing an opioid prescription and who completed the Screener and Opioid Assessment for Patients with Pain-Revised, a 24-item assessment. High-risk criteria from patients’ prescription drug monitoring program data were used as an endpoint. Using real-data simulation, we determined the sensitivity, specificity, and test length of each shortening technique. Results We included data from 188 ED patients. The original screener had a test length of 24 questions, a sensitivity of 44% and a specificity of 76%. The 12-question short form had a sensitivity of 41% and specificity of 75%. Curtailment and stochastic curtailment reduced the question length (mean test length ranging from 8.1–19.7 questions) with no reduction in sensitivity or specificity. Conclusion In an ED population completing computer-based screening, the techniques of curtailment and stochastic curtailment markedly reduced the screening tool’s length but had no effect on test characteristics. These techniques can be applied to improve efficiency of screening patients in the busy ED environment without sacrificing sensitivity or specificity.
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Affiliation(s)
- Scott G Weiner
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Jason A Hoppe
- University of Colorado Denver School of Medicine, Department of Emergency Medicine, Aurora, Colorado
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Anand V, Zhang Z, Kadri SS, Klompas M, Rhee C. Epidemiology of Quick Sequential Organ Failure Assessment Criteria in Undifferentiated Patients and Association With Suspected Infection and Sepsis. Chest 2019; 156:289-297. [PMID: 30978329 DOI: 10.1016/j.chest.2019.03.032] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 03/07/2019] [Accepted: 03/15/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The role of Quick Sequential Organ Failure Assessment (qSOFA) criteria in sepsis screening and management is controversial, particularly as they were derived only in patients with suspected infection. We examined the epidemiology and prognostic value of qSOFA in undifferentiated patients. METHODS We identified patients with ≥ 2 qSOFA criteria within 1 day of admission among all adults admitted to 85 US hospitals from 2012 to 2015 and assessed for suspected infection (using clinical cultures and administration of antibiotics) and sepsis (as defined on the basis of Sepsis-3 criteria). We also examined the discrimination of qSOFA for in-hospital mortality among patients with and without suspected infection, using regression models. RESULTS Of 1,004,347 hospitalized patients, 271,500 (27.0%) were qSOFA-positive on admission. Compared with qSOFA-negative patients, qSOFA-positive patients were older (median age, 65 vs 58 years), required ICU admission more often (28.5% vs 6.5%), and had higher mortality (6.7% vs 0.8%) (P < .001 for all comparisons). Sensitivities of qSOFA for suspected infection and sepsis were 41.3% (95% CI, 41.1%-41.5%) and 62.8% (95% CI, 62.4%-63.1%), respectively; positive predictive values were 31.0% (95% CI, 30.8%-31.1%) and 17.4% (95% CI, 17.2%-17.5%). The area under the receiver operating characteristic curve for mortality was lower for qSOFA in patients with suspected infection vs those without (0.814 vs 0.875; P < .001). CONCLUSIONS Only one in three patients who are qSOFA-positive on admission has suspected infection, and one in six has sepsis. qSOFA also has low sensitivity for identifying suspected infection and sepsis, and its prognostic significance is not specific to infection. More sensitive and specific tools for sepsis screening and risk stratification are needed.
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Affiliation(s)
- Vijay Anand
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Zilu Zhang
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
| | - Sameer S Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
| | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA; Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
| | - Chanu Rhee
- Department of Medicine, Brigham and Women's Hospital, Boston, MA; Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA.
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A Quality Improvement Project to Improve Sepsis-Related Outcomes at an Integrated Healthcare System. J Healthc Qual 2019; 41:369-375. [PMID: 30883463 DOI: 10.1097/jhq.0000000000000193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hospitals are encouraged to take steps to improve outcomes for patients with sepsis, a leading cause of morbidity and mortality. A retrospective analysis examined data (n = 4,475) from three health systems to better determine the impact of a 10-month sepsis quality improvement program that consisted of clinical alerts, audit and feedback, and staff education. Compared with the control group, the intervention group significantly decreased length of stay and costs per stay. The intervention group increased sepsis bundle compliance by more than 40%. A sepsis quality improvement program may improve sepsis health outcomes and decrease costs.
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Shu E, Ives Tallman C, Frye W, Boyajian JG, Farshidpour L, Young M, Campagne D. Pre-hospital qSOFA as a predictor of sepsis and mortality. Am J Emerg Med 2018; 37:1273-1278. [PMID: 30322666 DOI: 10.1016/j.ajem.2018.09.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 07/31/2018] [Accepted: 09/17/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The quick sequential organ failure assessment score (qSOFA) has been proposed as a simple tool to identify patients with sepsis who are at risk for poor outcomes. Its utility in the pre-hospital setting has not been fully elucidated. METHODS This is a retrospective observational study of adult patients arriving by ambulance in September 2016 to an academic emergency department in Fresno, California. The qSOFA score was calculated from pre-hospital vital signs. We investigated its association with sepsis, ED diagnosis of infection, and mortality. RESULTS Of 2292 adult medical patients transported by ambulance during the study period, the sensitivity of qSOFA for sepsis and in-hospital mortality were 42.9% and 40.6%, respectively. Specificity of qSOFA for sepsis and mortality were 93.8% and 91.9%, respectively. Of those with an ED diagnosis of infection compared to all patients, qSOFA was more specific but less sensitive for sepsis. Increasing qSOFA score was associated with a discharge diagnosis of sepsis (OR 4.21, 95% CI 3.41-5.21, p < 0.001), in-hospital mortality (OR 3.30, 95% CI 2.28-4.78, p < 0.001), and ED diagnosis of infection (OR 1.37, 95% CI 1.18-1.58, p < 0.001). Higher qSOFA score was associated with triage to a higher acuity zone and longer hospital and ICU length of stay, but not up-triage during ED stay. CONCLUSIONS Pre-hospital qSOFA is specific, but poorly sensitive, for sepsis and sepsis outcomes, especially among patients with an ED diagnosis of infection. Higher qSOFA score was associated with worse outcomes.
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Affiliation(s)
- Eileen Shu
- Emergency Medicine, UCSF Fresno, United States of America.
| | | | - William Frye
- Virginia Commonwealth University, United States of America.
| | | | | | - Megann Young
- Emergency Medicine, UCSF Fresno, United States of America.
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