Initial disease severity and quality of care of emergency department sepsis patients who are older or younger than 70 years of age

Predictors of In-Hospital Mortality in Older Inpatients with Suspected Infection

OBJECTIVES

To determine the rate and predictors of death in older individuals with suspected infection at any time during hospital stay in a geriatric acute ward and the prognostic ability of different tools [quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA), Modified and National Early Warning Scores (MEWS) and (NEWS)] in such population.

DESIGN

Prospective observational single-center cohort study.

SETTING AND PARTICIPANTS

Among patients admitted to an acute geriatric unit of an Italian University Hospital with at least 1 sepsis risk factor, all subjects with suspected infection at admission or during hospital stay (defined as antibiotic prescription and associated culture test) were considered.

METHODS

A geriatric assessment including comorbidity and social, functional, and cognitive status was performed for each patient. Clinical parameters were evaluated at least twice daily throughout hospital stay; qSOFA, MEWS, and NEWS were derived, with positive cutoffs set at ≥2, ≥5, and ≥7, respectively.

RESULTS

Among 305 older inpatients (median age 86.0 years, 49.2% female), 21% died during hospital stay. Sepsis was diagnosed in 31.8% of the overall sample and in 64.1% of deceased patients. Deceased patients showed a significantly higher prevalence of prior institutionalization, functional dependence, cognitive impairment, and multimorbidity. The prognostic accuracy of the qSOFA score at infection onset was only fair (area under the receiver operating characteristic curve 0.72; 95% CI, 0.65-0.79, P < .001) and comparable with that of MEWS and NEWS. After multivariable analysis, in-hospital death was positively associated with male sex [odds ratio (OR), 2.11; 95% CI, 1.01-4.44; P = .048] and abnormal white blood cells count (OR, 4.93; 95% CI, 2.36-10.29; P < .001), platelet count (OR, 2.61; 95% CI, 1.10-6.16; P = .029) and serum creatinine (OR, 2.70; 95% CI, 1.30-5.61; P = .008), along with any of the score considered, and negatively associated with autonomy in instrumental activities (OR, 0.78; 95% CI, 0.68-0.90; P < .001).

CONCLUSIONS

Prognosis in older inpatients with infection or sepsis appears to be determined both by the geriatric characteristics and by the severity of the acute event, expressed by recommended tools and blood test results.

Emergency department performance assessment using administrative data: A managerial framework

Administrative data play an important role in performance monitoring of healthcare providers. Nonetheless, little attention has been given so far to the emergency department (ED) evaluation. In addition, most of existing research focuses on a single core ED function, such as treatment or triage, thus providing a limited picture of performance. The goal of this study is to harness the value of routinely produced records proposing a framework for multidimensional performance evaluation of EDs able to support internal decision stakeholders in managing operations. Starting with the overview of administrative data, and the definition of the desired framework's characteristics from the perspective of decision stakeholders, a review of the academic literature on ED performance measures and indicators is conducted. A performance measurement framework is designed using 224 ED performance metrics (measures and indicators) satisfying established selection criteria. Real-world feedback on the framework is obtained through expert interviews. Metrics in the proposed ED performance measurement framework are arranged along three dimensions: performance (quality of care, time-efficiency, throughput), analysis unit (physician, disease etc.), and time-period (quarter, year, etc.). The framework has been judged as "clear and intuitive", "useful for planning", able to "reveal inefficiencies in care process" and "transform existing data into decision support information" by the key ED decision stakeholders of a teaching hospital. Administrative data can be a new cornerstone for health care operation management. A framework of ED-specific indicators based on administrative data enables multi-dimensional performance assessment in a timely and cost-effective manner, an essential requirement for nowadays resource-constrained hospitals. Moreover, such a framework can support different stakeholders' decision making as it allows the creation of a customized metrics sets for performance analysis with the desired granularity.

Comparison of Diagnostic Accuracies of qSOFA, NEWS, and MEWS to Identify Sepsis in Older Inpatients With Suspected Infection

OBJECTIVES

To determine and compare the accuracies of the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) and Modified and National Early Warning Scores (NEWS and MEWS) to identify sepsis in older inpatients with suspected infection.

DESIGN

Prospective diagnostic accuracy study.

SETTING AND PARTICIPANTS

Patients admitted to an acute geriatric unit of an Italian University Hospital with at least one sepsis risk factor and suspected infection defined as antibiotic prescription and associated culture test during hospital stay.

METHODS

Sepsis diagnosis was defined as the presence on discharge documents of International Classification of Diseases, Ninth revision, Clinical Modification codes for severe sepsis, septic shock, or for infection and acute organ disfunction. For each patient, clinical parameters were evaluated at least twice daily throughout hospital stay; qSOFA, NEWS, and MEWS were derived, and worst scores recorded. Positive cutoffs were set at ≥2, ≥7, and ≥5, respectively. Sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively), and positive and negative likelihood ratios, as well as areas under the receiver operating characteristic curve (AUROCs) were calculated.

RESULTS

Among 230 geriatric patients with suspected infection at risk for sepsis (median age 86 years, 49% women), 30.9% had a sepsis diagnosis. A qSOFA ≥2 was recorded in 111 (48.3%) patients, a MEWS ≥5 in 65 (28.3%), and a NEWS ≥7 in 115 (50.0%). The qSOFA showed the highest sensitivity [81.7%, 95% confidence interval (CI) 71.7%-89.5%], but low specificity (66.7%, 95% CI 59.1%-73.7%), resulting in a high NPV (89.1%; 95% CI 82.7%-93.8%) and poor PPV (52.3%, 95% CI 43.0%-61.4%). The AUROC for qSOFA was 0.76 (95% CI 0.69-0.83), comparable with that of NEWS (0.74, 95% CI 0.67-0.81, P = .44), but significantly higher than that of MEWS (0.70, 95% CI 0.63-0.77, P = .04).

CONCLUSIONS AND IMPLICATIONS

Repeated qSOFA determinations are useful to rule out sepsis in geriatric inpatients with suspected infection, but poorly support its diagnosis due to low specificity. More complex MEWS and NEWS do not perform better. Implementation of clinical scores to reliably identify sepsis in older patients is urgently needed.

Retrospective single-centre descriptive study of the characteristics, management and outcomes of adult patients with suspected sepsis in the emergency department

BACKGROUND

Guidelines for adults presenting to the emergency department (ED) with suspected sepsis recommend protocols and bundles that promote rapid and potentially intensive treatment, but give little consideration of how patient characteristics, such as age, functional status and comorbidities, might influence management. This study aimed to describe the characteristics, management and outcomes of adults attending the ED with suspected sepsis, and specifically describe the prevalence of comorbidities, functional impairment and escalations of care.

METHODS

We undertook a single-centre retrospective observational study involving medical record review of a random sample of adults admitted to an ED between February 2018 and January 2019 with suspected sepsis. Descriptive statistics were used with 95% confidence intervals (CIs) for key proportions.

RESULTS

We included 509 patients (median age 74 years), of whom 49.3% met the Sepsis-3 criteria. Less than half of the patients were living at home independently (42.5%) or could walk independently (41.5%), 19.3% were care home residents and 89.2% of patients had one or more comorbidity. 22% had a pre-existing do not attempt resuscitation order. 6.5% were referred to intensive care, and 34.3% of the 13.2% who died in-hospital had an escalation plan explicitly documented.

CONCLUSION

Adults with suspected sepsis have substantial functional limitations, comorbidities and treatment directives that should be considered in guidelines, especially recommendations for escalation of care.

Emergency department management of older people living with frailty: a guide for emergency practitioners

Emergency Departments (EDs) are increasingly seeing more seriously unwell older people living with frailty. In the context of limited resources and increasing demand it's the ED practitioner's challenge to unpick this constellation of physical, psychological, functional and social issues.To properly assess older people living with frailty at the ED it is crucial to use an holistic approach. This consists of triage with algorithms sensitive to the higher risk of older people living with frailty, a frailty assessment, and an assessment with the help of the principles of Comprehensive Geriatric Assessment. Multi-disciplinary care, a tailor-made treatment plan, based on what the person values most, will help the ED practitioner to deliver appropriate and valuable care during the ED stay, but also in transition from hospital to home.

Significance of body temperature in elderly patients with sepsis

Background

Elderly patients have a blunted host response, which may influence vital signs and clinical outcomes of sepsis. This study was aimed to investigate whether the associations between the vital signs and mortality are different in elderly and non-elderly patients with sepsis.

Methods

This was a retrospective observational study. A Japanese multicenter sepsis cohort (FORECAST, n = 1148) was used for the discovery analyses. Significant discovery results were tested for replication using two validation cohorts of sepsis (JAAMSR, Japan, n = 624; SPH, Canada, n = 1004). Patients were categorized into elderly and non-elderly groups (age ≥ 75 or < 75 years). We tested for association between vital signs (body temperature [BT], heart rate, mean arterial pressure, systolic blood pressure, and respiratory rate) and 90-day in-hospital mortality (primary outcome).

Results

In the discovery cohort, non-elderly patients with BT < 36.0 °C had significantly increased 90-day mortality (P = 0.025, adjusted hazard ratio 1.70, 95% CI 1.07–2.71). In the validation cohorts, non-elderly patients with BT < 36.0 °C had significantly increased mortality (JAAMSR, P = 0.0024, adjusted hazard ratio 2.05, 95% CI 1.29–3.26; SPH, P = 0.029, adjusted hazard ratio 1.36, 95% CI 1.03–1.80). These differences were not observed in elderly patients in the three cohorts. Associations between the other four vital signs and mortality were not different in elderly and non-elderly patients. The interaction of age and hypothermia/fever was significant (P < 0.05).

Conclusions

In septic patients, we found mortality in non-elderly sepsis patients was increased with hypothermia and decreased with fever. However, mortality in elderly patients was not associated with BT. These results illuminate the difference in the inflammatory response of the elderly compared to non-elderly sepsis patients.

Epidemiology of Community-Acquired Sepsis in Adult Patients: A Six Year Observational Study

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to an infection and it is a major cause of morbidity and mortality worldwide. The aim of this study is to describe epidemiology of community-acquired sepsis in the Intensive care unit (ICU) of the Macedonian tertiary care University Clinic for Infectious Diseases. A prospective observational study was conducted over a 6-year period from January, 2011 to December, 2016. All consecutive adults with community-acquired sepsis or septic shock were included in the study. Variables measured were incidence of sepsis, age, gender, comorbidities, season, source of infection, complications, interventions, severity indexes, length of stay, laboratory findings, blood cultures, 28-day and in hospital mortality. Of 1348 admissions, 277 (20.5%) had sepsis and septic shock. The most common chronic condition was heart failure (26.4%), and the most frequent site of infection was the respiratory tract (57.4%). Median Simplified Acute Physiology Score (SAPS II) was 50.0, and median Sequential Organ Failure Assessment (SOFA) score was 8.0. Blood cultures were positive in 22% of the cases. Gram-positive bacteria were isolated in 13% and Gram-negatives in 9.7% of patients with sepsis. The overall 28-day and in hospital mortality was 50.5% and 56.3% respectively. The presence of chronic heart failure, occurrence of ARDS, septic shock and the winter period may influence an unfavorable outcome. Mortality compared to previous years is unchanged but patients that we have been treating these last 6 years have had more severe illnesses. Better adherence to the Surviving Sepsis guidelines will reduce mortality in this group of severely ill patients.