Characteristics of the prehospital phase of adult emergency department patients with an infection: A prospective pilot study

Association between early manifestations of infection or sepsis and prognosis in a high complexity hospital in the city of Medellín

OBJECTIVE

To identify the first symptoms and signs of patients with suspected infection or sepsis and their association with the composite outcome of admission to the Intensive Care Unit (ICU) or mortality.

DESIGN

Prospective cohort study between June 2019 and March 2020.

SETTING

Hospital Universitario San Vicente Fundación, Colombia.

PATIENTS

Over 18 years of age with suspicion or confirmation of sepsis, which required hospitalization.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Symptoms and signs associated with infection, with their time of evolution, specified in the study.

RESULTS

From 1005 eligible patients, 261 were included. After multivariable adjustment with a logistic regression model, the main factors for ICU admission or mortality were heart rate (OR 1.04 with 95% CI 1.04-3.7), respiratory rate (OR 1.19 with 95% CI 1.0-1.4) and capillary refill time (OR 3.4 with 95% CI 1.9-6.1).

CONCLUSIONS

Heart rate, respiratory rate, and capillary refill may behave as early predictors of ICU admission and mortality in cases of sepsis.

Exploration of pre‐hospital patient delays in seeking care for symptoms of bacteremia and sepsis: A qualitative study

AIM

We explored patient pre-hospital delays in seeking care for symptoms of bacteremia and sepsis.

DESIGN

A qualitative descriptive study.

METHODS

In January 2021, we recruited a convenience sample of four men and six women who were former patients diagnosed with bacteremia. We conducted semi-structured interviews by telephone. The tape-recorded interviews were transcribed, coded and analysed using the Common-Sense Model of Self-Regulation. Data analysis continued until May 2021.

RESULTS

The three main themes included: gathering threads of information, weaving together the threads of information and impact and outcome of the illness. The main finding revealed was that an inability to recognize symptoms of bacteremia resulted in delayed help-seeking. Participants had difficulty recognizing their symptoms as being related to bacteremia when they lacked experience with infection or could not differentiate them from symptoms of other chronic co-morbid conditions. Recognizing symptoms and searching for their meaning was an early step in developing an action plan for seeking care. Patient-reported physical and psychological outcomes of the infection on their quality of life (QOL) varied widely, from none to major impact.

New clinical prediction model for early recognition of sepsis in adult primary care patients: a prospective diagnostic cohort study of development and external validation

BACKGROUND

Recognising patients who need immediate hospital treatment for sepsis while simultaneously limiting unnecessary referrals is challenging for GPs.

AIM

To develop and validate a sepsis prediction model for adult patients in primary care.

DESIGN AND SETTING

This was a prospective cohort study in four out-of-hours primary care services in the Netherlands, conducted between June 2018 and March 2020.

METHOD

Adult patients who were acutely ill and received home visits were included. A total of nine clinical variables were selected as candidate predictors, next to the biomarkers C-reactive protein, procalcitonin, and lactate. The primary endpoint was sepsis within 72 hours of inclusion, as established by an expert panel. Multivariable logistic regression with backwards selection was used to design an optimal model with continuous clinical variables. The added value of the biomarkers was evaluated. Subsequently, a simple model using single cut-off points of continuous variables was developed and externally validated in two emergency department populations.

RESULTS

A total of 357 patients were included with a median age of 80 years (interquartile range 71-86), of which 151 (42%) were diagnosed with sepsis. A model based on a simple count of one point for each of six variables (aged >65 years; temperature >38°C; systolic blood pressure ≤110 mmHg; heart rate >110/min; saturation ≤95%; and altered mental status) had good discrimination and calibration (C-statistic of 0.80 [95% confidence interval = 0.75 to 0.84]; Brier score 0.175). Biomarkers did not improve the performance of the model and were therefore not included. The model was robust during external validation.

CONCLUSION

Based on this study's GP out-of-hours population, a simple model can accurately predict sepsis in acutely ill adult patients using readily available clinical parameters.

Frequency of alterations in qSOFA, SIRS, MEWS and NEWS scores during the emergency department stay in infectious patients: a prospective study

BACKGROUND

For emergency department (ED) patients with suspected infection, a vital sign-based clinical rule is often calculated shortly after the patient arrives. The clinical rule score (normal or abnormal) provides information about diagnosis and/or prognosis. Since vital signs vary over time, the clinical rule scores can change as well. In this prospective multicentre study, we investigate how often the scores of four frequently used clinical rules change during the ED stay of patients with suspected infection.

METHODS

Adult (≥ 18 years) patients with suspected infection were prospectively included in three Dutch EDs between March 2016 and December 2019. Vital signs were measured in 30-min intervals and the quick Sequential Organ Failure Assessment (qSOFA) score, the Systemic Inflammatory Response Syndrome (SIRS) criteria, the Modified Early Warning Score and the National Early Warning Score (NEWS) score were calculated. Using the established cut-off points, we analysed how often alterations in clinical rule scores occurred (i.e. switched from normal to abnormal or vice versa). In addition, we investigated which vital signs caused most alterations.

RESULTS

We included 1433 patients, of whom a clinical rule score changed once or more in 637 (44.5%) patients. In 6.7-17.5% (depending on the clinical rule) of patients with an initial negative clinical rule score, a positive score occurred later during ED stay. In over half (54.3-65.0%) of patients with an initial positive clinical rule score, the score became negative later on. The respiratory rate caused most (51.2%) alterations.

CONCLUSION

After ED arrival, alterations in qSOFA, SIRS, MEWS and/or NEWS score are present in almost half of patients with suspected infection. The most contributing vital sign to these alterations was the respiratory rate. One in 6-15 patients displayed an abnormal clinical rule score after a normal initial score. Clinicians should be aware of the frequency of these alterations in clinical rule scores, as clinical rules are widely used for diagnosis and/or prognosis and the optimal moment of assessing them is unknown.

Prehospital delay is an important risk factor for mortality in community-acquired bloodstream infection (CA-BSI): a matched case-control study

OBJECTIVES

The aim of this study was to identify prehospital and early hospital risk factors associated with 30-day mortality in patients with blood culture-confirmed community-acquired bloodstream infection (CA-BSI) in Sweden.

METHODS

A retrospective case-control study of 1624 patients with CA-BSI (2015-2016), 195 non-survivors satisfying the inclusion criteria were matched 1:1 with 195 survivors for age, gender and microorganism. All forms of contact with a healthcare provider for symptoms of infection within 7 days prior CA-BSI episode were registered. Logistic regression was used to analyse risk factors for 30-day all-cause mortality.

RESULTS

Of the 390 patients, 61% (115 non-survivors and 121 survivors) sought prehospital contact. The median time from first prehospital contact till hospital admission was 13 hours (6-52) for non-survivors and 7 hours (3-24) for survivors (p<0.01). Several risk factors for 30-day all-cause mortality were identified: prehospital delay OR=1.26 (95% CI: 1.07 to 1.47), p<0.01; severity of illness (Sequential Organ Failure Assessment score) OR=1.60 (95% CI: 1.40 to 1.83), p<0.01; comorbidity score (updated Charlson Index) OR=1.13 (95% CI: 1.05 to 1.22), p<0.01 and inadequate empirical antimicrobial therapy OR=3.92 (95% CI: 1.64 to 9.33), p<0.01. In a multivariable model, prehospital delay >24 hours from first contact remained an important risk factor for 30-day all-cause mortality due to CA-BSI OR=6.17 (95% CI: 2.19 to 17.38), p<0.01.

CONCLUSION

Prehospital delay and inappropriate empirical antibiotic therapy were found to be important risk factors for 30-day all-cause mortality associated with CA-BSI. Increased awareness and earlier detection of BSI in prehospital and early hospital care is critical for rapid initiation of adequate management and antibiotic treatment.

The Presentation, Pace, and Profile of Infection and Sepsis Patients Hospitalized Through the Emergency Department: An Exploratory Analysis

To characterize the signs and symptoms of sepsis, compare them with those from simple infection and other emergent conditions and evaluate their association with hospital outcomes.

Design Setting Participants and INTERVENTION

A multicenter, retrospective cohort study of 408,377 patients hospitalized through the emergency department from 2012 to 2017 with sepsis, suspected infection, heart failure, or stroke. Infected patients were identified based on Sepsis-3 criteria, whereas noninfected patients were identified through diagnosis codes.

MEASUREMENTS AND MAIN RESULTS

Signs and symptoms were identified within physician clinical documentation in the first 24 hours of hospitalization using natural language processing. The time of sign and symptom onset prior to presentation was quantified, and sign and symptom prevalence was assessed. Using multivariable logistic regression, the association of each sign and symptom with four outcomes was evaluated: sepsis versus suspected infection diagnosis, hospital mortality, ICU admission, and time of first antibiotics (> 3 vs ≤ 3 hr from presentation). A total of 10,825 signs and symptoms were identified in 6,148,348 clinical documentation fragments. The most common symptoms overall were as follows: dyspnea (35.2%), weakness (27.2%), altered mental status (24.3%), pain (23.9%), cough (19.7%), edema (17.8%), nausea (16.9%), hypertension (15.6%), fever (13.9%), and chest pain (12.1%). Compared with predominant signs and symptoms in heart failure and stroke, those present in infection were heterogeneous. Signs and symptoms indicative of neurologic dysfunction, significant respiratory conditions, and hypotension were strongly associated with sepsis diagnosis, hospital mortality, and intensive care. Fever, present in only a minority of patients, was associated with improved mortality (odds ratio, 0.67, 95% CI, 0.64-0.70; p < 0.001). For common symptoms, the peak time of symptom onset before sepsis was 2 days, except for altered mental status, which peaked at 1 day prior to presentation.

Conclusions

The clinical presentation of sepsis was heterogeneous and occurred with rapid onset prior to hospital presentation. These findings have important implications for improving public education, clinical treatment, and quality measures of sepsis care.

Proteomic Profiles of Exosomes of Septic Patients Presenting to the Emergency Department Compared to Healthy Controls

BACKGROUND

Septic Emergency Department (ED) patients provide a unique opportunity to investigate early sepsis. Recent work focuses on exosomes, nanoparticle-sized lipid vesicles (30-130 nm) that are released into the bloodstream to transfer its contents (RNA, miRNA, DNA, protein) to other cells. Little is known about how early changes related to exosomes may contribute to the dysregulated inflammatory septic response that leads to multi-organ dysfunction. We aimed to evaluate proteomic profiles of plasma derived exosomes obtained from septic ED patients and healthy controls.

METHODS

This is a prospective observational pilot study evaluating a plasma proteomic exosome profile at an urban tertiary care hospital ED using a single venipuncture blood draw, collecting 40 cc Ethylenediaminetetraacetic acid (EDTA) blood.

MEASUREMENTS

We recruited seven patients in the ED within 6 h of their presentation and five healthy controls. Plasma exosomes were isolated using the Invitrogen Total Exosome Isolation Kit. Exosome proteomic profiles were analyzed using fusion mass spectroscopy and Proteome Discoverer. Principal component analysis (PCA) and differential expression analysis (DEA) for sepsis versus control was performed.

RESULTS

PCA of 261 proteins demonstrated septic patients and healthy controls were distributed in two groups. DEA revealed that 62 (23.8%) proteins differed between the exosomes of septic patients and healthy controls, p-value < 0.05. Adjustments using the False Discovery Rate (FDR) showed 23 proteins remained significantly different (FDR < 0.05) between sepsis and controls. Septic patients and controls were classified into two distinct groups by hierarchical clustering using the 62 nominally DE proteins. After adjustment multiple comparisons, three acute phase proteins remained significantly different between patients and controls: Serum amyloid A-1, C-reactive protein and Serum Amyloid A-2. Inflammatory response proteins immunoglobulin heavy constant Δ and Fc-fragment of IgG binding protein were increased.

CONCLUSION

Exosome proteomic profiles of septic ED patients differ from their healthy counterparts with regard to acute phase response and inflammation.

How well are sepsis and a sense of urgency documented throughout the acute care chain in the Netherlands? A prospective, observational study

OBJECTIVE

To investigate the documentation of sepsis and a sense of urgency throughout the acute care chain.

DESIGN

Prospective cohort study.

SETTING

Emergency department (ED) in a large district hospital in Heerlen, The Netherlands.

PARTICIPANTS

Participants included patients ≥18 years with suspected sepsis who visited the ED during out-of-hours between September 2017 and January 2018 (n=339) and had been referred by a general practitioner and/or transported by ambulance. We defined suspected sepsis as suspected or proven infection and the presence of ≥2 quick Sepsis-related Organ Failure Assessment and/or ≥2 Systemic Inflammatory Response Syndrome criteria.

OUTCOME MEASURES

We analysed how often sepsis and a sense of urgency were documented in the prehospital and ED medical records. A sense of urgency was considered documented when a medical record suggested the need of immediate assessment by a physician in the ED. We described documentation patterns throughout the acute care chain and investigated whether documentation of sepsis or a sense of urgency is associated with adverse outcomes (intensive care admission/30-day all-cause mortality).

RESULTS

Sepsis was documented in 16.8% of medical records and a sense of urgency in 22.4%. In 4.1% and 7.7%, respectively, sepsis and a sense of urgency were documented by all involved professionals. In patients with an adverse outcome, sepsis was documented more often in the ED than in patients without an adverse outcome (47.9% vs 13.7%, p<0.001).

CONCLUSIONS

Our study shows that in prehospital and ED medical records, sepsis and a sense of urgency are documented in one out of five patients. In only 1 out of 20 patients sepsis or a sense of urgency is documented by all involved professionals. It is possible that poor documentation causes harm, due to delayed diagnosis or treatment. Hence, it could be important to raise awareness among professionals regarding the importance of their documentation.

Contacting out-of-hours primary care or emergency medical services for time-critical conditions - impact on patient outcomes

BACKGROUND

Out-of-hours (OOH) healthcare services in Western countries are often differentiated into out-of-hours primary healthcare services (OOH-PC) and emergency medical services (EMS). Call waiting time, triage model and intended aims differ between these services. Consequently, the care pathway and outcome could vary based on the choice of entrance to the healthcare system. We aimed to investigate patient pathways and 1- and 1-30-day mortality, intensive care unit (ICU) stay and length of hospital stay for patients with acute myocardial infarction (AMI), stroke and sepsis in relation to the OOH service that was contacted prior to the hospital contact.

METHODS

Population-based observational cohort study during 2016 including adult patients from two Danish regions with an OOH service contact on the date of hospital contact. Patients <18 years were excluded. Data was retrieved from OOH service databases and national registries, linked by a unique personal identification number. Crude and adjusted logistic regression analyses were performed to assess mortality in relation to contacted OOH service with OOH-PC as the reference and cox regression analysis to assess risk of ICU stay.

RESULTS

We included 6826 patients. AMI and stroke patients more often contacted EMS (52.1 and 54.1%), whereas sepsis patients predominately called OOH-PC (66.9%). Less than 10% (all diagnoses) of patients contacted both OOH-PC & EMS. Stroke patients with EMS or OOH-PC & EMS contacts had higher likelihood of 1- and 1-30-day mortality, in particular 1-day (EMS: OR = 5.33, 95% CI: 2.82-10.08; OOH-PC & EMS: OR = 3.09, 95% CI: 1.06-9.01). Sepsis patients with EMS or OOH-PC & EMS contacts also had higher likelihood of 1-day mortality (EMS: OR = 2.22, 95% CI: 1.40-3.51; OOH-PC & EMS: OR = 2.86, 95% CI: 1.56-5.23) and 1-30-day mortality. Risk of ICU stay was only significantly higher for stroke patients contacting EMS (EMS: HR = 2.38, 95% CI: 1.51-3.75). Stroke and sepsis patients with EMS contact had longer hospital stays.

CONCLUSIONS

More patients contacted OOH-PC than EMS. Sepsis and stroke patients contacting EMS solely or OOH-PC & EMS had higher likelihood of 1- and 1-30-day mortality during the subsequent hospital contact. Our results suggest that patients contacting EMS are more severely ill, however OOH-PC is still often used for time-critical conditions.