Clinical Review

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

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

Author(s):

References

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From the Department of Medicine, University of Pennsylvania, and the Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA.

Abstract

Objective: To detail strategies to improve sepsis recognition and the quality of care provided to the septic patient.
Methods: Review of the literature.
Results: Severe sepsis affects nearly 3 million individuals each year in the United States, and cost estimates for these hospitalizations exceed $24 billion. Effective management is predicated on timely recognition. In this review, we detail strategies to improve early identification of potentially septic patients as well as the quality of care provided to the septic patient in the emergency department (ED). The strategies discussed are based upon an understanding of the signs and symptoms of sepsis and the clinical risk factors associated with sepsis, which can be used to design novel strategies to screen patients for sepsis and risk stratify patients at risk for clinical deterioration.
Conclusion: ED structures and processes can be used to increase adherence with sepsis management guidelines to improve patient outcomes.

Severe sepsis affects nearly 3 million individuals each year in the United States and cost estimates for these hospitalizations exceed $24 billion [1–3]. Sepsis is a life-threatening condition characterized by a suspected or identified infection accompanied by a vigorous host inflammatory response. In severe sepsis, end-organ dysfunction manifests in myriad forms, including altered mental status, acute kidney injury, liver dysfunction, pulmonary dysfunction, and hemodynamic compromise [4,5]. This protean presentation of a deadly condition makes identification and risk stratification both challenging and essential to improving patient outcomes. The majority of patients with severe sepsis will receive their initial care within an emergency department (ED) [6,7]. It is essential that emergency medicine providers have the means to appropriately identify patients presenting with severe sepsis in a timely manner—thus facilitating life-saving measures such as early intravenous fluid resuscitation and administration of timely and appropriate antimicrobials.

In this review, we detail strategies to improve sepsis recognition and the quality of care provided to the septic patient in the ED. The strategies discussed are based upon an understanding of the signs and symptoms of sepsis and the clinical risk factors associated with sepsis, which can be used to design novel strategies to screen patients for sepsis and risk stratify patients for clinical deterioration. Then, we review suggested ED structures and processes to increase adherence with sepsis-based guidelines to improve patient outcomes. Successful implementation is predicated on hospital administrative support towards the efforts given the time and resources required and strong and committed leadership across the health care system.

Epidemiology of Severe Sepsis

Estimates of annual cases of severe sepsis vary, ranging from 1 million to 3 million cases in the United States [1–3]. In-hospital mortality for this condition ranges from 14% to 30% [5]. The incidence of severe sepsis in the United States has been increasing at a rate of 13% annually, with an estimated cost of greater than $24 billion per year [1,2]. In 2 large cohorts of hospitalized patients, it was found that sepsis contributed to 1 in every 2 to 3 deaths following inpatient admission [8]. Coincident with these increased estimates, advances in the early identification and treatment of sepsis have led to decreasing mortality rates over the past decade [1,9].