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)

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These complementary strategies, which serve as the afferent arm of the system, summon health care providers to the bedside of a vulnerable patient. However, clinical effectiveness in the management of severe sepsis requires a robust, sophisticated, and mature efferent arm capable of delivering expert care to the now recognized septic patient.

Principles of Effective Management Post-Recognition

Risk Stratification

An elevated serum lactate level was initially described in pathological states in the mid 19th century by Johann Joseph Scherer [39] and has long been associated with increased mortality in hospitalized patients [40]. Lactate is a useful biomarker for risk stratification in a variety of patients arriving to the ED, particularly those who have been identified at high risk for sepsis. Jansen and colleagues examined the measurement of pre-hospital serum lactate at the time of paramedic on-scene assessment in a group of acutely ill patients [41]. Patients with point-of-care lactate levels of 3.5 mmol/L or greater were found to have an in-hospital mortality of 41% versus 12% for those with lactate levels less than 3.5 mmol/L. Within the population with an elevated lactate, patients with a systolic blood pressure greater than 100 mgHg experienced a mortality of nearly 30%, while it was greater than 50% in hypotensive patients with an elevated lactate, highlighting the value of both hemodynamic and serum lactate measures. Upon arrival to the ED, lactate measurements have a strong correlation with mortality. In one retrospective cohort, lactate level was linearly associated with mortality in a broad array of patients older than age 65 years [42]. An initial serum lactate level in the ED in the intermediate (2.0 – 3.9 mmol/L) or high range (≥ 4 mmol/L) has been associated with increased odds of death 2 to 5 times higher independent of organ dysfunction in severe sepsis specifically [43].

As the association between serum lactate levels and death is independent of organ dysfunction, serum lactate is a simple and reliable tool to both enhance detection and risk-stratify patients presenting to the ED with severe sepsis. Given the frequency with which hyperlactatemia is present in patients with suspected infection [43], operationalizing serum lactate measures with the initial phlebotomy draw is an important step to risk-stratify patients. This step can be coupled later with intravenous fluid resuscitation for those with marked elevations (≥ 4 mmol/L), in accord with guideline recommendations [4]. Screening of initial lactate values can be further expedited by utilizing fingerstick point-of-care lactate devices [44]. Last, while serial lactate measures can be incorporated into triage decisions, there is no clear threshold that warrants ICU admission. Rather, persistent elevations in serum lactate can be used to identify patients who require close observation regardless of their admission location.

Several scoring systems have been developed to augment sepsis risk stratification within the ED. The most prominent of these are the Predisposition Insult Response and Organ failure (PIRO), Sequential Organ Failure Assessment (SOFA), and Mortality in the Emergency Department Sepsis (MEDS) scores, and the National early warning score (NEWS) [45-48]. The MEDS score incorporates host factors including age and co-morbid illness, as well as physiologic and laboratory tests which can be obtained rapidly in an ED setting. Multiple prospective and retrospective examinations of the MEDS scoring systems have demonstrated that it performs optimally in ED patients with sepsis but not those with severe sepsis, in terms of predicting 30-day mortality [46,47]. The PIRO score more extensively incorporates predisposing co-morbidities, physiologic and laboratory parameters, and has been modified to consider presumed source of infection, leading to a stronger predictive ability for mortality in more severely ill patients. In patients presenting to the ED with severe sepsis and septic shock, a prospective observational study found the PIRO to be the best predictor of mortality, compared to SOFA and MEDS scores [45]. In a recent study by Corfield et al, sepsis patients with a higher NEWS, according to initial ED vital signs (temperature, pulse, respiratory rate, systolic blood pressure, oxyhemoglobin saturation) and consciousness level, were significantly more likely to be admitted to an ICU within 48 hours or to experience in-hospital mortality [48].