Early Sepsis: Why Do We Miss It And How Do We Improve

Author: Anisha Turner, MD (EM/FM Resident Physician, LSU Health Science Center) and Nathan Martin, MD (EM Attending Physician, LSU Health Science Center) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF)

SEPSIS IS THE NEW BLACK

If you weren’t aware, sepsis is the new black, or in other words, the new ‘it’ thing in the ER. Even though the septic patient has existed for years, there has been a rejuvenated focus that was further ignited by the new reporting requirements implemented by the Centers for Medicare and Medicaid Services (CMS) in October 2015. Of course this is a big deal, as sepsis has a huge impact on hospital costs, patient mortality, patient functional impairment, and now hospital reimbursement. Since nearly 3 million ED visits per year are related to sepsis[1],[2],[3], improving detection of early sepsis is paramount.

WHY DO WE MISS IT?

Despite the decades of studies and advancements in sepsis management, sepsis remains one of the most deadly emergency department arrival or hospital-acquired conditions[4]. As a result, many are asking why we miss it.  Although the reasons are bountiful, there are several that are worth mentioning.

1. We can’t use the gold standard in the ED
   The gold standard of sepsis is blood cultures. Unfortunately, cultures take 2-3 days to result, and we dare not wait until then to make the diagnosis. As a result, the SIRS diagnostic criterion has been developed to assist in early recognition. Unfortunately, this leads us to reason #2.

2. Documentation ≠ SIRS negative

Unfortunately, “trust no one” is not just a cliché when it comes to patient care. Many physicians trust triage vitals and utilize this information to frame how they view the patient prior to entering a room. This notion was studied in a prospective observational study, in which initial triage decisions were revised in 7.9% of the emergency department patients after determination of the vital signs[5]. Unfortunately, several studies have shown that triage vitals are not always documented, and if so, are not always accurate. It has been shown that of the elderly patients with potential infection presenting to US EDs, 7.7% had no record of BP and 5.7% had no record of HR[6]. Lack of record has been shown to be greater in pediatric emergency departments, with 69-85%, 15-60%, 1.6-42%, and 1.4-16.5% having no blood pressure, respiratory rate, heart rate, or body temperature in the chart respectively[7],[8]. Regarding incorrect measurements, one study showed that the difference in blood pressure in those triages that use automated blood pressure cuffs was large enough to impact clinical decision making, with only 50% of repeat measurement being within 10 mm Hg of the first measurement, and nearly one third of measurements differing by 15 mm Hg or more[9]. Another study concluded that triage nurses inaccurately measure respiratory rate in the ED as well[10].  At the end of the day, the best advice is to measure vitals yourselves if any measurements are missing or there is any doubt regarding accuracy.

3. SIRS negative ≠ negative sepsis

According to the definition of sepsis, SIRS + infection equal sepsis. Yet, a retrospective database review conducted over 14 years with over 1.1 million admissions for severe sepsis to 172 ICUs showed that only 87.9% were SIRS positive, leaving 12.1% SIRS negative based on the traditional definition[11]. This means that almost 1 in 8 septic patients were SIRS negative using the traditional definition! These may be patients who are elderly and cannot mount a response, take medications that affect the heart rate, are immunocompromised, or are in a population for which the criteria has not been validated such as pregnant, postpartum, or pediatric patients[4],[12],[13]. Even though this study consisted of ICU patients, this can also be applied to the ED, as ED physicians are usually the first-hand practitioners. The SIRS criterion is not perfect and may lead to missed sepsis diagnoses.

4. SIRS positive ≠ positive sepsis

ED physicians are trained to decipher one thing well if nothing else: the difference between sick and non-sick. Unfortunately, the SIRS criterion is not the best instrument for this. SIRS can be positive in patients with something as simple as a viral infection, as the etiology is broad, including trauma, inflammation, and ischemia.

5. SIRS without source is what?

Sure, if a source is discovered the diagnosis is infectious and therefore sepsis, but a source is not identified in approximately 1/3 of cases[14]. Since not all individuals who have SIRS criteria are septic and not all patients who are septic meet the SIRS criteria, clinical judgment must be used in order to accurately diagnose the septic patient[15].

HOW CAN WE IMPROVE?

Early detection of sepsis is vital. Here are several ways to improve detection.

1. Pay Attention To The Documentation

One thing to pay attention to is the patient’s documented vitals EARLY, although one should take them with a grain of salt as it is known that certain vitals may not be documented correctly. The earlier one detects SIRS criteria, the earlier the diagnosis of early sepsis can be established. Also pay attention to certain complaints that the patient expresses to the nurse, as the patient may forget to express certain symptoms to his or her physician and the nurse may pick up on something else. Many lawsuits or misses have been found from discrepancy between nurses’ and doctors’ documentation, so glancing at all documentation may save money and a life.

2. Maximize Clinical Bedside Medicine

In addition to observing the patient’s vitals, a good practice is to disrobe the patient and to use clinical bedside medicine efficiently. Disrobing patients may reveal an underlying rash or cellulitis. Feeling the skin may reveal cold peripheries or clamminess. Utilizing the stethoscope may reveal lower lobe consolidations indicating pneumonia or a new onset murmur indicating possible endocarditis. Utilize the ultrasound to assess the gallbladder or appendix. There is so much to be gathered from actually doing what physicians do best: seeing, speaking to, and examining the patient.

3. Don’t Miss A Source

Even though the most common sources are lung, urine, and intraabdominal processes[16], other sources must not be overlooked. With each patient, it may be useful to use the mnemonic LUCCASSS: Lung, Urine, CNS, Cardiac, Abdomen, Skin, Spine, and Septic Arthritis to assist in covering all possible etiologies of sepsis in order to assist in changing the diagnosis from SIRS positive to sepsis.

Please see a prior emDocs post on Sepsis and Sources: http://www.emdocs.net/the-sepsis-patient-not-improving-after-iv-fluids-and-resuscitation-what-should-be-considered-how-can-we-improve/

4. Practice Worse Case Scenario Emergency Medicine

Everyone has sepsis until proven otherwise! Unfortunately with the SIRS criteria, if you have a fever and tachycardia, you are possibly septic and care should be taken to assure that the patient doesn’t have a source. Although the patient may be triaged as a “lower acuity” patient, ED physicians must avoid the wellness bias and focus on ruling out sepsis.

5. Trust your own clinical suspicion and don’t be distracted by a checklist of criteria

Even though a checklist may be used to guide clinical management, physicians are not slaves to it. Unlike checklists, physicians are able to use their own clinical suspicion and experience to guide management. If every patient with +SIRS criteria was actually admitted to the hospital, physicians would not be able to treat everyone else. On the other hand, if physicians discharged every patient that did not meet SIRS criteria despite clinical suspicion, many lives would be in jeopardy. The best advice is to avoid becoming slaves of a checklist criterion. Instead use it as an adjunct to clinical medicine.

6. Don’t forget the bands

Other than vitals, WBC is listed as a criterion of SIRS. WBC can be normal in 30-40% of patients with sepsis[11]. Yet, adding a differential to the CBC in the ED can assist in catching early sepsis. In one study looking at patients with normal leukocyte counts, it was found that higher band counts were associated with greater likelihood of having any significant positive culture, but particularly with positive blood cultures and C. difficile infection[17]. Word of advice: before you discharge a patient from the ED with a normal WBC count and negative SIRS, wait for the differential and assure that bandemia is not present. 

7. Lactate, Procalcitonin, and CRP

Lactate is already a validated screening tool for sepsis, but other biomarkers are being studied, such as procalcitonin and CRP. For example, Tromp and colleagues studied a panel of biomarkers in patients presenting to the ED with suspected sepsis and found that the procalcitonin had the best predictive value of bacteremia[18].  Unfortunately, there is not sufficient information to confirm the routine use of procalcitonin and CRP in all septic patients.

8. Establishing a Sepsis Protocol

Implementing a sepsis protocol at triage can prove useful. This could be done by educating and training nursing staff in detecting possible septic patients at triage as well as obtaining screening tools such as point-of-care lactate levels. This could be further facilitated by utilizing computer-based screening tools in EDs that use electronic medical records, which could flag patients with +SIRS criteria.

9. Using EMS

Since EMS is the first to see many patients with sepsis, establishing early intervention in the pre-hospital setting could be an appropriate target. In a pilot prospective cohort study conducted in the pre-hospital setting, early identification of providers utilizing a screening tool and a point-of-care venous lactate meter was shown to be feasible[19]. Unfortunately many EMS systems have not established sepsis care bundles, a target for intervention.

References/Further Reading

[1] Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001; 29:1303-10.

[2] Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992; 101:1644-55.

[3] Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B et al.. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001; 345:1368-77.

[4] Yealy, D., Huang, D., Delaney, A., Knight, M., Randolph, A., Daniels, R., & Nutbeam, T. Recognizing and managing sepsis: What needs to be done? BMC Medicine BMC Med 2015; 13:98.

[5] Cooper RJ, Schriger DL, Flaherty HL, Lin EJ, Hubbell KA. Effect of vital signs on triage decisions. Ann Emerg Med 2002; 39: 223-232.

[6] Pines JM, Prosser JM, Everett WW, Goyal M. Predictive values of triage temperature and pulse for antibiotic administration and hospital admission in elderly patients with potential infection. Am J Emerg Med 2006; 24: 679-683.

[7] Gravel J, Opatrny L, Gouin S. High rate of missing vital signs data at triage in a paediatric emergency department. Paediatr Child Health 2006; 11: 211-215.

[8] Thompson M, Coad N, Harnden A, Mayon-White R, Perera R, Mant D. How well do vital signs identify children with serious infections in paediatric emergency care? Arch Dis Child 2009; 94: 888- 893.

[9] Cienki, J., Deluca, L., & Daniel, N. The Validity of Emergency Department Triage Blood Pressure Measurements. Acad Emergency Med Academic Emergency Medicine, 2004; 11(3), 237-243.

[10] Lovett, P., Buchwald, J., Stürmann, K., & Bijur, P. The vexatious vital: Neither clinical measurements by nurses nor an electronic monitor provides accurate measurements of respiratory rate in triage. Annals of Emergency Medicine, 2005; 45(1), 68-76.

[11] Kaukonen K-M, Bailey M, Pilcher D, Cooper DJ, Bellomo R. Systemic Inflammatory Response Syndrome Criteria In Defining Severe Sepsis. New England journal of Medicine. 2015.

[12] Obstetrics & Gynecology, Vol. 120, No. 3, Sept.2012, p.689-706.

[13] Goldstein B, Giroir B, Randolph A. International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definition for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care med. 2005; 6: 2-8.

[14] Munford, Robert S.; Suffredini, Anthony F. (2014).”Ch. 75: Sepsis, Severe Sepsis and Septic Shock”. In Bennett, John E.; Dolin, Raphael; Blaser, Martin J.; Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases (8th ed.). Philadelphia: Elsevier Health Sciences. pp. 914–34.

[15] Perman S, et al. (2012). Initial Emergency Department Diagnosis and Management of Adult Patients with Severe Sepsis and Septic Shock. Retrieved July 15, 2013 from http://www.sjtrem.com/content/20/1/41.

[16] Angus, D & Poll, Tom van der. Severe Sepsis and Septic Shock. N Engl J Med 2013; 369: 840-851.

[17] Drees, M., Kanapathippillai, N., & Zubrow, M. Bandemia with Normal White Blood Cell Counts Associated with Infection. The American Journal of Medicine, 2012; 125(11).

[18] Tromp M, Lansdrop B, Bleeker-Rovers CP, Gunnewiek JM, Kullberg BJ, Pickkers P: serial and panel analyses of biomarkers do not improve the prediction of bacteremia compared to one procalcitonin measurement. J Infect 2012, 65:292-301.

[19] Guerra WF, Mayfield TR, Meyers MS , Clouatre AE, Riccio JC. Early detection and treatment of patients with severe sepsis by prehospital personnel. J Emerg Med. 2013; 44:1116-25.