Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Many patients meeting criteria for severe sepsis are not given a sepsis-relateddiagnosis by emergency physicians (EP). This study 1) compares emergency department (ED)interventions and in-hospital outcomes among patients with severe sepsis, based on the presenceor absence of sepsis-related diagnosis, and 2) assesses how adverse outcomes relate to three-hoursepsis bundle completion among patients fulfilling severe sepsis criteria but not given a sepsisrelateddiagnosis.

Methods: We performed a retrospective cohort study using patients meeting criteria for severesepsis at two urban, academic tertiary care centers from March 2015 through May 2015. Weincluded all ED patients with the following: 1) the 1992 Consensus definition of severe sepsis,including two or more systemic inflammatory response syndrome criteria and evidence of organdysfunction; or 2) physician diagnosis of severe sepsis or septic shock. We excluded patientstransferred to or from another hospital and those <18 years old. Patients with an EP-assignedsepsis diagnosis created the “Physician Diagnosis” group; the remaining patients composed the“Consensus Criteria” group. The primary outcome was in-hospital mortality. Secondary outcomesincluded completed elements of the current three-hour sepsis bundle; non-elective intubation;vasopressor administration; intensive care unit (ICU) admission from the ED; and transfer to theICU in < 24 hours. We compared proportions of each outcome between groups using the chi-squaretest, and we also performed a stratified analysis using chi square to assess the association betweenfailure to complete the three-hour bundle and adverse outcomes in each group.

Results: Of 418 patients identified with severe sepsis we excluded 54, leaving 364 patients foranalysis: 121 “Physician Diagnosis” and 243 “Consensus Criteria.” The “Physician Diagnosis” grouphad a higher in-hospital mortality (12.4% vs 3.3%, P < 0.01) and compliance with the three-hour sepsisbundle (52.1% vs 20.2%, P < 0.01) compared with the “Consensus Criteria” group. An incompletethree-hour sepsis bundle was not associated with a higher incidence of death, intubation, vasopressoruse, ICU admission or transfer to the ICU in <24 hours in patients without a sepsis diagnosis.

Conclusion: “Physician Diagnosis” patients more frequently received sepsis-specific interventionsand had a higher incidence of mortality. “Consensus Criteria” patients had infrequent adverseoutcomes regardless of three-hour bundle compliance. EPs’ sepsis diagnoses reflect riskstratificationbeyond the severe sepsis criteria.