Hi Stuart, My musings...
Good points, particularly around the need for prospective identification. Having helped devise the CEM standards which have just been audited, we (UK Sepsis Group and GSA) recognise the importance of prospective ED identification. We do need to remember, though, that only around 30-40% of patients who have sepsis at any point in their hospital stay will qualify as severe sepsis within the ED. We also need to prospectively identify in wards/ on floors. This will present a challenge until we can adequately resource sepsis management. Using blood cultures to retrospectively identify is an imperfect workaround as c.50% will slip through the net (also may skew toward the better managed). Using Modified Early Warning Scores on wards to trigger screens is not bad but also imperfect- a typical MEWS trigger of >4 is only 50% specific and around 80% sensitive. We screen all with MEWS triggers plus all with elevated WCC (identified by electronic prompt) as a redundancy. Plenty of commercial and research bodies are exploring early recognition technologies using PCT, presepsin and others, and early pathogen identification. A number of UK EDs routinely measure lactate for all majors and non-injured minors: non-specific, but few would argue that hyperlactataemia merits urgent review! A big question is how to get the data gaps reliably filled in prospective screening- particularly the labs. Clearly we can't recommend a sepsis screen based on a single vital signs SIRS criterion alone, but it would be useful to know what the specificity of a clinical suspicion of infection + single vital signs SIRS criterion is for sepsis. Informatics systems can help/ automate but are not a currently realistic option for many- we (UK Sepsis Group in partnership with Sepsis Alliance) in common with many others including Welsh ICS and innumerate single centres are developing/ have developed not-for-profit simple apps to support early recognition by junior staff on the wards. Cheers Ron On Thu, Apr 12, 2012 at 9:07 PM, Stuart Nuttall <[email protected]>wrote: > Hi Dr Hess, > > I would certainly agree although appreciate there may be UK/US differences > > I've been involved in conducting the College of Emergency Medicine Sepsis > Audit for our ED this spring. Trying to identify the patients > retrospectively through coding (either hospital or ED coding systems) > failed to generate any meaningful data. > > In my opinion, given the current coding systems in use, prospective > identification of these patients using a screening tool in the ED may be > more reliable. This is then retained when the patient leaves the ED. These > patients can then be audited. I'm aware that for this method patients will > still slip though the net and the diagnosis may become more apparent once > they have hit the ward but it does seem to be an improvement on just using > coding. > > I think I remember someone mentioning on this list last year that they > chase up all patients through the ED (possibly hospital) who had blood > cultures or raised WCC's to try and ensure capture of as many patients as > possible - more thorough but more time consuming I guess. Would be > interested to hear what other departments do. > > Regards > > Dr Stuart Nuttall > Consultant in Emergency Medicine Leeds Teaching Hospitals. > > On 12 Apr 2012, at 13:09, Hess, Dr. Donald wrote: > > ** > > After reading a recent article in the April 4, 2012 issue of JAMA > (Lindauer PK, et al, Association of Diagnostic Coding With Trends in > Hospitalizations and Mortality of Patients With Pneumonia, 2003-2009 - > http://jama.ama-assn.org/content/307/13/1405.full), I decided to look at > my institution’s administrative data regarding the number of > hospitalizations in the past 4 years that were coded with the ICD9# for > either sepsis or severe sepsis as the primary diagnosis. There were none. > Zero. I have long suspected that one obstacle to diagnosing sepsis or > severe sepsis is that most physicians (and perhaps coders, too) regard it > as a secondary diagnosis. That sepsis is always secondary to something > else…not a primary diagnosis that represents a final common pathway due to > a number of different causes. There are likely a number of other cognitive > factors related to the avoidance of diagnosing sepsis and severe sepsis as > a primary diagnosis. But evidently physicians & coders at other > institutions are doing it. I look forward to your comments. **** > > Regards, **** > > Dr. **Don Hess** **** > > ** ** > _______________________________________________ > > Sepsisgroups mailing list > [email protected] > http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org > ** > > > > _______________________________________________ > Sepsisgroups mailing list > [email protected] > http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org > > -- Dr Ron Daniels CEO: Global Sepsis Alliance Chair: United Kingdom Sepsis Group Principal Trustee: U.K Sepsis Trust Founding Director: Survive Sepsis Fellow: NHS Improvement Faculty *Suspect Sepsis: save someone's life today. * *Join us for World Sepsis Day on September 13th<http://www.globalsepsisalliance.org/> Twitter: @sepsisuk * * *
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