cme/ce Emergency Medicine 4 Comments

Newman's Notes: Sepsis Mission Impossible

In an exception to the rule, Newman highlights a sepsis chart review study worth paying attention to.

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Action Points

  • In a recent study, 15% of patients at a university hospital and 9.8% of those seen at a trauma center didn't meet the criteria for severe sepsis criteria until more than 3 hours after they arrived.
  • Point out that the study calls into question the adoption of quality metrics that define time of presentation as ED arrival.


This week, Newman highlights a study from the Annals of Emergency Medicine called "Many ED patients with severe sepsis and septic shock do not meet diagnostic criteria within 3 hours of arrival."

A Rare Favorite

This article is one of my favorites. One of the reasons this article is the personal favorite is because it's a chart review, and you won't hear me saying very often that a chart review study is a personal favorite.

Chart reviews are full of bias, there are all kinds of problems in chart reviews. You often can't get very valid or reliable information.

However, there are certain types of information that are obtained from chart reviews -- things like laboratory values, or things like the times at which vital signs changed -- and those metrics are very valid, and very appropriate. This chart review asked an incredibly interesting question.

First of all, here's the background for this chart review. We know that sepsis is a huge problem. We've been noting and tracking sepsis for the last 20 years in this country and particularly in the last 10 or 15 years ever since early goal directed therapy became a big deal and we noticed that sepsis has a huge mortality associated with it.

Performance Metric Pipeline

These authors basically looked at the sepsis metrics in their two institutions, a university setting and a public trauma center -- retrospectively, for a total of 505 patients. Just like everybody, they're tracking sepsis metrics very closely, now as part of the quality improvement metrics. They looked at their QI metrics and said: "Hey, I wonder what's the point at which patients who were defined on chart review later as having had sepsis were actually sepsis or septic shock by the definable criteria of septic shock?"

In other words, we happen to know that there are a number of performance metrics coming down the pipe.

Some of them are pay for performance, they're incentives, some of them are punitive, some of them are just public reporting on hospital websites. When those metrics come down the line from the National Quality Forum and from the centers for Medicare and Medicaid services, we're all going to have to start treating sepsis with attention to those metrics.

And what are those metrics looking like? Well, it appears those metrics are going to ask us to invoke sepsis bundles. Something we're pretty much all already doing. But they're going to ask us to invoke those bundles within 3 hours of patients hitting the door.

Now, that all sounds good and well and fair and 3 hours ought to be enough time to start getting IV fluids on board and to deliver antibiotics and to send blood cultures.

However, we wouldn't do any of those things if patients weren't septic until more than 3 hours after they hit the door.

"Little" 15% and 10% Problem

So, we have a little problem here. The authors noticed that the quality metrics are assuming that patients are septic when they hit the door. But when they looked at their own data on their chart review, they found something fascinating.

They found that 15% (95% CI 11.9-19.3) of their patients at the university hospital and 9.8% (95% CI 5.5-15.7) in the trauma center didn't have the sepsis criteria until more than 3 hours after they hit the door.

Patients with septic shock tended to present within 3 hours from ED arrival more often than those with severe sepsis.

Now, the National Quality Forum and the CMS quality metrics that have currently been devised assume that patients were septic when they hit the door. But if it turns out that our sepsis patients who are usually captured and defined when they are diagnosed as sepsis and then discharged later on with a diagnosis code of sepsis; those patients didn't have sepsis or septic shock until 3 hours or more 10% of the time and 15% of the time in these institutions.

Mission: Impossible?

This is a nifty little chart review and what they've discovered is that in fact a huge proportion of patients who hit the door and then become septic later, become septic so much later that it would've been physically impossible to meet a quality metric that asks us to treat them within 3 hours because they weren't septic until more than 3 hours after they hit the door.

So, the final thing that I will point out is if you look at figure three in this article, you'll note that the median time in one of the institutions to patients actually having severe sepsis was 68 minutes. Now, median means half of the values are below and half of the values are above.

At the university hospital, median times from hitting the ED door to first sepsis criteria were 68 minutes (interquartile range 34 to 130 minutes) and at the trauma center, 31 minutes (interquartile range 8 to 73 minutes).

Half of those patients were not even septic until more than an hour after they hit the door making it either difficult or literally impossible to deliver the entire sepsis bundle until after the quality metric time was ticking down.

What that means to emergency departments and emergency physicians and everybody else who is interested in these quality metrics is that the NQS and the CMS are going to have to take a good, hard look at their quality metrics and make sure that they're not making it impossible for the emergency department folks who are trying to treat sepsis to treat it based on the quality metrics that they devise.

Newman and authors of the study reported no relevant financial disclosures.


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