Dynamic Fluid Response Measures to Guide Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment

ObjectiveTo derive and validate a new clinical prediction rule to risk-stratify emergency department (ED) patients admitted with suspected sepsis.DesignRetrospective prognostic study of prospectively collected data.SettingED.ParticipantsPatients aged ≥18 years who met two Systemic Inflammatory Response Syndrome criteria or one Red Flag sepsis criteria on arrival, received intravenous antibiotics for a suspected infection and admitted.Primary outcome measureIn-hospital all-cause mortality.MethodThe data were divided into derivation and validation cohorts. The simplified-Mortality in Severe Sepsis in the ED score and quick-SOFA scores, refractory hypotension and lactate were collectively termed ‘component scores’ and cumulatively termed the ‘Risk-stratification of ED suspected Sepsis (REDS) score’. Each patient in the derivation cohort received a score (0–3) for each component score. The REDS score ranged from 0 to 12. The component scores were subject to univariate and multivariate logistic regression analyses. The receiver operator characteristic (ROC) curves for the REDS and the components scores were constructed and their cut-off points identified. Scores above the cut-off points were deemed high-risk. The area under the ROC (AUROC) curves and sensitivity for mortality of the high-risk category of the REDS score and component scores were compared. The REDS score was internally validated.Results2115 patients of whom 282 (13.3%) died in hospital. Derivation cohort: 1078 patients with 140 deaths (13%). The AUROC curve with 95% CI, cut-off point and sensitivity for mortality (95% CI) of the high-risk category of the REDS score were: derivation: 0.78 (0.75 to 0.80); ≥3; 85.0 (78 to 90.5). Validation: 0.74 (0.71 to 0.76); ≥3; 84.5 (77.5 to 90.0). The AUROC curve and the sensitivity for mortality of the REDS score was better than that of the component scores. Specificity and mortality rates for REDS scores of ≥3, ≥5 and ≥7 were 54.8%, 88.8% and 96.9% and 21.8%, 36.0% and 49.1%, respectively.ConclusionThe REDS score is a simple and objective score to risk-stratify ED patients with suspected sepsis.

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Application of Lean principles to improve early cardiac care in the emergency department

CJEM ◽

10.2310/8000.2011.110284 ◽

2011 ◽

Vol 13 (05) ◽

pp. 325-332 ◽

Cited By ~ 9

Author(s):

Zoë Piggott ◽

Erin Weldon ◽

Trevor Strome ◽

Alecs Chochinov

Keyword(s):

Emergency Department ◽

Cardiac Care ◽

Early Care ◽

Rapid Improvement ◽

Lean Principles ◽

Standard Work ◽

Coronary Syndrome ◽

Physician Assessment ◽

Before And After ◽

Electrocardiogram Ecg

ABSTRACTObjective:To achieve our goal of excellent emergency cardiac care, our institution embarked on a Lean process improvement initiative. We sought to examine and quantify the outcome of this project on the care of suspected acute coronary syndrome (ACS) patients in our emergency department (ED).Methods:Front-line ED staff participated in several rapid improvement events, using Lean principles and techniques such as waste elimination, supply chain streamlining, and standard work to increase the value of the early care provided to patients with suspected ACS. A chart review was also conducted. To evaluate our success, proportions of care milestones (first electrocardiogram [ECG], ECG interpretation, physician assessment, and acetylsalicylic acid [ASA] administration) meeting target times were chosen as outcome metrics in this before-and-after study.Results:The proportion of cases with 12-lead ECGs completed within 10 minutes of patient triage increased by 37.4% (p< 0.0001). The proportion of cases with physician assessment initiated within 60 minutes increased by 12.1% (p= 0.0251). Times to ECG, physician assessment, and ASA administration also continued to improve significantly over time (pvalues < 0.0001). Post-Lean, the median time from ECG performance to physician interpretation was 3 minutes. All of these improvements were achieved using existing staff and resources.Conclusions:The application of Lean principles can significantly improve attainment of early diagnostic and therapeutic milestones of emergency cardiac care in the ED.

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Nursing care of patient emergencies

Oxford Handbook of Adult Nursing ◽

10.1093/med/9780199231355.003.0033 ◽

2009 ◽

pp. 1023-1108

Keyword(s):

Emergency Department ◽

Nursing Care ◽

Emergency Situation ◽

First Aid ◽

Hospital Environment ◽

The Unconscious ◽

Unconscious Patient ◽

Medical Emergencies

Part 1. General principles of first aid for nurses outside the emergency department environment Medical emergencies 1025 General principles of first aid for nurses 1026 Priorities when faced with an emergency situation 1028 Care of the unconscious patient (both within and outside the hospital environment) ...

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The Mortality in Emergency Department Sepsis Score as a Predictor of 1-Month Mortality among Adult Patients with Sepsis: Weighing the Evidence

ISRN Emergency Medicine ◽

10.1155/2013/896802 ◽

2013 ◽

Vol 2013 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Bayushi Eka Putra ◽

Ling Tiah

Keyword(s):

Emergency Department ◽

Outcome Measure ◽

Selection Process ◽

Area Under The Curve ◽

C Reactive Protein ◽

Consensus Process ◽

Suspected Sepsis ◽

Reactive Protein ◽

Sepsis Score ◽

Better Than

Objective. To evaluate the performance of Mortality in Emergency Department Sepsis (MEDS) score in comparison to biomarkers as a predictor of mortality in adult emergency department (ED) patients with sepsis. Methods. A literature search was performed using PubMed, ScienceDirect, SpringerLink, and Ovid databases. Studies were appraised by using the C2010 Consensus Process for Levels of Evidence for prognostic studies. The respective values for area under the curve (AUC) were obtained from the selected articles. Results. Four relevant articles met the selection process. Three studies defined the 1-month mortality as death occurring within 28 days of ED presentation, while the remaining one subcategorised the outcome measure as (5-day) early and (6- to 30-day) late mortality. In all four studies, the MEDS score performed better than the respective comparators (C-reactive protein, lactate, procalcitonin, and interleukin-6) in predicting mortality with an AUC ranging from 0.78 to 0.89 across the studies. Conclusion. The MEDS score has a better prognostic value than the respective comparators in predicting 1-month mortality in adult ED patients with suspected sepsis.

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Academy of Emergency Medicine and Care-Society of Clinical Biochemistry and Clinical Molecular Biology consensus recommendations for clinical use of sepsis biomarkers in the emergency department

Emergency Care Journal ◽

10.4081/ecj.2017.6877 ◽

2017 ◽

Vol 13 (2) ◽

Cited By ~ 2

Author(s):

Giuseppe Lippi ◽

Martina Montagnana ◽

Fiamma Balboni ◽

Andrea Bellone ◽

Ivo Casagranda ◽

...

Keyword(s):

Emergency Department ◽

Emergency Medicine ◽

Clinical Biochemistry ◽

Clinical Information ◽

Clinical Value ◽

Suspected Sepsis ◽

Consensus Document ◽

Diagnostic Threshold ◽

High Negative Predictive Value ◽

Routine Assessment

Increasing evidence is emerging that the measurement of circulating biomarkers may be clinically useful for diagnosing and monitoring sepsis. Eight members of AcEMC (Academy of Emergency Medicine and Care) and eight members of SIBioC (Italian Society of Clinical Biochemistry and Laboratory Medicine) were identified by the two scientific societies for producing a consensus document aimed to define practical recommendations about the use of biomarkers for diagnosing of sepsis and managing antibiotic therapy in the emergency department (ED). The cumulative opinions allowed defining three grade A recommendations (i.e., highly recommended indications), entailing ordering modality (biomarkers always available on prescription), practical use (results should be interpreted according to clinical information) and test ordering defined according to biomarker kinetics. Additional grade B recommendations (i.e., potentially valuable indications) entailed general agreement that biomarkers assessment may be of clinical value in the diagnostic approach of ED patients with suspected sepsis, suggestion for combined assessment of procalcitonin (PCT) and Creactive protein (CRP), free availability of the selected biomarker(s) on prescription, adoption of diagnostic threshold prioritizing high negative predictive value, preference for more analytically sensitive techniques, along with potential clinical usefulness of measuring PCT for monitoring antibiotic treatment, with serial testing defined according to biomarker kinetics. PCT and CRP were the two biomarkers that received the largest consensus as sepsis biomarkers (grade B recommendation), and a grade B recommendation was also reached for routine assessment of blood lactate. The assessment of biomarkers other than PCT and CRP was discouraged, with exception of presepsin for which substantial uncertainty in favor or against remained.

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