Keywords reflecting sepsis presentation based on mode of emergency department arrival: a retrospective cross-sectional study

Background Current sepsis screening tools are predominantly based on vital signs. However, patients with serious infections frequently present with normal vital signs and there has been an increased interest to include other variables such as symptoms in screening tools to detect sepsis. The majority of patients with sepsis arrive to the emergency department by emergency medical services. Our hypothesis was that the presentation of sepsis, including symptoms, may differ between patients arriving to the emergency department by emergency medical services and patients arriving by other means. This information is of interest to adapt future sepsis screening tools to the population in which they will be implemented. The aim of the current study was to compare the prevalence of keywords reflecting the clinical presentation of sepsis based on mode of arrival among septic patients presenting to the emergency department. Methods Retrospective cross-sectional study of 479 adult septic patients. Keywords reflecting sepsis presentation upon emergency department arrival were quantified and analyzed based on mode of arrival, i.e., by emergency medical services or by other means. We adjusted for multiple comparisons by applying Bonferroni-adjusted significance levels for all comparisons. Adjustments for age, gender, and sepsis severity were performed by stratification. All patients were admitted to the emergency department of Södersjukhuset, Stockholm, and discharged with an ICD-10 code compatible with sepsis between January 1, and December 31, 2013. Results “Abnormal breathing” (51.8% vs 20.5%, p value < 0.001), “abnormal circulation” (38.4% vs 21.3%, p value < 0.001), “acute altered mental status” (31.1% vs 13.1%, p value < 0.001), and “decreased mobility” (26.1% vs 10.7%, p value < 0.001) were more common among patients arriving by emergency medical services, while “pain” (71.3% vs 40.1%, p value < 0.001) and “risk factors for sepsis” (50.8% vs 30.8%, p value < 0.001) were more common among patients arriving by other means. Conclusions The distribution of most keywords related to sepsis presentation was similar irrespective of mode of arrival; however, some differences were present. This information may be useful in clinical decision tools or sepsis screening tools.

Performance of NEWS2, RETTS, clinical judgment and the Predict Sepsis screening tools with respect to identification of sepsis among ambulance patients with suspected infection: a prospective cohort study

Background There is little evidence of which sepsis screening tool to use in the ambulance setting. The primary aim of the current study was to compare the performance of NEWS2 (National Early Warning score 2) and RETTS (Rapid Emergency Triage and Treatment System) with respect to identification of sepsis among ambulance patients with clinically suspected infection. The secondary aim was to compare the performance of the novel Predict Sepsis screening tools with that of NEWS2, RETTS and clinical judgment. Methods Prospective cohort study of 323 adult ambulance patients with clinically suspected infection, transported to hospitals in Stockholm, during 2017/2018. The sensitivity, specificity, and AUC (Area Under the receiver operating Curve) were calculated and compared by using McNemar´s test and DeLong’s test. Results The prevalence of sepsis in the current study population was 44.6% (144 of 323 patients). No significant difference in AUC was demonstrated between NEWS2 ≥ 5 and RETTS ≥ orange. NEWS2 ≥ 7 demonstrated a significantly greater AUC than RETTS red. The Predict Sepsis screening tools ≥ 2 demonstrated the highest sensitivity (range 0.87–0.91), along with RETTS ≥ orange (0.83), but the lowest specificity (range 0.39–0.49). The AUC of NEWS2 (0.73) and the Predict Sepsis screening tools (range 0.75–0.77) was similar. Conclusions The results indicate that NEWS2 could be the better alternative for sepsis identification in the ambulance, as compared to RETTS. The Predict Sepsis screening tools demonstrated a high sensitivity and AUCs similar to that of NEWS2. However, these results need to be interpreted with caution as the Predict Sepsis screening tools require external validation. Trial registration: ClinicalTrials.gov, NCT03249597. Registered 15 August 2017—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03249597.

Sepsis knowledge, skills and attitudes among ward-based nurses

Background: Nurses are in a prime position to identify sepsis early by screening patients for sepsis, a skill that should be embedded into their daily practice. However, compliance with the sepsis bundle remains low. Aims: To explore the effects of sepsis training on knowledge, skills and attitude among ward-based nurses. Methods: Registered nurses from 16 acute surgical and medical wards were invited to anonymously complete a questionnaire. Findings: Response rate was 39% (98/250). Nurses with sepsis training had better knowledge of the National Early Warning Score 2 for sepsis screening, and the systemic inflammatory response syndrome (SIRS) criteria, demonstrated a more positive attitude towards sepsis screening and management, were more confident in screening patients for sepsis and more likely to have screened a patient for sepsis. Conclusions: Sepsis training improves nurses' attitudes, knowledge and confidence with regards to sepsis screening and management, resulting in adherence to evidence-based care, and should become mandatory for all clinical staff.

Diagnostic Utility of Cord Blood Serum Procalcitonin in Early Onset Neonatal Sepsis in Comparision to Sepsis Screening Parameters

Neonatal sepsis is an important cause of neonatal deaths globally. Diagnosis of neonatal sepsis is established based on microbiological tests of sepsis screen and clinical status. Mid phase markers of inflammation like CRP & Serum Procalcitonin are considered useful and sensitive for diagnosis. Most of the studies evaluating serum PCT as a diagnostic marker for neonatal septicemia have been carried out in peripheral venous blood with smaller sample sizes with inclusion of neonates without considering perinatal sepsis score. This hospital based, prospective study compares the diagnostic utility of cord blood Procalcitonin (PCT) with venous blood PCT; alone and as part of sepsis screening parameters currently in use in perinatal sepsis score positive neonates. Statistical analysis for cord blood Serum Procalcitonin (PCT) for detecting blood culture positive patients showed that PCT has a sensitivity of 44.4%, a high specificity of 86.4%, a low PPV of 33.3% and a high NPV of 91.1%. Overall diagnostic accuracy is 80.9%, indicating that cord blood PCT is a good test for identifying these patients (p < 0.05). However, venous blood PCT failed to demonstrate similar results. Conclusions- Umbilical blood sampling protects the neonates from pain of venipunctures. Cord blood PCT estimations have statistically significant correlation with blood culture and other sepsis screen parameters and better sensitivity and specificity than venous blood PCT. This early serological biomarker is valuable for the diagnostic armamentarium of neonatal septicemia for early diagnosis and management while awaiting blood culture reports and helps in reducing separation of probable sepsis neonates from mother, thus contributing in developmental supportive care.

Independent Validation of Sepsis Index for Sepsis Screening in the Emergency Department

(1) Background: The early detection of sepsis is still challenging, and there is an urgent need for biomarkers that could identify patients at a high risk of developing it. We recently developed an index, namely the Sepsis Index (SI), based on the combination of two CBC parameters: monocyte distribution width (MDW) and mean monocyte volume (MMV). In this study, we sought to independently validate the performance of SI as a tool for the early detection of patients at a high risk of sepsis in the Emergency Department (ED). (2) Methods: We enrolled all consecutive patients attending the ED with a request of the CBC. MDW and MMV were measured on samples collected in K3-EDTA tubes on the UniCel DxH 900 haematology analyser. SI was calculated based on the MDW and MMV. (3) Results: We enrolled a total of 703 patients stratified into four subgroups according to the Sepsis-2 criteria: control (498), infection (105), SIRS (52) and sepsis (48). The sepsis subgroup displayed the highest MDW (median 27.5, IQR 24.6–32.9) and SI (median 1.15, IQR 1.05–1.29) values. The ROC curve analysis for the prediction of sepsis showed a good and comparable diagnostic accuracy of the MDW and SI. However, the SI displayed an increased specificity, positive predictive value and positive likelihood ratio in comparison to MDW alone. (4) Conclusions: SI improves the diagnostic accuracy of MDW for sepsis screening.