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

Introduction: Sepsis order sets improve compliance with the established guidelines, but clinicians must be careful to initiate these protocols on appropriate patients. Many conditions can mimic sepsis as defined by SEP-1 (two or more SIRS* criteria and a suspected infection) such as trauma, COPD, etc. SEP-1 criteria alone can lead to initiating a sepsis protocol without true infection based solely on vital signs.

Objective: To assess the incidence of patients who had a sepsis order set, but an infection was not discovered during their hospital course.

Methods: This study is a single-center retrospective chart review of all “SIRS positive” patients >21 years old who presented to a busy community ED who had the sepsis order set initiated from the emergency department in 2017. A total of 1577 encounters met inclusion criteria. The discharge diagnoses were reviewed to identify unique diagnoses. Similar diagnoses (e.g. RLQ abdominal pain and abdominal pain) were grouped together into the more generalized diagnosis. Several of the unique discharge diagnoses (161) were vague and required individual chart review by two people.

Results: Two hundred fifty-one unique discharge diagnoses were identified and then categorized as infectious or not. Conditions which may be inflammatory versus infectious (e.g. diverticulitis), but are classically treated with antibiotics were counted as infectious. One hundred sixty-one charts were reviewed by two physicians, of which, 130 (81%) were identified as having an infectious condition (K = 0.87). The most common sepsis mimic was abdominal pain, followed by COPD, and cough. A third (33.6%) did not have an infection identified.

Conclusion: SEP-1 criteria for diagnosis and treating sepsis are not specific, with one-third false positives. Identification criteria with higher specificity is needed, and may reduce healthcare expense.

*SIRS (Systemic Inflammatory Response Syndrome) is defined as temperature > 38C° or < 36C°, heart rate > 90 beats per minute, respiratory rate > 20 or PaCO2 < 32 mmHg, and WBC > 12k or < 4k/mm3.