In the continuing quest to accelerate time to treatment for sepsis patients who present to the ED, investigators at Intermountain Healthcare in Utah have begun to focus not on patient factors, but what clinicians and systems can do to make a difference in this area. One of their findings offers intriguing possibilities.
Investigators, supervised by Ithan Peltan, MD, MSc, the senior author of the study and an attending physician in the shock trauma ICU at Intermountain Medical Center and Intermountain Healthcare TeleCritical Care in Salt Lake City, found a link between the triage score assigned to a patient and how long he or she has to wait before receiving antibiotics.
The discovery provides a potential new target for emergency providers grasping for different ways to improve their care of patients with a condition that is both more deadly and common than stroke or heart attack, but much more difficult to diagnose. “There are many reasons why we care about early treatment of sepsis, the most important being that early, appropriate treatment of patients with sepsis seems to improve outcomes,” Peltan explains. “In particular, the data seem to be strongest for early antibiotics.”
For instance, Peltan notes that his group and many others have published data using retrospective methods that suggest there is a strong and linear association between door to antibiotic times and sepsis mortality. “‘Every hour matters’ is the mantra that has been adopted,” he says. “The challenge then is to understand what are the factors that help us deliver door to antibiotics efficiently and what factors can get in our way.”
For this study, researchers considered whether a one-point difference in the score assigned to a patient at triage in the ED is associated with a difference in door to antibiotics time for patients who are otherwise similar. Specifically, the researchers focused on those patients assigned a triage score of 2, signaling “emergent,” compared to a triage score of 3, signaling “urgent.” The study included sepsis patients who were treated in four Intermountain Healthcare EDs in Utah between July 2013 and January 2017. During this period, 591 sepsis patients received a triage score of 2 in the ED, and 208 received a triage score of 3. Investigators analyzed these cases, determining that the patients assigned a triage score of 3 waited an average of 32 minutes longer to receive antibiotics than the patients assigned a triage score of 2.
How much of a difference might 32 minutes make in terms of outcomes? Peltan notes that his data suggest this translates into about a 0.5% increase in absolute mortality. This difference may not sound like much until one considers how common a diagnosis of sepsis is in the ED. “Our data and other data show somewhere on the order of 1% to 3% of all adult ED patients meet sepsis criteria,” he says. “Then, when you apply [the 0.5% increase in absolute mortality] at the population level, this could be very important.”
It is difficult to ascertain precisely why patients with similar characteristics were assigned different triage scores, Peltan notes. “While triage nurses are very experienced in using these [triage scales], and certainly such scales have standardized approaches and criteria, there is a certain amount of subjectivity that goes into assigning a triage score,” he says. Also, Peltan says that there may have been some differences between the two groups of patients that investigators were simply unable to pick up through objective measures.
The more important question may be what can be done to facilitate quicker recognition of sepsis so that all patients with the condition receive accelerated care. Peltan would like to see improved tools to alert clinicians of a potential sepsis case. “We certainly don’t have a single diagnostic tool like an ECG that we use for MI [myocardial infarction] recognition or the sort of straightforward clinical assessment that we use for stroke recognition that pulls those patients out of the standard triage protocols and into separate pathways that allow clinicians to meet aggressive time to treatment goals that have been established for those conditions,” he explains.
Peltan advises that improved informatics and more advanced machine learning approaches could deliver more accurate sepsis screening tools capable of changing provider behavior. “With the current tools, there is too little accuracy to completely change our protocols based on their information alone,” he says. Peltan adds that some other health systems are working on such tools. His own group is interested in developing a tool for the improved recognition of sepsis, too.
Another step that Peltan would like to see is better recognition of sepsis as a medical emergency, both at triage in the ED and in the prehospital setting. “This would help triage nurses and others prioritize the care of these patients,” he offers. Like the model for MIs and strokes, there should be a designated pathway for treatment for sepsis patients. “Recognition at all stages of the healthcare system can help get these patients the care they need,” Peltan says.
Some hospitals have begun using sepsis teams that are activated when sepsis is suspected as opposed to after it is diagnosed. “These are attractive in that they address the delay to diagnosis, which does seem to be a big part of delayed treatment,” Peltan says. “Conceptually, it should also help to minimize the risk of overtreatment or the risk of giving antibiotics to everyone with possible sepsis as a solution to the door to antibiotics treatment challenge.”