Reference: Knack et al. Early Physician Gestalt Versus Usual Screening Tools for the Prediction of Sepsis in Critically Ill Emergency Patients. Ann Emerg Med 2024
Date: July 25, 2024
Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called www.First10EM.com
Case: Your hospital is running Morbidity and Mortality (M&M) rounds after a few recent cases in which the diagnosis of sepsis was identified late, and antibiotics were delayed. They are planning on instituting a mandatory screening tool at triage, and one of the main purposes of the meeting is to compare the available tools, such as qSOFA and MEWS. As the local evidence-based medicine (EBM) nerd, they ask for your opinion on the evidence.
Background: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. It is a medical emergency that requires prompt recognition and treatment to improve patient outcomes. We have covered the topic of sepsis many times on the SGEM (SGEM#69, SGEM#90, SGEM#92, SGEM#113, SGEM#168, SGEM#174, SGEM Xtra, SGEM#346, SGEM#371 and SGEM Peds Xtra).
There is a lot of emphasis on identifying sepsis early, with the idea that early intervention will save lives. However, despite a strong push for early antibiotics, the evidence of benefit is mostly lacking. There is observational data that is widely cited to suggest that early completion of sepsis bundles improves outcomes but considering that physicians don’t purposefully delay antibiotics in patients with known sepsis, this data is severely limited by multiple confounders [1].
A randomized control trial (RCT) done in the prehospital setting enrolled 2,698 patients. They were randomized to ceftriaxone 2gm intravenous (IV) in the ambulance or usual cares (fluids and supplementary oxygen) until arrive to the ED. The primary outcome reported was no statistical difference in mortality at 28 days (8% in both groups) despite giving antibiotics 96 minutes earlier [2]. All of the secondary outcomes (mortality at 90 days, misdiagnoses, hospital length of stay, ICU admission rate, ICU length of stay, and quality of life) also did not show a statistical difference between the intervention group and the control group (SGEM#207).
Thus, early identification of sepsis might not be as important as sometimes stated in guidelines. However, getting the right diagnosis is clearly important for our patients, and as good as we are, no clinician is perfect. Acknowledging our imperfections, many have suggested that screening tools or decision tools might help increase accuracy when screening for sepsis. Many such tools exist, such as the Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), quick SOFA (qSOFA) and theModified Early Warning (MEWS) score.
Unfortunately, the enthusiasm for decision instruments often outstrips the evidence. For a decision instrument to benefit patients, it needs to have more than a high sensitivity. It needs to change physician practice for the better. It needs to be better than current clinical practice, or just plain clinical judgement. There is an article published in AEM, with an author list that includes the who’s who of decision rules – from Jeff Kline to Nathan Kupperman to my BFF Chris Carpenter. That document tells us “Before widespread implementation, CDRs should be compared to clinical judgement.” [3]
Unfortunately, most of our rules haven’t cleared this basic evidentiary hurdle. Dave Schriger and colleagues reviewed publications in the Annals of Emergency Medicine from 1998 to 2015 and found that only 11% of the studies compared decision aids to clinical judgement [4]. In those that did compare to clinical judgement, physician judgement was superior in 29% and equivalent or mixed in 46%. The decision aid only outperformed clinical judgement in 10% of papers (or two total trials). A similar review by Sanders et al 2015 concludes that clinica...
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