Open Access Highly Accessed Original Research

Lack of clinically evident signs of organ failure affects ED treatment of patients with severe sepsis

Dirkjan Kakebeeke1, Alice Vis2, Ernie RJT de Deckere2, Maro H Sandel3 and Bas de Groot1*

Author Affiliations

1 Leiden University Medical Centre, Leiden, The Netherlands

2 Medical Centre Haaglanden, The Hague, The Netherlands

3 HAGA Hospital, The Hague, The Netherlands

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International Journal of Emergency Medicine 2013, 6:4  doi:10.1186/1865-1380-6-4

Published: 27 February 2013

Abstract

Background

It is not known whether lack of recognition of organ failure explains the low compliance with the “Surviving Sepsis Campaign” (SSC) guidelines. We evaluated whether compliance was higher in emergency department (ED) sepsis patients with clinically recognizable signs of organ failure compared to patients with only laboratory signs of organ failure.

Methods

Three hundred twenty-three ED patients with severe sepsis and septic shock were prospectively included. Multivariable binary logistic regression was used to assess if clinical and biochemical signs of organ failure were associated with compliance to a SSC-based resuscitation bundle. In addition, two-way analysis of variance was used to investigate the relation between the predisposition, infection, response and organ failure (PIRO) score (3 groups: 1–7, 8–14, 15–24) as a measure of illness severity and time to antibiotics with disposition to ward or ICU as effect modifier.

Results

One hundred twenty-five of 323 included sepsis patients with new-onset organ failure were admitted to the ICU, and in all these patients the SSC resuscitation bundle was started. Respiratory difficulty, hypotension and altered mental status as clinically recognizable signs of organ failure were independent predictors of 100% compliance and not illness severity per se. Corrected ORs (95% CI) were 3.38 (1.08–10.64), 2.37 (1.07–5.23) and 4.18 (1.92–9.09), respectively. Septic ED patients with clinically evident organ failure were more often admitted to the ICU compared to a ward (125 ICU admissions, P < 0.05), which was associated with shorter time to antibiotics [ward: 127 (113–141) min; ICU 94 (80–108) min (P = 0.005)].

Conclusions

The presence of clinically evident compared to biochemical signs of organ failure was associated with increased compliance with a SSC-based resuscitation bundle and admission to the ICU, suggesting that recognition of severe sepsis is an important barrier for successful implementation of quality improvement programs for septic patients. In septic ED patients admitted to the ICU, the time to antibiotics was shorter compared to patients admitted to a normal ward.

Keywords:
Severe sepsis; Septic shock; Emergency services hospital; “Surviving Sepsis Campaign,” Compliance; Protocol adherence