By Stacey Kusterbeck
Better measures are needed to identify sepsis in patients presenting to the ED, says Chadd Kraus, DO, DrPH, FACEP, an attending emergency physician (EP) and system director of emergency medicine research at Geisinger Medical Center in Danville, PA.
Kraus and colleagues analyzed responses from 26 members of an expert consensus panel regarding sepsis diagnostics in the ED.1 The panel included experts in the fields of emergency medicine, intensive care, pharmacology, and pathology. They concluded there are significant gaps in tools used to assess the risk of sepsis in the ED.
There was a strong consensus among participants regarding the need for a test to indicate the severity of dysregulated host immune response. There was some uncertainty over which patients would benefit most from such a test. However, the panel did agree that ideally, the sepsis test should be conducted at triage and produce results in less than 30 minutes.
The panel also agreed the test would be most valuable for achieving better sepsis outcomes and for alleviating the need for unnecessary antibiotics. “Rapid diagnostic tests could help to improve timely diagnosis of sepsis, particularly in patients presenting to the ED with symptoms that might not initially appear as sepsis-related,” Kraus says.
It is critically important to detect sepsis early and initiate treatment. “Delays and misdiagnosis can increase morbidity and mortality [rates] among patients with sepsis,” Kraus warns.
Patients with sepsis, particularly those who present without clinical signs and symptoms to suggest an infection during initial evaluation, can present a diagnostic challenge. “As a result, there could be a delay in the diagnosis of sepsis,” Kraus says. “These rapid diagnostic tests might help to ensure diagnosis early in the ED visit so treatment can be initiated.”
Allegations of delayed identification or treatment of sepsis are common allegations in malpractice claims against EPs.2 “As with any delays in diagnosis for time-sensitive conditions, delays in sepsis diagnosis and treatment could present medico-legal risks to emergency physicians,” Kraus cautions. One contributing factor to bad outcomes in sepsis patients is that EDs lack access to diagnostic testing to help predict the risk of sepsis in a timely manner. “Historically, so much of the work around sepsis patients or patients with bloodstream infection is focused on pathogen detection,” says Nathan A. Ledeboer, PhD, professor and vice chair in the department of pathology at the Medical College of Wisconsin.
For example, emergency staff might use lactate, serum procalcitonin, and C-reactive protein to assist in decision-making when sepsis is suspected. In many cases, these tests are not specific for sepsis, and are markers of inflammation. Then, there are the pathogen detection tests, which aim to identify the causative pathogen of sepsis earlier.
“We call those sepsis diagnostic tests. The reality is, they’re not sepsis diagnostic tests. They’re pathogen detection tests,” Ledeboer argues.
There are new technologies going to market that actually are sepsis risk prediction tools. These will allow EDs to predict who is likely to be septic, and who is not likely to be septic, with better accuracy and consistency. “Currently, so much of what we are doing is reliant upon clinical expertise. If we can narrow that by adding an additional data point, that may help us to be more consistent in identifying who is potentially septic and needs more directed care or admission, and who’s at lower risk,” Ledeboer offers.
The tools have only just emerged in the past six to 18 months. Thus, more data are needed on how the tools perform in various kinds of EDs (e.g., departments in academic medical centers vs. units in community hospitals or critical access facilities). Leaders need to consider not only whether to implement a new technology, but also how the department can leverage the greatest benefit from the tool. The expertise of a multidisciplinary team is needed to inform these decisions. Input from emergency medicine, infectious disease, lab medicine, nursing, and critical care experts is vital. “The first thing EDs can do, right now, is make sure their sepsis teams are reflective of all of the different areas of expertise needed to look at these technologies,” Ledeboer says. “EDs also need to stay on top of where the literature is going with this.”
The new technologies are expected to provide a result for septic patients in a similar time frame to cardiac troponin levels for patients with suspected myocardial infarction. “Just like myocardial infarction, sepsis is a medical emergency,” Ledeboer stresses.
With better tools at their disposal, EPs can make a more informed, faster decision on how to manage septic patients.
“It ultimately comes down not only to delivering better care, but delivering better care as quickly as we possibly can,” Ledeboer says. “That’s exactly where we need to take sepsis care.”
REFERENCES
1. Kraus CK, Nguyen HB, Jacobsen RC, et al. Rapid identification of sepsis in the emergency department. J Am Coll Emerg Physicians Open 2023;4:e12984.
2. Neilson HK, Fortier JH, Finestone PJ, et al. Diagnostic delays in sepsis: Lessons learned from a retrospective study of Canadian medico-legal claims. Crit Care Explor 2023;5:e0841.
An expert panel agreed a test is needed to indicate the severity of dysregulated host immune response. Although there was some uncertainty over which patients would benefit most from such a test, the panel agreed the sepsis test should be conducted at triage and produce results in less than 30 minutes.
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