Early diagnosis of sepsis in emergency departments, time to treatment, and association with mortality: An observational study

Autoři: Gunnar Husabø aff001;  Roy M. Nilsen aff003;  Hans Flaatten aff004;  Erik Solligård aff005;  Jan C. Frich aff007;  Gunnar T. Bondevik aff002;  Geir S. Braut aff009;  Kieran Walshe aff011;  Stig Harthug aff012;  Einar Hovlid aff001
Působiště autorů: Department of Social Science, Western Norway University of Applied Sciences, Sogndal, Norway aff001;  Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway aff002;  Department of Health and Functioning, Western Norway University of Applied Sciences, Bergen, Norway aff003;  Department of Clinical Medicine, University of Bergen, Bergen, Norway aff004;  Clinic of Anaesthesia and Intensive Care, St. Olavs Hospital, Trondheim, Norway aff005;  Department of Circulation and Medical Imaging and Mid-Norway Sepsis Research Group, Norwegian University of Science and Technology, Trondheim, Norway aff006;  Institute of Health and Society, University of Oslo, Oslo, Norway aff007;  National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway aff008;  Stavanger University Hospital, Stavanger, Norway aff009;  Norwegian Board of Health Supervision, Oslo, Norway aff010;  Alliance Manchester Business School, University of Manchester, Manchester, England, United Kingdom aff011;  Department of Research and Development, Haukeland University Hospital, Bergen, Norway aff012;  Department of Clinical Science, University of Bergen, Bergen, Norway aff013
Vyšlo v časopise: PLoS ONE 15(1)
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pone.0227652



Early recognition of sepsis is critical for timely initiation of treatment. The first objective of this study was to assess the timeliness of diagnostic procedures for recognizing sepsis in emergency departments. We define diagnostic procedures as tests used to help diagnose the condition of patients. The second objective was to estimate associations between diagnostic procedures and time to antibiotic treatment, and to estimate associations between time to antibiotic treatment and mortality.


This observational study from 24 emergency departments in Norway included 1559 patients with infection and at least two systemic inflammatory response syndrome criteria. We estimated associations using linear and logistic regression analyses.


Of the study patients, 72.9% (CI 70.7–75.1) had documented triage within 15 minutes of presentation to the emergency departments, 44.9% (42.4–47.4) were examined by a physician in accordance with the triage priority, 44.4% (41.4–46.9) were adequately observed through continual monitoring of signs while in the emergency department, and 25.4% (23.2–27.7) received antibiotics within 1 hour. Delay or non-completion of these key diagnostic procedures predicted a delay of more than 2.5 hours to antibiotic treatment. Patients who received antibiotics within 1 hour had an observed 30-day all-cause mortality of 13.6% (10.1–17.1), in the timespan 2 to 3 hours after admission 5.9% (2.8–9.1), and 4 hours or later after admission 10.5% (5.7–15.3).


Key procedures for recognizing sepsis were delayed or not completed in a substantial proportion of patients admitted to the emergency department with sepsis. Delay or non-completion of key diagnostic procedures was associated with prolonged time to treatment with antibiotics. This suggests a need for systematic improvement in the initial management of patients admitted to emergency departments with sepsis.

Klíčová slova:

Antibiotics – Critical care and emergency medicine – Death rates – Diagnostic medicine – Norwegian people – Physicians – Sepsis – triage


1. Rhee C, Dantes R, Epstein L, Murphy DJ, Seymour CW, Iwashyna TJ, et al. Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009–2014. JAMA. 2017;318(13):1241–9. doi: 10.1001/jama.2017.13836 28903154

2. Prescott HC, Osterholzer JJ, Langa KM, Angus DC, Iwashyna TJ. Late mortality after sepsis: propensity matched cohort study. BMJ. 2016;353:i2375. doi: 10.1136/bmj.i2375 27189000

3. Reinhart K, Daniels R, Kissoon N, Machado FR, Schachter RD, Finfer S. Recognizing Sepsis as a Global Health Priority—A WHO Resolution. N Engl J Med. 2017;377(5):414–7. doi: 10.1056/NEJMp1707170 28658587

4. Page DB, Donnelly JP, Wang HE. Community-, Healthcare-, and Hospital-Acquired Severe Sepsis Hospitalizations in the University HealthSystem Consortium. Crit Care Med. 2015;43(9):1945–51. doi: 10.1097/CCM.0000000000001164 26110490

5. Morr M, Lukasz A, Rübig E, Pavenstädt H, Kümpers P. Sepsis recognition in the emergency department–impact on quality of care and outcome? BMC Emerg Med. 2017;17(1):11. doi: 10.1186/s12873-017-0122-9 28330460

6. Singer M, Deutschman CS, Seymour C, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801–10. doi: 10.1001/jama.2016.0287 26903338

7. Goodwin A, Srivastava V, Shotton H, Protopapa K, Butt A, Mason M. Just say sepsis. A review of the process of care received by patients with sepsis London: National Confidential Enquiry into Patient Outcome and Death. 2015.

8. Gatewood MOK, Wemple M, Greco S, Kritek PA, Durvasula R. A quality improvement project to improve early sepsis care in the emergency department. BMJ Qual Saf. 2015;24(12):787–95. doi: 10.1136/bmjqs-2014-003552 26251506

9. Pruinelli L, Westra BL, Yadav P, Hoff A, Steinbach M, Kumar V, et al. Delay Within the 3-Hour Surviving Sepsis Campaign Guideline on Mortality for Patients With Severe Sepsis and Septic Shock. Crit Care Med. 2018;46(4):500–5. doi: 10.1097/CCM.0000000000002949 29298189

10. Torsvik M, Gustad LT, Mehl A, Bangstad IL, Vinje LJ, Damås JK, et al. Early identification of sepsis in hospital inpatients by ward nurses increases 30-day survival. Critical Care. 2016;20(1):244. doi: 10.1186/s13054-016-1423-1 27492089

11. Damiani E, Donati A, Serafini G, Rinaldi L, Adrario E, Pelaia P, et al. Effect of performance improvement programs on compliance with sepsis bundles and mortality: a systematic review and meta-analysis of observational studies. PLoS One. 2015;10(5):e0125827. doi: 10.1371/journal.pone.0125827 25946168

12. Levy MM, Rhodes A, Phillips GS, Townsend SR, Schorr CA, Beale R, et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study. Crit Care Med. 2015;43(1):3–12. doi: 10.1097/CCM.0000000000000723 25275252

13. Seymour CW, Gesten F, Prescott HC, Friedrich ME, Iwashyna TJ, Phillips GS, et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med. 2017;376(23):2235–44. doi: 10.1056/NEJMoa1703058 28528569

14. OECD. Health at a Glance 2017: OECD Indicators. Paris: OECD Publishing; 2017.

15. Hovlid E, Frich JC, Walshe K, Nilsen RM, Flaatten HK, Braut GS, et al. Effects of external inspection on sepsis detection and treatment: a study protocol for a quasiexperimental study with a stepped-wedge design. BMJ Open. 2017;7(9).

16. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39(2):165–228. doi: 10.1007/s00134-012-2769-8 23361625

17. National Institute for Health and Care Excellence. Sepsis: recognition, diagnosis and early management (NICE guideline 51). 2016.

18. Knoop ST, Skrede S, Langeland N, Flaatten HK. Epidemiology and impact on all-cause mortality of sepsis in Norwegian hospitals: A national retrospective study. PLoS One. 2017;12(11):e0187990. doi: 10.1371/journal.pone.0187990 29149187

19. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis. 1987;40(5):373–83. doi: 10.1016/0021-9681(87)90171-8 3558716

20. Van Buuren S. Flexible imputation of missing data: Chapman and Hall/CRC; 2018.

21. Gohil SK, Cao C, Phelan M, Tjoa T, Rhee C, Platt R, et al. Impact of policies on the rise in sepsis incidence, 2000–2010. Clin Infect Dis. 2016;62(6):695–703. doi: 10.1093/cid/civ1019 26787173

22. Vincent J-L, Martin GS, Levy MM. qSOFA does not replace SIRS in the definition of sepsis. Crit Care. 2016;20(1):210–. doi: 10.1186/s13054-016-1389-z 27423462

23. Nasa P, Juneja D, Singh O. Severe sepsis and septic shock in the elderly: An overview. World J Crit Care Med. 2012;1(1):23–30. doi: 10.5492/wjccm.v1.i1.23 24701398

24. Houston C, Sanchez LD, Fischer C, Volz K, Wolfe R. Waiting for Triage: Unmeasured Time in Patient Flow. West J Emerg Med. 2015;16(1):39–42. doi: 10.5811/westjem.2014.11.22824 25671006

25. The Royal College of Emergency Medicine. Severe Sepsis and Septic Shock, Clinical Audit 2016/17. National Report.; 2017.

26. Hayden GE, Tuuri RE, Scott R, Losek JD, Blackshaw AM, Schoenling AJ, et al. Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED. Am J Emerg Med. 2016;34(1):1–9. doi: 10.1016/j.ajem.2015.08.039 26386734

27. National Institute for Health and Care Excellence. Sepsis. Quality standard QS1612017.

28. Liu VX, Fielding-Singh V, Greene JD, Baker JM, Iwashyna TJ, Bhattacharya J, et al. The Timing of Early Antibiotics and Hospital Mortality in Sepsis. Am J Respir Crit Care Med. 2017;196(7):856–63. doi: 10.1164/rccm.201609-1848OC 28345952

29. Stoneking LR, Winkler JP, DeLuca LA, Stolz U, Stutz A, Luman JC, et al. Physician documentation of sepsis syndrome is associated with more aggressive treatment. West J Emerg Med. 2015;16(3):401–7. doi: 10.5811/westjem.2015.3.25529 25987914

30. Marik PE, Farkas JD, Spiegel R, Weingart S. POINT: Should the Surviving Sepsis Campaign Guidelines Be Retired? Yes. Chest. 2019;155(1):12–4. doi: 10.1016/j.chest.2018.10.008 30616719

31. Patel JJ, Bergl PA. COUNTERPOINT: Should Broad-Spectrum Antibiotics Be Routinely Administered to All Patients With Sepsis as Soon as Possible? No. Chest. 2019;156(4):647–9. doi: 10.1016/j.chest.2019.05.031 31590707

32. IDSA Sepsis Task Force. Infectious Diseases Society of America (IDSA) POSITION STATEMENT: Why IDSA Did Not Endorse the Surviving Sepsis Campaign Guidelines. Clin Infect Dis. 2017;66(10):1631–5.

33. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43(3):304–77. doi: 10.1007/s00134-017-4683-6 28101605

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