Extended Acute Sepsis Care in Emergency Departments in NTWC

Abstract Description

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Authors (including presenting author) :

Lui CT(1), Ching KC(1), Chan SW(1), Wong SH(2), Wong CY(2), SC Ho(2), Chan YW(1), So FL(2), CC Chan(1), WM Wong(2), H Tang(3), Lee LY(3), Fung HT(1), Lau CL (1)(2)(3)

Affiliation :

(1) Department of Accident and Emergency, Tuen Mun Hospital (2) Department of Accident and Emergency, Pok Oi Hospital (3) Department of Accident and Emergency, Tin Shui Wai Hospital

Introduction :

Sepsis is an emerging clinical condition that is commonly encountered in emergency department (ED) requiring early assessment and intervention to optimize patients’ outcome. Evidence existed to support early septic workup and antibiotic within 60-min pledge could improve patients’ outcome, hospital length of stay and cost.

Objectives :

To conduct a clinical audit to evaluate the epidemiology and impact of standardized guideline for severe sepsis patients on patients’ outcome.

Methodology :

A standardized guideline/protocol was implemented in 3 EDs in NTWC in Mar 2014. Data was extracted for all triage Cat 1 and 2 attendance matching sepsis-related ICD-9 codes. Details of medical records were screened to include adult patients fulfilling severe sepsis criteria. There were 3 periods included: Sep-2012 to Aug 2013 (pre-protocol), Sep-2015 to Aug 2016 and Sep-2017 to Aug-2018 (post-protocol). Measured parameters included blood culture rate, antibiotic delivery in ED, ICU admission, mortality, etc.

Result & Outcome :

The absolute number of severe sepsis cases matched inclusion criteria were 52, 90 and 124 in the 3 periods. Sepsis is an emerging condition presenting to ED. The incidence of severe sepsis per hundred-thousand ED attendances increased from 15 to 35 throughout 2012 to 2017. There was observed increasing trend of urosepsis, intraabdominal sepsis and sepsis of unknown source. There was increasing trend of severe sepsis involving younger patients with age < 65 (from 27% to 32%). The blood culture rate in ED increased from 17.3% to 75.6% and then 87.1%. The antibiotic in ED increased from 19.2% to 90.3% after protocol. Patients received antibiotic within 60-min increased from 15.4% to 83.9%. The median door-to-antibiotic delivery was 35min. The ED to ICU admission rate remained static of 4%. There was observed increased delayed septic shock after admission (from 8% to 16%) and subsequent ICU admission. There was no major change in mortality rate (28.8% to 26.6%). To conclude, sepsis is an emerging challenge of ED. A sepsis protocol in ED could dramatically improve the patient care. Universal sepsis screening tools, risk stratification strategies, and an extended multidisciplinary sepsis care model should be the next step to further upkeep the care standard.