Factors and Outcomes Associated with Under- and Overdiagnosis of Sepsis in the First Hour of Emergency Department Care

Factors and Outcomes Associated with Under- and Overdiagnosis of Sepsis in the First Hour of Emergency Department Care

Authors: Shivansh R Pandey, Sarah K S Knack, Brian E Driver, et al.
Journal: Academic Emergency Medicine, 2024

Conclusions

• Key Findings:
• Certain patient subgroups (e.g., elderly, hypoxic, hypotensive, renal insufficiency) are at higher risk for misdiagnosis of sepsis in the ED.
• Abnormal laboratory markers (e.g., lactate, leukocytosis, bandemia, urinalysis) can act as “rescue” triggers for missed diagnoses.
• Antibiotic Administration: Missed sepsis diagnoses led to delays in antibiotic administration but did not independently increase inpatient mortality when adjusted for severity of illness.
• Clinical Implications:
• Prompt recognition of abnormal lab values can mitigate diagnostic errors.
• Improving clinician awareness of high-risk subgroups could enhance diagnostic accuracy.
• Systems-level interventions targeting early identification could reduce delays in care.

Takeaway Points

1. High-Risk Groups for Diagnostic Error: Elderly, hypoxic, hypotensive, and renal-impaired patients.
2. Laboratory Rescue Markers: Elevated lactate, leukocytosis, bandemia, positive urinalysis.
3. Outcome Impacts: Antibiotic delays occurred but did not independently increase mortality.
4. Interventions Needed: Focus on integrating real-time laboratory markers and improving early recognition protocols in ED workflows.

Methods

• Study Design: Secondary analysis of a prospective, single-center, observational cohort study of undifferentiated critically ill medical patients.
• Timeframe: September 2020 – May 2022
• Population: 2,484 eligible patients presenting to the ED.
• Primary Outcome: Explicit hospital discharge diagnosis of sepsis present on arrival.
• Clinician Suspicion Assessment:
• Measured using a Visual Analog Scale (VAS) (0%–100%) at 15 and 60 minutes post-arrival.
• A VAS score of ≥50% indicated suspicion of sepsis.

Results

1. Diagnostic Accuracy

• VAS ≥50% at 15 minutes:
• Sensitivity: 83% (95% CI: 78%–87%)
• Specificity: 85% (95% CI: 83%–86%)
• Common Diagnostic Pitfalls:
• Older age
• Hypoxia
• Hypotension
• Renal insufficiency
• Leukocytosis
• Abnormal body temperature (high or low)

2. Missed Diagnoses

• At 15 minutes: 48 (17%) missed sepsis cases
• At 60 minutes: 23 (8%) missed sepsis cases
• Laboratory Findings in Missed Cases:
• Elevated lactate
• Leukocytosis
• Bandemia
• Positive urinalysis

3. Outcomes Associated with Missed Diagnoses

• Antibiotic Delay: Median delay of 48 minutes (IQR: 27–64 minutes) in missed cases.
• Mortality: Missed diagnoses were not independently associated with increased mortality after controlling for severity of illness (risk ratios close to 1 across VAS scores).