Sepsis recognition tools in acute ambulatory care: associations with process of care and clinical outcomes in a service evaluation of an Emergency Multidisciplinary Unit in Oxfordshire

C. Fielder Camm, Gail Hayward, Tania C. N. Elias, Jordan S. T. Bowen, Roya Hassanzadeh, Thomas R. Fanshawe, Sarah T. Pendlebury, Daniel Lasserson

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Abstract

Objective: To assess the performance of currently available sepsis recognition tools in patients referred to a community based acute ambulatory care unit. 


Design: Service evaluation of consecutive patients over a four month period.


Setting: Community based acute ambulatory care unit 


Data collection and outcome measures: Observations, blood results, and outcome data were analysed from patients with a suspected infection. Clinical features at first assessment were used to populate sepsis recognition tools including: systemic inflammatory responses syndrome (SIRS) criteria, national early warning score (NEWS), quick sequential organ failure assessment (qSOFA), and National Institute for Health and Care Excellence (NICE) criteria. Scores were assessed against the clinical need for escalated care (use of IV antibiotics, fluids, ongoing ambulatory care or hospital treatment) and poor clinical outcome (all-cause mortality and readmission at 30 days after index assessment). 


Results: Of 533 patients (median age 81 years), 316 had suspected infection with 120 patients requiring care escalated beyond simple community care. SIRS had the highest positive predictive value (50.9%, 95% confidence interval (CI) [41.6% to 60.3%]) and negative predictive value (68.9%, 95% CI [62.6% to 75.3%]) for the need for escalated care. Both NEWS and SIRS were better at predicting the need for escalated care than qSOFA and NICE criteria in patients with suspected infection (all p<0.001). While new onset confusion predicted the need for escalated care for infection in patients ≥85 years old (n= 114), 23.7% of patients ≥85 years had new onset confusion without evidence for infection.


Conclusions: Acute ambulatory care clinicians should use caution in applying the new NICE endorsed criteria for determining need for intravenous therapy and hospital based location of care. NICE criteria have poorer performance when compared against NEWS and SIRS and new onset confusion was prevalent in patients aged ≥ 85 years without infection. Strengths and limitations of this study•Acute ambulatory care is applicable to an increasingly prevalent healthcare delivery model•Consecutive patient evaluation to minimise selection bias•Not all elements of the sepsis recognition models were available for scoringKey WordsGeneral Medicine, Geriatric Medicine, Quality in Healthcare, Epidemiology
Original languageEnglish
Article numbere020497
JournalBMJ open
Volume8
Early online date9 Apr 2018
DOIs
Publication statusPublished - 2018

Keywords

  • General Medicine
  • Geriatric Medicine
  • Quality in Healthcare
  • Epidemiology

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