Severe sepsis in the emergency department and its association with a complicated clinical course

Objective: Infection severity as determined by clinical criteria has been r ecently classified and studied in hospitalized inpatients. The objective of the study was to use modified criteria to determine the clinical course as sociated with three levels of infection severity in infected patients admit ted from the ED. Methods: This was a retrospective cohort study involving a ll patients 18 years of age and older admitted through the ED of an urban t eaching hospital during a four-month period whose primary reason for requir ing hospitalization was an infection that was recognized in the ED. ED reco rds were reviewed for criteria used to classify patients by three levels of infection severity: no systemic inflammatory response syndrome, sepsis, an d severe sepsis (SS). The relationships between these classifications as we ll as certain clinical characteristics and any complicated clinical course as measured by death and/or admission to an intensive care unit (ICU), and/ or prolonged hospitalization, were analyzed. Results: Of 408 patients enter ed into the study, 138 (33.8%) fulfilled the criteria of SS in the ED. Pati ents with SS in the ED had a mortality of only 4.3%, though with an increas ed risk of dying compared with that of the other groups combined [relative risk (RR) = 11.64, 95% confidence interval (CI) = 1.43 to 96.53], an increa sed risk of ICU stay (RR = 7.65, 95% CI = 4.08 to 14.36), and an increased risk of prolonged hospitalization (RR = 1.99, 95% CI = 1.38 to 2.88). Altho ugh age over 60 years and several comorbid conditions also were identified by univariate analysis as risk factors, multivariate analysis revealed that only SS and diabetes' mellitus (DM) were independent predictors of a compl icated course. In the authors' institution, the positive predictive value ( PPV) of SS for complicated clinical course was 0.48 and the negative predic tive value (NPV) of no SS for no complicated course was 0.77. The PPV of [S S + DM] was 0.83, and the NPV of [SS, DM, or both] was also 0.83. Conclusio n: Although the strongest correlate of a complicated clinical course identi fied in the ED is SS as defined by the study criteria, its specificity and PPV are low. The mortality of ED patients with SS is much lower than the mo rtality rates reported for inpatients with SS. SS as defined by the study c riteria is too sensitive and therefore lacks utility in the ED setting.