017 Process management of sepsis. The implementation of a modified triage tool (SEPTIC) in an inner city Emergency Department and its effects on the management of sepsis
Authors: O'Connor G , Breslin T , Brazil E , McInerney J 
Published: September 2011

Objectives and Backgrounds

In the last decade, treatment of sepsis in a timely and structured fashion, has been driven by strong evidence and consensus expert opinion. Incidence of sepsis exceeds that of other more commonly recognised conditions such as breast cancer and the crude mortality rates vary between 28 and 50% across multiple studies. It is recognised that up to half of all those admitted to ICU with sepsis come through Emergency Departments. Unfortunately the triage systems for categorising priority and urgency of illness or injury in the undifferentiated patient cohorts coming through the ED were developed prior to the era of early goal directed therapy and sepsis bundles. In response to the College of Emergency Medicine target guidelines for sepsis management we developed a simple tool as an add-on to the Manchester triage system. This revenue neutral, quick triage tool functions to increase recognition of the potentially septic patient by focusing awareness and assigning a higher priority to sepsis related deranged triage measurements. The tool (SEPTIC) functions as an aide-memoir at the point of triage and allows assignment of higher triage category (2) to the potentially septic patient. The SEPTIC mnemonic focuses on the following variables: Shock—clinical evidence of shock or inadequate tissue perfusion, Extremities—prolonged capillary refill time, Pulse—rate >100, Temperature—fever or hypothermia, Inspiratory rate— >20, and Confusion—new onset of confusion.

Methods

We audited our management of severe sepsis before and after implementation of this tool, using the College of Emergency Medicine's and the Surviving Sepsis Campaign's agreed standards. We measured the compliance with the following individual surrogate markers. Serum lactate measurement; Timely administration of intravenous antibiotics; Intravenous fluid bolus administration; Documented senior ED or ICU consultation; Urinary output measurement; Documented high flow oxygen; Complete set of vital signs at triage. We retrospectively tracked all admissions with severe sepsis over two fortnightly periods, before and after implementation of the new SEPTIC tool.

Results

Our management of sepsis as indicated by compliance with the above surrogate markers improved. Across the specific categories the compliance before and afterwards respectively (with appropriate p values) was as follows: Serum lactate measurement 58% vs 93% (p<0.05); Administration of intravenous antibiotics 69% vs 93% (p,0.05); Intravenous fluid bolus administration 62% vs 79% (p<0.05); Blood cultures taken 50% vs 71% (p<0.05); Documented senior ED or ICU consultation 58% vs 57% (p>0.05); Urinary output measurement 12% vs 50% (p<0.05); Documented high flow oxygen 23% vs 71% (p<0.05); Complete set of vital signs at triage 38% vs 36% (p>0.05). These indicate significant improvement with task specific items but ongoing poor documentation of items which we postulate are being performed but not verifiable in retrospect.

Conclusions

We describe a new triage tool for potentially septic patients which improves awareness and identification of this critical cohort of patients.