title: Sepsis Screening in General Hospitalised Patients in a Developing Nation Health Setting
Creators: name: Alberto, Laura M.
Publisher: name: Griffith University
Year: 2019
Subjects: subject: Sepsis screening
subject: Developing nations
subject: Health
subject: Hospitalised patients

description: Sepsis is a major cause of morbidity and mortality, and a World Health Organization-recognised global concern. Estimations based on population level studies show sepsis affects over 30 million people, and 6-9 million will die every year. Those who survive will experience mental, physical and/or cognitive impairments or die prematurely due to underlying conditions related to acquiring sepsis. To reduce morbidity and mortality, early signs of sepsis need to be recognised and treated early. Since the early 1990s, researchers from the United States of America, Norway and China have tested tools for the early recognition of sepsis in general hospitalised population. This evidence is predominantly from the developed world, so relates to only a small percentage of the global problem. Little data has been produced in developing areas where the global burden of sepsis most likely resides. The overall purpose of this study was to improve sepsis care through early recognition of sepsis and timely provision of treatment in a developing nation health setting. Its aim was to implement and test a sepsis screening tool and guidelines for early sepsis care in general hospitalised patients. The screening tool was the quick Sequential [Sepsis-Related] Organ Failure Assessment (qSOFA)-based Sepsis Screening (SS) tool and the guidelines for early sepsis care incorporated in the 6-hour (6-h) bundle. An interrupted times series study with prospective data collection was conducted in five general medical-surgical wards in a tertiary referral private hospital in Buenos Aires, Argentina, from April to November 2017. The primary outcomes assessed in this study were the accuracy of sepsis diagnosis and the timing of implementation of the 6-h bundle. Secondary outcomes were the adoption of the screening tool and adherence to the 6-h bundle of sepsis care. The outcomes that involved time were considered in respect to the moment the patient met the qSOFA-based SS tool criteria defined as time zero. In 1,151 patients (median age 69.9 [IQR, 29.0] years; 619 females [53.8%]), 47 (4.1%) patients had sepsis, 413 (35.9%) had infection and 691 (60.0%) other diagnosis at discharge. The most frequent sources of infection in patients with sepsis were pulmonary (n=19, 34.8%), urinary (n=18, 38.3%) and abdominal (n=12, 25.5%). Two hundred and thirteen patients (18.5%) scored ≥2 qSOFA points and 145 (12.6%) met the qSOFA-based SS tool criteria. The qSOFA-based SS tool had moderate sensitivity (60%), good specificity (89%), a very low positive predictive value (19%) and very high negative predictive value (98%). The qSOFA score in isolation had a reasonable predictive validity for sepsis diagnosis at discharge (area under receiver operating characteristics curve 0.77 [95% CI, 0.70–0.83] p&lt;0.001). Among 145 (12.6%) patients who met the qSOFA-based SS tool criteria, 39 of 64 intervention patients received the first 6-h bundle element in a median of 8 hours (95% CI, 0.1–16), and 48 of 81 baseline patients in a median of 22 hours (95% CI, 3– 41); these times did not differ significantly (p=0.525). In a subgroup analysis of patients who met the qSOFA-based SS tool criteria and received the first 6-h bundle element within 48 hours of time zero, it was confirmed that there was no difference in time to treatment (median 6 hours versus 4 hours) between the groups, which represented a very low effect size (U=736, z=-1.716, p=0.086, r=0.03). A similar trend was observed in patients with sepsis at discharge; 18 of 25 intervention patients received the first 6-h bundle element at a median of 5 hours (95% CI, 4-6), and 15 of 22 baseline patients at a median of 12 hours (95% CI, 0–33) from time zero; the difference in these times was not statistically significant (p=0.470). The implementation strategies derived from the evaluation of setting characteristics helped patients to be regularly screened, while activation of sepsis alerts was more difficult to achieve, and some patients received delayed treatment. Importantly, most patients with sepsis received treatment within the target time regardless of the activation of the alert, including those patients who did not meet the criteria of the qSOFA-based SS tool but still developed sepsis. This finding suggests there is a clinical judgment process outside the screening mechanism that influences treatment decisions. This study broadens knowledge of early recognition of sepsis in developing nation health settings, by validating a simple four-variable tool to screen for sepsis in a general hospitalised patient population in Argentina. This tool could be valuable where no other mechanism to screen for sepsis is in place. While there is much to be done to expand our understanding of early recognition of sepsis in developing nations, this first interrupted times series study provides a platform for such future research.