Nancy Melville

January 23, 2015

PHOENIX — A simple screening tool predicts sepsis early in trauma patients and reduces mortality, according to a new study.

"The findings show that the sepsis screening tool is a reliable and valid method for the early identification of sepsis in the trauma population," said Laura Moore, MD, from the University of Texas Health Science Center in Houston.

Dr. Moore presented the results here at the Society of Critical Care Medicine 44th Critical Care Congress.

In previous research, Dr. Moore and her team showed that sepsis screening improves outcomes in surgical patients. This time, they assessed trauma patients.

"In all of our populations, the screening tool continues to have a very high negative predictive value, which is extremely important when you're screening for something like sepsis," she pointed out.

The screening tool involves the twice-daily assessment of white blood cell count, respiratory rate, temperature, and heart rate. Each measure is given a score of 0 to 4.

"If the score is 4 or higher, the nurse then calls the clinician, who comes to the bedside to evaluate for the presence of a possible infection. If an infection is detected, the appropriate sepsis therapies are initiated," she explained.

In their study, the researchers looked at 10,201 screenings from 1637 trauma patients admitted to the Texas Trauma Institute, which is a busy level 1 trauma center.

The incidence of sepsis in these patients was 7.3%.

The sensitivity of the screening tool was 92.5%, the specificity was 97.4%, the positive predictive value was 73.5%, and the negative predictive value was 99.4%.

There was no difference between the patients with sepsis and those without in terms of age or sex. However, in patients with sepsis, injury severity score was higher, stays in the hospital and in the intensive care unit (ICU) were longer, and the number of ICU-free days was lower (< .0001 for all).

The use of the sepsis screening tool was associated with a reduction in the 30-day ICU mortality rate, from 13% to 8% (P = .08).

Challenges of Early Detection

"The early recognition of sepsis continues to present a significant challenge to clinicians because the signs and symptoms can be very nonspecific, particularly in the surgical and trauma populations," said Dr. Moore.

Altered mental status, for instance, which is a common clinical presentation of sepsis, is also common in trauma and surgery patients for reasons other than sepsis.

"Patients could be on multiple pain medications causing an altered mental status, or maybe they are elderly, are sundowning, or have ICU psychosis. But altered mental status could also be a presenting symptom of sepsis due to hyperfusion of the brain," she explained.

Hypothermia can be another missed early symptom of sepsis.

"Clinicians commonly receive calls from a nurse about a patient who is febrile or hyperthermic, but when was the last time you got a call about a patient who was hypothermic, which could be another presenting sign of sepsis?" she asked.

The sepsis screening tool helps to address those kinds of lapses. "Since implementing the screening tool, we anecdotally have seen an increase in the number of patients we are identifying with sepsis and a concomitant decrease in the number of patients presenting with septic shock," Dr. Moore reported. "I think this speaks to the effectiveness of the screening tool."

"What this allows us to do is pick patients up earlier in the course of sepsis, rather than waiting for them to fall off the cliff before beginning interventions," she explained.

The bedside screening system offers numerous benefits, according to Elizabeth Mann-Salinas, PhD, RN, from the US Army Institute of Surgical Research in San Antonio, Texas. "I believe it is incredibly useful for several reasons," she said.

"The nurses become very attuned to the subtle early signs of sepsis and can alert the physician earlier to intervene before obvious signs of shock and concomitant organ dysfunction or failure occur," Dr. Mann-Salinas told Medscape Medical News.

In addition, "the physician will screen patients for associated risk factors to more clearly identify potential sepsis. This study demonstrates that it takes a knowledgeable clinician to sort through the complex syndrome of sepsis because it varies so much by individual patient," she explained.

The tool can be automated with electronic medical records to trigger an alert when sepsis is suspected; however, Dr. Mann-Salinas, who has been working with her colleagues to implement the risk assessment in an automated manner, reported that so far, at least in the burn unit, some wrinkles need to be ironed out.

"The system works in principle — it can mine data continuously and identify patterns; unfortunately, in the burn population, we just do not know what the pattern is exactly," she said.

"Right now, we can just screen for overt shock, so the alerts are arriving too late to be meaningful clinically. We are continuing to refine the algorithms," Dr. Mann-Salinas reported.

Dr. Moore and Dr. Mann-Salinas have disclosed no relevant financial relationships.

Society of Critical Care Medicine (SCCM) 44th Critical Care Congress: Abstract 8. Presented January 18, 2015.


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