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Purpose Monocyte distribution width (MDW) is a biomarker for the early identification of sepsis. We assessed its accuracy in patients presenting with suspected sepsis in the emergency department (ED). Methods This was a single gate, single centre study in consecutive adults (≥ 18 years) admitted to the ED with suspected sepsis and clinical history compatible with infection, between 01 January and 31 December 2020 (n = 2570). Results The overall median MDW was 22.0 (IQR 19.3, 25.6). Using Sepsis-3 (qSOFA) to define sepsis, the Area Under Curve (AUC) for a receiver operator characteristic (ROC) relationship was 0.59 (95% CI 0.56, 0.61). Discrimination was similar using other clinical scores, and to that of C-reactive protein. At an MDW cutoff of 20.0, sensitivity was 0.76 (95% CI 0.73, 0.80) and specificity 0.35 (95% CI 0.33, 0.37) for Sepsis-3. MDW showed better performance to discriminate infection, with AUC 0.72 (95% CI 0.69, 0.75). At MDW 20.0, sensitivity for infection was 0.72 (95% CI 0.70, 0.74) and specificity 0.64 (95% CI 0.59, 0.70). A sensitivity analysis excluding coronavirus disease (COVID-19) admissions (n = 552) had no impact on the AUC. MDW distribution at admission was similar for bacteraemia and COVID-19. Conclusions In this population of ED admissions with a strong clinical suspicion of sepsis, MDW had a performance to identify sepsis comparable to that of other commonly used biomarkers. In this setting, MDW could be a useful additional marker of infection.

Background Early treatment is advocated in the management of patients with suspected sepsis in the emergency department (ED). We sought to understand the association between the ED treatments and outcome in patients admitted with suspected sepsis. The treatments studied were: (i) the time to antibiotics, where time zero is the time the patient was booked in which is also the triage time; (ii) the volume of intravenous fluid (IVF); (iii) mean arterial pressure (MAP) after 2000 ml of IVF and (iv) the final MAP in the ED. Methods We performed a retrospective analysis of the ED database of patients aged ≥ 18 year who met two SIRS criteria or one red flag sepsis criteria on arrival, received intravenous antibiotics for a suspected infection and admitted between 8th February 2016 and 31st August 2017. The primary outcome measure was all-cause in-hospital mortality. The four treatments stated above were controlled for severity of illness and subject to multivariate logistic regression and Cox proportional-hazard regression to identify independent predictors of mortality. Results Of the 2,066 patients studied 272 (13.2%) died in hospital. The median time to antibiotics was 48 (interquartile range 30–82) minutes. The time to antibiotics was an independent predictor of mortality only in those who developed refractory hypotension (RH); antibiotics administered more than 55 mins after arrival was associated with an odds ratio (OR) for mortality of 2.75 [95% confidence interval (CI) 1.22–6.14]. The number-needed-to-treat was 4. IVF > 2000 ml (95% CI > 500– > 2100), except in RH, and a MAP ≤ 66 mmHg after 2000 ml of IVF were also independent predictors of mortality. The OR for mortality of IVF > 2,000 ml in non-RH was 1.80 (95% CI 1.15–2.82); Number-needed-to-harm was 14. The OR for morality for a MAP ≤ 66 mmHg after 2000 ml of IVF was 3.42 (95% CI 2.10–5.57). A final MAP Conclusion In this study, antibiotics were found to be time-critical in RH. Intravenous fluids > 2000 ml (except in RH) and a MAP ≤ 66 mmHg after 2000 ml of IVF were also independent predictors of mortality.

Aims/Objectives/BackgroundEarly treatment is advocated in the management of patients with suspected sepsis. We sought to understand the association between the emergency department (ED) treatments and outcome in these patients. The treatments studied were: (i) the time to antibiotics, (ii) the volume of intravenous fluid (IVF), (iii) mean arterial pressure (MAP) after 2,000 ml of IVF and (iv) the final MAP in the ED.Methods/DesignA retrospective analysis of the ED database of adult patients who met two SIRS criteria or one red flag sepsis criteria on arrival, received intravenous antibiotics for a suspected infection and admitted between February 2016 and August 2017, was performed. The primary outcome measure was all-cause in-hospital mortality. The four treatments stated above were controlled for severity of illness and subject to multivariate logistic regression and Cox proportional-hazard regression to identify independent predictors of mortality.Results/ConclusionsOf the 2,066 patients studied 272 (13.2%) died in hospital. The median time to antibiotics was 48 (Interquartile range 30–82) minutes. The time to antibiotics was an independent predictor of mortality only in those who developed refractory hypotension (RH); antibiotics administered more than 55 mins after arrival was associated with an odd-ratio (OR) for mortality of 2.75 [95% confidence interval (CI) 1.22–6.14]. The number-needed-to-treat was 4. IVF >2,000 ml (95%CI >500->2,100), except in RH, and a MAP≤66 mmHg after 2,000 mls of IVF were also independent predictors of mortality. The OR for mortality of IVF>2,000 ml in non-RH was 1.80 (95%CI 1.15–2.82); Number-needed-to-harm was 14. The OR for morality for a MAP≤66 mmHg after 2,000 ml of IVF was 3.42 (95%CI 2.10–5.57). A final MAPAntibiotics were time-critical only in refractory hypotension. Intravenous fluids >2,000 mls in non-RH and a MAP≤66 mmHg after 2,000 ml of IVF were also independent predictors of mortality.

ObjectiveTo derive and validate a new clinical prediction rule to risk-stratify emergency department (ED) patients admitted with suspected sepsis.DesignRetrospective prognostic study of prospectively collected data.SettingED.ParticipantsPatients aged ≥18 years who met two Systemic Inflammatory Response Syndrome criteria or one Red Flag sepsis criteria on arrival, received intravenous antibiotics for a suspected infection and admitted.Primary outcome measureIn-hospital all-cause mortality.MethodThe data were divided into derivation and validation cohorts. The simplified-Mortality in Severe Sepsis in the ED score and quick-SOFA scores, refractory hypotension and lactate were collectively termed ‘component scores’ and cumulatively termed the ‘Risk-stratification of ED suspected Sepsis (REDS) score’. Each patient in the derivation cohort received a score (0–3) for each component score. The REDS score ranged from 0 to 12. The component scores were subject to univariate and multivariate logistic regression analyses. The receiver operator characteristic (ROC) curves for the REDS and the components scores were constructed and their cut-off points identified. Scores above the cut-off points were deemed high-risk. The area under the ROC (AUROC) curves and sensitivity for mortality of the high-risk category of the REDS score and component scores were compared. The REDS score was internally validated.Results2115 patients of whom 282 (13.3%) died in hospital. Derivation cohort: 1078 patients with 140 deaths (13%). The AUROC curve with 95% CI, cut-off point and sensitivity for mortality (95% CI) of the high-risk category of the REDS score were: derivation: 0.78 (0.75 to 0.80); ≥3; 85.0 (78 to 90.5). Validation: 0.74 (0.71 to 0.76); ≥3; 84.5 (77.5 to 90.0). The AUROC curve and the sensitivity for mortality of the REDS score was better than that of the component scores. Specificity and mortality rates for REDS scores of ≥3, ≥5 and ≥7 were 54.8%, 88.8% and 96.9% and 21.8%, 36.0% and 49.1%, respectively.ConclusionThe REDS score is a simple and objective score to risk-stratify ED patients with suspected sepsis.

OBJECTIVES The aim of this study was to determine the outcome of patients with severe sepsis and septic shock who did and did not receive early goal-directed therapy (EGDT) in the emergency department (ED). The primary end point was the in-hospital mortality rate. The secondary end points were lengths of stay in the ICU and in hospital. METHOD Patients with sepsis who satisfied two of the four systemic inflammatory response criteria and who either had a lactate of greater than 4 mmol/l or a systolic blood pressure of less than 90 mmHg after 20-30 ml/kg of fluid, were included. Patients who had EGDT commenced, and all patients who were admitted to ICU who met EGDT criteria over a 4-year period from 1 January 2006 to 31 December 2009, were studied. RESULTS One hundred and seventy-four patients with sepsis met the criteria for EGDT. Ninety-seven patients had EGDT commenced in the ED. The mortality rate in the EGDT group was 22.7% compared with 42.9% in the non-EGDT group (P=0.004). The length of stay in ICU was [(median and interquartile range)] 3D(5) versus 4D(8), P value less than 0.0001. There was no difference in the length of in-hospital stay. CONCLUSION Initiating EGDT in the ED in patients with severe sepsis and septic shock was associated with a significant reduction in in-hospital mortality and length of stay in ICU.

BACKGROUND The MISSED score was derived and validated in emergency department (ED) patients with sepsis who were admitted to the ICU. This score has now been refined and simplified. The independent variables associated with mortality are age at least 65 years, serum albumin 27 g/l or less, and an international normalized ratio at least 1.3. The simplified MISSED score ranges from 0 to 3 depending on the number of variables present. OBJECTIVE The primary objective is to validate the simplified MISSED score for predicting all-cause mortality in the ED population admitted with sepsis. The secondary end-point is to validate the risk stratification for ICU admission. METHODS This is a pragmatic retrospective study of prospectively collected data. ED patients admitted with a diagnosis of sepsis in the year 2012 were studied. Those on warfarin were excluded. The simplified MISSED score was calculated for each patient. The test characteristics for mortality of the simplified MISSED score and the odds ratios of the high-risk groups for the secondary end-point were calculated. RESULTS In total, 674 patients, including 65 deaths, were studied. The area under the curve for the simplified MISSED score was 0.74 [95% confidence interval (CI) 0.70-0.77; P

Emergency Departments (ED) have a pivotal role in managing patients with severe sepsis and septic shock.1 In our survey in 2006, 20.5% EDs in England were able to commence the pathway to Early Goal-Directed Therapy (EGDT).2 We repeated the survey in 2011 to evaluate any change in 5 years. One hundred and eighty-five EDs were surveyed using a form similar to that in 2006. The data from 2006 was reanalysed. EDs satisfying four criteria were assumed …

Aim: To identify the extent to which emergency departments (EDs) in England are involved in the initiation of the pathway to early goal-directed therapy (EGDT) in patients with severe sepsis and septic shock. Method: A survey of 173 EDs in England was carried out over a 2-month period starting in March 2006. Results: 117 (67.6%) departments responded. 22 (18.8%) departments satisfied the following criteria: had a strategy to identify these patients, measured lactate, had a written protocol including EGDT and provided training for their staff. A further 10 (8.5%) EDs were working on initiating the pathway to EGDT. Conclusion: 18.8% of EDs in England are able to initiate the pathway to EGDT in patients with severe sepsis and septic shock.

Objective To derive and validate a new scoring system to predict in-hospital mortality in septic patients in the emergency department (ED). Patients and method Septic patients admitted to the ICU and those in whom early goal-directed therapy (EGDT) was carried out in the ED were identified from the ED record. Univariate and multivariate regression analyses identified independent variables associated with mortality. The variables were given a score weighted by the odds ratio, the sum of which yielded the Mortality In Severe Sepsis in the Emergency Department (MISSED) score. The performance of the MISSED score in predicting mortality was compared with that of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, the EGDT criteria and the severe sepsis criteria. The Hosmer-Lemeshow test was performed to calibrate the model. Results Independent variables identified were age at least 65 years, albumin level up to 27 g/l and international normalized ratio of 1.2 or more. The MISSED score ranged from 0-9; cut-off point 5.5. Mortality rates associated with a score of 0, less than 5.5 and 5.5 or more were 7.4, 17.7 and 40.6%, respectively. The sensitivity of the score was 96.8% (95% confidence interval 87.8-99.4%). The mortality rate and specificity associated with a score of 9 were 62.9 and 91.6% respectively. The area under the curve for the MISSED score and the APACHE II score were equal. The performance of the MISSED score of 5.5 or more in predicting mortality was similar to that of the EGDT criteria. The sensitivity of the score was equal to that for the severe sepsis criteria. The Hosmer-Lemeshow test confirmed good calibration. Conclusion The MISSED score should be used in the ED.