Samir A. Haydar

Effect of Bedside Ultrasonography on the Certainty of Physician Clinical Decisionmaking for Septic Patients in the Emergency Department

STUDY OBJECTIVE Sepsis protocols promote aggressive patient management, including invasive procedures. After the provision of point-of-care ultrasonographic markers of volume status and cardiac function, we seek to evaluate changes in emergency physician clinical decisionmaking and physician assessments about the clinical utility of the point-of-care ultrasonographic data when caring for adult sepsis patients. METHODS For this prospective before-and-after study, patients with suspected sepsis received point-of-care ultrasonography to determine cardiac contractility, inferior vena cava diameter, and inferior vena cava collapsibility. Physician reports of treatment plans, presumed causes of observed vital sign abnormalities, and degree of certainty were compared before and after knowledge of point-of-care ultrasonographic findings. The clinical utility of point-of-care ultrasonographic data was also evaluated. RESULTS Seventy-four adult sepsis patients were enrolled: 27 (37%) sepsis, 30 (40%) severe sepsis, 16 (22%) septic shock, and 1 (1%) systemic inflammatory response syndrome. After receipt of point-of-care ultrasonographic data, physicians altered the presumed primary cause of vital sign abnormalities in 12 cases (17% [95% confidence interval {CI} 8% to 25%]) and procedural intervention plans in 20 cases (27% [95% CI 17% to 37%]). Overall treatment plans were changed in 39 cases (53% [95% CI 41% to 64%]). Certainty increased in 47 (71%) cases and decreased in 19 (29%). Measured on a 100-mm visual analog scale, the mean clinical utility score was 65 mm (SD 29; 95% CI 58 to 72), with usefulness reported in all cases. CONCLUSION Emergency physicians found point-of-care ultrasonographic data about cardiac contractility, inferior vena cava diameter, and inferior vena cava collapsibility to be clinically useful in treating adult patients with sepsis. Increased certainty followed acquisition of point-of-care ultrasonographic data in most instances. Point-of-care ultrasonography appears to be a useful modality in evaluating and treating adult sepsis patients.

Comparison of qSOFA score and SIRS criteria as screening mechanisms for emergency department sepsis

Objectives: The Quick Sequential [Sepsis‐related] Organ Failure Assessment (qSOFA) score has been shown to accurately predict mortality in septic patients and is part of recently proposed diagnostic criteria for sepsis. We sought to ascertain the sensitive of the score in diagnosing sepsis, as well as the diagnostic timeliness of the score when compared to traditional systemic inflammatory response syndrome (SIRS) criteria in a population of emergency department (ED) patients treated in the ED, admitted, and subsequently discharged with a diagnosis of sepsis. Methods: Electronic health records of 200 patients who were treated for suspected sepsis in our ED and ultimately discharged from our hospital with a diagnosis of sepsis were randomly selected for review from a population of adult ED patients (N = 1880). Data extracted included the presence of SIRS criteria and the qSOFA score as well as time required to meet said criteria. Results: In this cohort, 94.5% met SIRS criteria while in the ED whereas only 58.3% met qSOFA. The mean time from arrival to SIRS documentation was 47.1 min (95% CI: 36.5–57.8) compared to 84.0 min (95% CI: 62.2–105.8) for qSOFA. The median ED “door” to positive SIRS criteria was 12 min and 29 min for qSOFA. Conclusions: Although qSOFA may be valuable in predicting sepsis‐related mortality, it performed poorly as a screening tool for identifying sepsis in the ED. As the time to meet qSOFA criteria was significantly longer than for SIRS, relying on qSOFA alone may delay initiation of evidence‐based interventions known to improve sepsis‐related outcomes.

In Reply to Hauswald.

To the Editor: We read with interest the commentary by Dr. Hauswald regarding our recently published article describing efforts to reduce emergency department (ED) length of stay through use of standardized holding orders by emergency physicians at the time of admission. We agree that understanding the nuanced differences between the work of quality improvement (QI) and research is challenging in our roles as clinicians, administrators, researchers, educators, and QI specialists. Our institution is fortunate to have an institutional review board (IRB) that is informed, accessible, and willing to help us make decisions that protect patients to the very best of our ability. While we often refer to the Common Rule for guidance regarding the definition of research, we also consider the current state of the science, potential risks and benefits for our patients, and the theoretical framework guiding the project. We believe that it is helpful to consider the interplay between research and QI activities, as depicted in Figure 1. With this approach, teams may identify an opportunity for improving a process or outcome, conduct a review of internal and external evidence, evaluate evidence strength, and then determine whether the current state of the science supports proceeding to a test of change. If evidence is limited in strength or volume, the conduct of additional research may be necessary prior to implementing a practice change. If the totality of evidence is sufficiently strong to warrant a closely monitored practice change, evidence-based practice or QI methods may be more appropriate. In either case, consultation with the local IRB or privacy board, in addition to research and quality experts, should guide decision-making to optimize the potential for high-quality patient-oriented outcomes. The framework guiding our project was drawn from the work of Donabedian; his structure-process-outcome model provided our foundation. Here we feel compelled to clarify that our project was conducted by a multidisciplinary team of clinicians from the front lines of patient care using Clinical Microsystem methodologies. Our team included inpatient and ED clinicians including nurses, faculty, residents, and technicians: our interventions were developed by this team using a “bottom up” approach rather than the “centralized” process with minimal opportunity for input from those “affected” as described in the commentary. Hauswald’s comments regarding command decision-making suggest we should have emphasized more clearly in our article that an interdisciplinary group of providers identified the admission process as a primary deterrent to safe and effective patient care, ultimately proposing and