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Sepsis: The Need for Epidemiological Studies in the Emergency Department
The Journal of Emergency Medicine, Vol. 46, No. 3, pp. e93–e94, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
Letters to the Editor , SEPSIS: THE NEED FOR EPIDEMIOLOGICAL STUDIES IN THE EMERGENCY DEPARTMENT
disease. Additionally, other characteristics unique to the ED setting, such as waiting time and overcrowding, mode of arrival, source of referral, triage score, and disposition from the ED may influence outcomes and hence, should be examined. Fourthly, the handful of large ED-focused studies on sepsis was cross-sectional in design and hence, lacked the link with outcomes (7,8). These studies found that the length of stay in the ED was significantly longer for severe sepsis attendances than other ED visits. Also, ambulances are highly utilized as a mode of arrival by sepsis patients, and 10% of the patients were discharged from the ED and half were admitted to the wards instead of the ICU. The relationship of these characteristics to outcome has not been widely explored. Compared to patient characteristics, such characteristics may be more amenable to modification through changes in workflows and policies. The need for high-quality epidemiological studies of sepsis is particularly pressing in the ED at this present time when sepsis has escalated toward being a public health problem. These studies are invaluable in determining health care resource allocation and are essential for the design of higher-order studies such as randomised control trials. Hence, it is prudent that researchers and funding institutions strive to create conducive environments for good epidemiological studies in the ED to flourish.
, To the Editor: Epidemiological studies describe factors that influence the distribution of disease in populations. Although these studies are often considered as ranking low in the hierarchy of evidence, they remain valuable in relation to sepsis in the emergency department (ED). Firstly, there are indications that ED utilization by sepsis patients is becoming significant. The incidence of sepsis is increasing worldwide and a considerable proportion of patients with sepsis, up to 71%, first present to the ED (1–3). ED use by populations at risk for sepsis, principally the older age group, has increased in the last two decades. The elderly are consistently overrepresented in ED attendance compared to their proportions in the general population (4). Furthermore, previous study has shown that the volume and duration of stay of critically ill patients in the ED are increasing, and therefore, directly impact patients at the severe end of the spectrum (5). Secondly, the descriptive knowledge of epidemiological studies helps ED physicians characterize sepsis and its spectrum, and consequently, assist in “fine tuning” management to seek better outcomes. In addition, longitudinally designed studies are vital as a surveillance tool for understanding the temporal changes and effects on ED patients. They are also useful for monitoring compliance with new protocols and strategies. These latter studies should extend for longer periods instead of halting at in-hospital outcomes because the median survival for hospital survivors of sepsis can be much lower compared to controls from the general population after hospitalization for sepsis (6). Thirdly, extensive literature had focused on sepsis patients admitted to the intensive care unit (ICU), which presents a skewed view of the epidemiology of the disease because patients in the ICU form a small subset of sepsis patients, the very ill, that might have presented to the ED. Conversely, the presenting complaints and course of disease in the acute period prior to admission to either wards or specialist high-dependence and critical units are equally imperative in understanding the
Irwani Ibrahim, MD, MPH Emergency Medicine Department and Department of Surgery National University Health Systems Singapore http://dx.doi.org/10.1016/j.jemermed.2013.08.108 REFERENCES 1. Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003;348:1546–54. 2. Padkin A, Goldfrad C, Brady AR, Young D, Black N, Rowan K. Epidemiology of severe sepsis occurring in the first 24 hrs in intensive care units in England, Wales, and Northern Ireland. Crit Care Med 2003;31:2332–8. 3. Sundararajan V, Macisaac CM, Presneill JJ, Cade JF, Visvanathan K. Epidemiology of sepsis in Victoria, Australia. Crit Care Med 2005; 33:71–80.
e93
e94 4. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2002 emergency department summary. Adv Data 2004;18: 1–34. 5. Lambe S, Washington DL, Fink A, et al. Trends in the use and capacity of California’s emergency departments, 1990–1999. Ann Emerg Med 2002;39:389–96. 6. Quartin AA, Schein RM, Kett DH, Peduzzi PN. Magnitude and duration of the effect of sepsis on survival. Department of Veterans
Letters to the Editor Affairs Systemic Sepsis Cooperative Studies Group. JAMA 1997; 277:1058–63. 7. Wang HE, Shapiro NI, Angus DC, Yealy DM. National estimates of severe sepsis in United States emergency departments. Crit Care Med 2007;35:1928–36. 8. Strehlow MC, Emond SD, Shapiro NI, Pelletier AJ, Camargo CA Jr. National study of emergency department visits for sepsis, 1992 to 2001. Ann Emerg Med 2006;48:326–31.
Letters to the Editor , SEPSIS: THE NEED FOR EPIDEMIOLOGICAL STUDIES IN THE EMERGENCY DEPARTMENT
disease. Additionally, other characteristics unique to the ED setting, such as waiting time and overcrowding, mode of arrival, source of referral, triage score, and disposition from the ED may influence outcomes and hence, should be examined. Fourthly, the handful of large ED-focused studies on sepsis was cross-sectional in design and hence, lacked the link with outcomes (7,8). These studies found that the length of stay in the ED was significantly longer for severe sepsis attendances than other ED visits. Also, ambulances are highly utilized as a mode of arrival by sepsis patients, and 10% of the patients were discharged from the ED and half were admitted to the wards instead of the ICU. The relationship of these characteristics to outcome has not been widely explored. Compared to patient characteristics, such characteristics may be more amenable to modification through changes in workflows and policies. The need for high-quality epidemiological studies of sepsis is particularly pressing in the ED at this present time when sepsis has escalated toward being a public health problem. These studies are invaluable in determining health care resource allocation and are essential for the design of higher-order studies such as randomised control trials. Hence, it is prudent that researchers and funding institutions strive to create conducive environments for good epidemiological studies in the ED to flourish.
, To the Editor: Epidemiological studies describe factors that influence the distribution of disease in populations. Although these studies are often considered as ranking low in the hierarchy of evidence, they remain valuable in relation to sepsis in the emergency department (ED). Firstly, there are indications that ED utilization by sepsis patients is becoming significant. The incidence of sepsis is increasing worldwide and a considerable proportion of patients with sepsis, up to 71%, first present to the ED (1–3). ED use by populations at risk for sepsis, principally the older age group, has increased in the last two decades. The elderly are consistently overrepresented in ED attendance compared to their proportions in the general population (4). Furthermore, previous study has shown that the volume and duration of stay of critically ill patients in the ED are increasing, and therefore, directly impact patients at the severe end of the spectrum (5). Secondly, the descriptive knowledge of epidemiological studies helps ED physicians characterize sepsis and its spectrum, and consequently, assist in “fine tuning” management to seek better outcomes. In addition, longitudinally designed studies are vital as a surveillance tool for understanding the temporal changes and effects on ED patients. They are also useful for monitoring compliance with new protocols and strategies. These latter studies should extend for longer periods instead of halting at in-hospital outcomes because the median survival for hospital survivors of sepsis can be much lower compared to controls from the general population after hospitalization for sepsis (6). Thirdly, extensive literature had focused on sepsis patients admitted to the intensive care unit (ICU), which presents a skewed view of the epidemiology of the disease because patients in the ICU form a small subset of sepsis patients, the very ill, that might have presented to the ED. Conversely, the presenting complaints and course of disease in the acute period prior to admission to either wards or specialist high-dependence and critical units are equally imperative in understanding the
Irwani Ibrahim, MD, MPH Emergency Medicine Department and Department of Surgery National University Health Systems Singapore http://dx.doi.org/10.1016/j.jemermed.2013.08.108 REFERENCES 1. Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003;348:1546–54. 2. Padkin A, Goldfrad C, Brady AR, Young D, Black N, Rowan K. Epidemiology of severe sepsis occurring in the first 24 hrs in intensive care units in England, Wales, and Northern Ireland. Crit Care Med 2003;31:2332–8. 3. Sundararajan V, Macisaac CM, Presneill JJ, Cade JF, Visvanathan K. Epidemiology of sepsis in Victoria, Australia. Crit Care Med 2005; 33:71–80.
e93
e94 4. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2002 emergency department summary. Adv Data 2004;18: 1–34. 5. Lambe S, Washington DL, Fink A, et al. Trends in the use and capacity of California’s emergency departments, 1990–1999. Ann Emerg Med 2002;39:389–96. 6. Quartin AA, Schein RM, Kett DH, Peduzzi PN. Magnitude and duration of the effect of sepsis on survival. Department of Veterans
Letters to the Editor Affairs Systemic Sepsis Cooperative Studies Group. JAMA 1997; 277:1058–63. 7. Wang HE, Shapiro NI, Angus DC, Yealy DM. National estimates of severe sepsis in United States emergency departments. Crit Care Med 2007;35:1928–36. 8. Strehlow MC, Emond SD, Shapiro NI, Pelletier AJ, Camargo CA Jr. National study of emergency department visits for sepsis, 1992 to 2001. Ann Emerg Med 2006;48:326–31.