Sepsis care in the ED: The earlier, the better

By: Tony Briningstool, MD, FACEP | CEO, Sound Emergency Medicine 

In the fast-paced environment of a hospital emergency department (ED), every second counts. Throughout my time as an ED physician, I’ve witnessed firsthand how sepsis can swiftly turn routine patient treatment into a life-or-death race against the clock. Sepsis is a tricky foe as it’s difficult to identify. It may present as a simple infection when in fact, beneath the surface, a patient’s body is waging all-out war. 

The prevalence and danger of sepsis makes the emergency department a crucial identification and treatment point. Early recognition and rapid intervention are crucial, yet not always easy to achieve in the midst of caring for dozens of patients during a busy shift. As emergency medicine professionals, it is our duty to understand the nuances of sepsis and use practical strategies and evidence-based approaches to treat and document it effectively. One-, three-, and six-hour sepsis treatment bundles are required by the Centers for Medicare and Medicaid Services (CMS) and inform our emergency clinicians’ response to this high-risk pathologic process before it spirals out of control. 

Why the focus on sepsis? 

Sepsis has rapidly become the third-leading cause of death in the U.S. Claiming more than 250,000 lives annually, this life-threatening emergency happens when the body’s overactive and toxic response to an infection damages its vital organs. While sepsis can affect all people, patients who are very young, very old, chronically ill, or immunodeficient are at a higher risk of contracting an infection that could lead to septic shock. 

Sepsis isn’t just dangerous — it’s expensive. The Sepsis Alliance, an organization founded to raise sepsis awareness among both patients and clinicians, reports that costs for acute sepsis hospitalization and skilled nursing are estimated at $62 billion annually. This, combined with being the number one cause of readmission to the hospital, makes sepsis the most expensive diagnosis in the healthcare system. A problem of this magnitude can only be solved by an organized effort. But where do we start? 

Understanding the challenges to identifying sepsis is our first line of defense against it. Sepsis is difficult to diagnose quickly because: 

1. It affects all manner of patients. While some patients can be considered “higher risk,” sepsis develops in patients in all disciplines and from all walks of life. Physicians must be looking for it to find it. 
2. It requires intentional teamwork. Communication with nurses, transport, and hospitalist care teams must be seamless to avoid delays in sepsis management at critical points of care transition during a patient’s hospital stay. 
3. It can present as something else entirely. With no specific lab test to confirm it, sepsis’s subtle symptoms can sometimes be overlooked, dismissed, or attributed to an alternative diagnosis. When prompt treatment is key to a patient’s survival, these red herrings could be the difference between life and death. 

The emergency department plays a key role in sepsis care 

You can find a case of sepsis in the ED on any given day. Of those cases, statistics show almost 30 percent of those patients will die. This puts an enormous responsibility on emergency medicine clinicians to identify sepsis early and accurately because if an ailing ED patient is transferred to a different hospital department without a sepsis diagnosis, their likelihood of mortality skyrockets. 

Sound Emergency Medicine’s Champions for Sepsis programs are a huge focus for us, our hospital partners, and our medical directors. With emphasis on early identification and intentional leaders who foster strong teamwork, we’re able to begin sepsis treatment in the ED and coordinate care management no matter what hospital department a patient ends up in. These strategies work best when they’re implemented intentionally and fully understood by every clinician in the ED.  

Vision for excellence 

It is imperative for emergency medicine (EM) leaders to educate their teams on what excellence looks like. Outlining a process for sepsis care that can be followed consistently creates the best results for patients. Our EM teams embody care excellence and take ownership in articulating the right expectations to our ED team and throughout hospital departments. For our hospital partners, it’s what sets us apart. 

Excellence in sepsis care begins with a team that is thoroughly educated on the following: 

• Timely sepsis recognition. Every member of the clinical team can confidently identify the beginnings of a septic infection. 

• Systemized sepsis management. Vasopressors and other forms of treatment are applied early and correctly. 

• Accurate documentation. Clinicians know to reassess perfusion with a time stamp after treatment. This is crucial for securing payments as well. 

• Consistent feedback. Highlight feedback for individual providers in a blame-free manner to keep the spirit of education alive in the ED. 

• Measure outcomes. It’s impossible to know if a current system is broken without measuring it. Track sepsis patients in and outside the ED to inform improvements to sepsis identification and treatment. 

 Early identification 

As mentioned earlier, when dealing with sepsis, time is your greatest enemy. Early identification is key and while any patient can develop sepsis, bookmarking patients with the highest risk ensures their condition does not slip between the cracks. Factors such as elevated white blood cell count, heart rate, respiratory rate, or increased or decreased temperature are all important. 

If a patient has at least two of these symptoms, they could potentially develop sepsis. Also, all patients who have systemic inflammatory response syndrome (SIRS) could quickly develop sepsis. It’s imperative that EM clinicians work together to identify and monitor patients with these symptoms and confirm whether they are SIRS-positive. 

Pairing a SIRS identification with a sepsis treatment bundle creates a systematic approach to treatment. These protocols combine therapies to improve patient outcomes and should be tracked and completed withing the first six hours a patient is in the hospital. 

Team coordination 

If a patient’s sepsis isn’t identified or clearly communicated in the ED, there’s a higher chance of fast deterioration down the line. Team coordination between the ED, ICU, and in-patient units of the hospital is vital. Bedside handoff is a vulnerable time for patients, and gaps in care appear whenever a patient is moved. Sepsis patients are incredibly dynamic, and effective communication between disciplines ensures these critical points of care don’t make things worse for the patient. 

For example, the all-important six-hour recheck cannot happen if a patient is transferred out of the ED without having the need communicated to the next clinical team. Documenting a time frame for that check ensures it’s completed once the patient leaves the ED.  

Ending sepsis one patient at a time 

An ED team’s responsibility to hold the frontline against sepsis cannot be understated. These tips are just the start of a healthcare culture shift that puts sepsis identification at the forefront of emergency clinicians’ minds. When teams make coordinated efforts against this prolific problem, the results are seen in patient outcomes, cost reduction, and team alignment. 

Learn more about Sound’s emergency medicine programs here.