The sensitivity of qSOFA calculated at triage and during emergency department treatment to rapidly identify sepsis patients.

The quick sequential organ failure assessment (qSOFA) score has been proposed as a means to rapidly identify adult patients with suspected infection, in pre-hospital, Emergency Department (ED), or general hospital ward locations, who are in a high-risk category with increased likelihood of "poor outcomes:" a greater than 10% chance of dying or an increased likelihood of spending 3 or more days in the ICU. This score is intended to replace the use of systemic inflammatory response syndrome (SIRS) criteria as a screening tool; however, its role in ED screening and identification has yet to be fully elucidated. In this retrospective observational study, we explored the performance of triage qSOFA (tqSOFA), maximum qSOFA, and first initial serum lactate (> 3 mmol/L) at predicting in-hospital mortality and compared these results to those for the initial SIRS criteria obtained in triage. A total of 2859 sepsis cases were included and the in-hospital mortality rate was 14.4%. The sensitivity of tqSOFA ≥ 2 and maximum qSOFA ≥ 2 to predict in-hospital mortality were 33% and 69%, respectively. For comparison, the triage SIRS criteria and the initial lactate > 3 mmol/L had sensitivities of 82% and 65%, respectively. These results demonstrate that in a large ED sepsis database the earliest measurement of end organ impairment, tqSOFA, performed poorly at identifying patients at increased risk of mortality and maximum qSOFA did not significantly outperform initial serum lactate levels.

Transgender and Gender-Nonconforming Patients in the Emergency Department: What Physicians Know, Think, and Do.

STUDY OBJECTIVE: We explore self-reported knowledge, attitudes, and behaviors of emergency physicians in regard to the care of transgender and gender-nonconforming patients to identify opportunities to improve care of this population. METHODS: From July to August 2016, we electronically surveyed the American College of Emergency Physicians' Emergency Medicine Practice-Based Research Network of 654 active emergency physician participants. We performed frequency tabulations to analyze the closed-ended response items. RESULTS: Of the 399 respondents (61% response rate), 88.0% reported caring for transgender and gender-nonconforming patients in the emergency department (ED), although 82.5% had no formal training about this population. The majority of physicians (86.0%) were comfortable asking about personal pronouns. Only 26.1% of respondents knew the most common gender-affirming surgery for female-to-male patients; 9.8% knew the most common nonhormone gender-affirming medication that male-to-female patients use. Almost no respondents (<3%) were aware of emergency medicine practitioners' performing inappropriate examinations on transgender and gender-nonconforming patients. CONCLUSION: Although transgender and gender-nonconforming people represent a minority of ED patients nationwide, the majority of respondents reported personally providing care to members of this population. Most respondents lacked basic clinical knowledge about transgender and gender-nonconforming care.

Risk factors for mortality despite early protocolized resuscitation for severe sepsis and septic shock in the emergency department.

PURPOSE: The purpose was to identify risk factors associated with in-hospital mortality among emergency department (ED) patients with severe sepsis and septic shock managed with early protocolized resuscitation. METHODS: This was a retrospective, observational cohort study in an academic, tertiary care ED. We enrolled 411 adult patients with severe sepsis and lactate ≥4.0 mmol/L (n = 203) or septic shock (n = 208) who received protocolized resuscitation from 2005 to 2009. Emergency department variables, microbial cultures, and in-hospital outcomes were obtained from the medical record. Multivariable regression was used to identify factors independently associated with in-hospital mortality. RESULTS: Mean age was 59.5 ± 16.3 years; 57% were male. Mean lactate was 4.8 mmol/L (3.5-6.7), 54% had positive cultures, and 27% received vasopressors in the ED. One hundred and five (26%) patients died in-hospital. Age, active cancer, do-not-resuscitate status on ED arrival, lack of fever, hypoglycemia, and intubation were independently associated with increased in-hospital mortality. Lactate clearance and diabetes were associated with a decreased risk of in-hospital death. CONCLUSIONS: We identified a number of factors that were associated with in-hospital mortality among ED patients with severe sepsis or septic shock despite treatment with early protocolized resuscitation. These findings provide insights into aspects of early sepsis care that can be targets for future intervention.

Hospital-based acute care use in survivors of septic shock.

OBJECTIVES: Septic shock is associated with increased long-term morbidity and mortality. However, little is known about the use of hospital-based acute care in survivors after hospital discharge. The objectives of the study were to examine the frequency, timing, causes, and risk factors associated with emergency department visits and hospital readmissions within 30 days of discharge. DESIGN: Retrospective cohort study. SETTING: Tertiary, academic hospital in the United States. PATIENTS: Patients admitted with septic shock (serum lactate≥4 mmol/L or refractory hypotension) and discharged alive to a nonhospice setting between 2007 and 2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The coprimary outcomes were all-cause hospital readmission and emergency department visits (treat-and-release encounters) within 30 days to any of the three health system hospitals. Of 269 at-risk survivors, 63 (23.4%; 95% CI, 18.2-28.5) were readmitted within 30 days of discharge and another 12 (4.5%; 95% CI, 2.3-7.7) returned to the emergency department for a treat-and-release visit. Readmissions occurred within 15 days of discharge in 75% of cases and were more likely in oncology patients (p=0.001) and patients with a longer hospital length of stay (p=0.04). Readmissions were frequently due to another life-threatening condition and resulted in death or discharge to hospice in 16% of cases. The reasons for readmission were deemed potentially related to the index septic shock hospitalization in 78% (49 of 63) of cases. The most common cause was infection related, accounting for 46% of all 30-day readmissions, followed by cardiovascular or thromboembolic events (18%). CONCLUSIONS: The use of hospital-based acute care appeared to be common in septic shock survivors. Encounters often led to readmission within 15 days of discharge, were frequently due to another acute condition, and appeared to result in substantial morbidity and mortality. Given the potential public health implications of these findings, validation studies are needed.