Is Triage Time a Valid Measure of “Time Zero” for Severe Sepsis and Septic Shock Patients in the Emergency Department?

BackgroundThe 2012 Surviving Sepsis Campaign (SSC) Guidelines recommend early, protocolized, resuscitation of all patients with sepsis-induced tissue hypoperfusion (SITH): a systolic blood pressure (SBP)<90mmHg after initial fluid challenge or a blood lactate concentration ≥ 4mmol/L. The SSC sepsis bundle involves obtaining lactate levels, blood cultures, and administering antibiotics and 30mL/kg crystalloid within three hours of development of SITH. These recommendations are the current standard of care and are consistent with the measures endorsed by the National Quality Forum.Study ObjectivesThe SSC has confirmed the use of triage time as “time zero” in the emergency department (ED) for data collection and compliance reporting with the sepsis bundle. The purpose of this study was to assess the validity of triage time as a surrogate for time of presentation of SITH in the ED.MethodsThis was a retrospective consecutive chart review study conducted at a tertiary care ED where both direct bedding and standard triage are employed. All ED charts between September and December 2012 were reviewed. Patients included in the analysis were >18 years old, had a lactate ordered, a documented new infection, and met both SIRS criteria (2 of the following: P>90, RR>20, T>101 or <96.8, WBC>12,000 or <4,000) and SITH criteria (defined in this study as a SBP<90 regardless of fluid administration and/or a lactate≥4mmol/L) in the ED. Statewide Planning and Research Cooperative System (SPARCS) reports from September to December 2012 were cross-referenced to ensure that all patients meeting inclusion criteria were included in analysis. Discharged patients were excluded. Relevant data was extracted, including triage time, vital signs, laboratory values and time meeting SIRS criteria and SITH criteria. Descriptive statistics were calculated (median and 95% confidence intervals).Results29,305 charts were reviewed. Of the 7,760 charts that screened in with lactate order, 194 met inclusion criteria and were included in data analysis. 44.1% of patients met SITH criteria with a SBP<90 (and normal lactate), 40.0% with a lactate≥4 (and normal SBP), and 14.4% with both a SBP<90 and a lactate ≥4. Only 14.4% of patients met 2 of the 3 available SIRS criteria at triage. 82.1% of patients met SIRS criteria with a P>90, 53.8% of patients with a RR>20, 27.2% of patients with a T>101 or <96.8, and 49.7% of patients with a WBC>12,000/<4,000. Patients met SIRS criteria a median of 38 minutes (95% CI: 47.42-70.58) after triage. Only 12.3% of patients had a SBP<90 at triage. Patients met SITH criteria (a SBP<90 and/or a lactate≥4) a median of 54 minutes (95% CI: 77.93-116.10) after triage.ConclusionsThe American College of Emergency Physicians (ACEP) has raised significant concerns regarding the scientific validity and reliability of triage time as “time zero.” In this study only 14.4% of patients met 2 of the 3 SIRS criteria available at triage, and even fewer- 12.3% of patients- had a SBP<90mmHg at triage. Patients met SIRS criteria 38 minutes after triage, and SITH criteria 54 minutes after triage. As many lab values are not yet available at triage, this time is not an accurate surrogate for time of identification of SITH. Future efforts should focus on identifying a marker that may allow for more appropriate reporting of compliance with the sepsis resuscitation bundle. BackgroundThe 2012 Surviving Sepsis Campaign (SSC) Guidelines recommend early, protocolized, resuscitation of all patients with sepsis-induced tissue hypoperfusion (SITH): a systolic blood pressure (SBP)<90mmHg after initial fluid challenge or a blood lactate concentration ≥ 4mmol/L. The SSC sepsis bundle involves obtaining lactate levels, blood cultures, and administering antibiotics and 30mL/kg crystalloid within three hours of development of SITH. These recommendations are the current standard of care and are consistent with the measures endorsed by the National Quality Forum. The 2012 Surviving Sepsis Campaign (SSC) Guidelines recommend early, protocolized, resuscitation of all patients with sepsis-induced tissue hypoperfusion (SITH): a systolic blood pressure (SBP)<90mmHg after initial fluid challenge or a blood lactate concentration ≥ 4mmol/L. The SSC sepsis bundle involves obtaining lactate levels, blood cultures, and administering antibiotics and 30mL/kg crystalloid within three hours of development of SITH. These recommendations are the current standard of care and are consistent with the measures endorsed by the National Quality Forum. Study ObjectivesThe SSC has confirmed the use of triage time as “time zero” in the emergency department (ED) for data collection and compliance reporting with the sepsis bundle. The purpose of this study was to assess the validity of triage time as a surrogate for time of presentation of SITH in the ED. The SSC has confirmed the use of triage time as “time zero” in the emergency department (ED) for data collection and compliance reporting with the sepsis bundle. The purpose of this study was to assess the validity of triage time as a surrogate for time of presentation of SITH in the ED. MethodsThis was a retrospective consecutive chart review study conducted at a tertiary care ED where both direct bedding and standard triage are employed. All ED charts between September and December 2012 were reviewed. Patients included in the analysis were >18 years old, had a lactate ordered, a documented new infection, and met both SIRS criteria (2 of the following: P>90, RR>20, T>101 or <96.8, WBC>12,000 or <4,000) and SITH criteria (defined in this study as a SBP<90 regardless of fluid administration and/or a lactate≥4mmol/L) in the ED. Statewide Planning and Research Cooperative System (SPARCS) reports from September to December 2012 were cross-referenced to ensure that all patients meeting inclusion criteria were included in analysis. Discharged patients were excluded. Relevant data was extracted, including triage time, vital signs, laboratory values and time meeting SIRS criteria and SITH criteria. Descriptive statistics were calculated (median and 95% confidence intervals). This was a retrospective consecutive chart review study conducted at a tertiary care ED where both direct bedding and standard triage are employed. All ED charts between September and December 2012 were reviewed. Patients included in the analysis were >18 years old, had a lactate ordered, a documented new infection, and met both SIRS criteria (2 of the following: P>90, RR>20, T>101 or <96.8, WBC>12,000 or <4,000) and SITH criteria (defined in this study as a SBP<90 regardless of fluid administration and/or a lactate≥4mmol/L) in the ED. Statewide Planning and Research Cooperative System (SPARCS) reports from September to December 2012 were cross-referenced to ensure that all patients meeting inclusion criteria were included in analysis. Discharged patients were excluded. Relevant data was extracted, including triage time, vital signs, laboratory values and time meeting SIRS criteria and SITH criteria. Descriptive statistics were calculated (median and 95% confidence intervals). Results29,305 charts were reviewed. Of the 7,760 charts that screened in with lactate order, 194 met inclusion criteria and were included in data analysis. 44.1% of patients met SITH criteria with a SBP<90 (and normal lactate), 40.0% with a lactate≥4 (and normal SBP), and 14.4% with both a SBP<90 and a lactate ≥4. Only 14.4% of patients met 2 of the 3 available SIRS criteria at triage. 82.1% of patients met SIRS criteria with a P>90, 53.8% of patients with a RR>20, 27.2% of patients with a T>101 or <96.8, and 49.7% of patients with a WBC>12,000/<4,000. Patients met SIRS criteria a median of 38 minutes (95% CI: 47.42-70.58) after triage. Only 12.3% of patients had a SBP<90 at triage. Patients met SITH criteria (a SBP<90 and/or a lactate≥4) a median of 54 minutes (95% CI: 77.93-116.10) after triage. 29,305 charts were reviewed. Of the 7,760 charts that screened in with lactate order, 194 met inclusion criteria and were included in data analysis. 44.1% of patients met SITH criteria with a SBP<90 (and normal lactate), 40.0% with a lactate≥4 (and normal SBP), and 14.4% with both a SBP<90 and a lactate ≥4. Only 14.4% of patients met 2 of the 3 available SIRS criteria at triage. 82.1% of patients met SIRS criteria with a P>90, 53.8% of patients with a RR>20, 27.2% of patients with a T>101 or <96.8, and 49.7% of patients with a WBC>12,000/<4,000. Patients met SIRS criteria a median of 38 minutes (95% CI: 47.42-70.58) after triage. Only 12.3% of patients had a SBP<90 at triage. Patients met SITH criteria (a SBP<90 and/or a lactate≥4) a median of 54 minutes (95% CI: 77.93-116.10) after triage. ConclusionsThe American College of Emergency Physicians (ACEP) has raised significant concerns regarding the scientific validity and reliability of triage time as “time zero.” In this study only 14.4% of patients met 2 of the 3 SIRS criteria available at triage, and even fewer- 12.3% of patients- had a SBP<90mmHg at triage. Patients met SIRS criteria 38 minutes after triage, and SITH criteria 54 minutes after triage. As many lab values are not yet available at triage, this time is not an accurate surrogate for time of identification of SITH. Future efforts should focus on identifying a marker that may allow for more appropriate reporting of compliance with the sepsis resuscitation bundle. The American College of Emergency Physicians (ACEP) has raised significant concerns regarding the scientific validity and reliability of triage time as “time zero.” In this study only 14.4% of patients met 2 of the 3 SIRS criteria available at triage, and even fewer- 12.3% of patients- had a SBP<90mmHg at triage. Patients met SIRS criteria 38 minutes after triage, and SITH criteria 54 minutes after triage. As many lab values are not yet available at triage, this time is not an accurate surrogate for time of identification of SITH. Future efforts should focus on identifying a marker that may allow for more appropriate reporting of compliance with the sepsis resuscitation bundle.