Sepsis Alerts in Emergency Departments Linked to Lower Mortality

Sepsis alert systems used in emergency departments (EDs) were tied to better patient outcomes, including lower risk of death and shorter hospital stays, according to a systematic review and meta-analysis.

In the analysis, sepsis alert systems were associated with a 19% reduction in mortality (RR 0.81, 95% CI 0.71-0.91), reported Yeon Joo Lee, MD, of the Seoul National University Bundang Hospital in Seongnam, South Korea, and colleagues in JAMA Network Open.

Length of hospital stay was also shorter in EDs that used sepsis alert systems (standardized mean difference -0.15, 95% CI -0.20 to -0.11).

A subanalysis of data found that alerts were also associated with better adherence to sepsis bundle elements, including shorter time to fluid administration, blood culture, antibiotic administration, and lactate measurement. Of note, electronic alerts were associated with a reduced mortality rate (RR 0.78, 95% CI 0.67-0.92) and adherence to blood culture guidelines (RR 1.14, 95% CI 1.03-1.27), whereas non-electronic alert systems had no association with these outcomes.

Other meta-analyses have found mixed results for ED sepsis alert systems on patient outcomes, the authors noted.

“If we’ve learned anything in the last 25 years, it’s that recognition of potential sepsis is the key to better outcomes. From there, less is clear,” said Jeremy Faust, MD, an emergency physician at Brigham and Women’s Hospital in Boston and MedPage Today’s editor in chief.

He noted that previous randomized trials and other studies have shown that adherence to sepsis bundles often doesn’t lead to improved outcomes. “What those studies have shown is that if we deploy good sepsis screening tools — early and continuously — we can detect cases sooner, which is particularly crucial in the most severe cases,” Faust emphasized.

Studies such as this one should not be interpreted in isolation, Gillian Schmitz, MD, past-president of the American College of Emergency Physicians, who was not associated with the analysis, told MedPage Today. She pointed to one retrospective study that showed 60% to 75% of patients who met sepsis criteria did not actually have sepsis.

“[Emergency medicine] is the only specialty that has a waiting room of undifferentiated patients,” Schmitz said. “The benefit of these alerts is that patients that do truly have sepsis are identified earlier,” she said.

However, “the cost is that up to 75% of patients who trigger the alert end up not having sepsis, costing the healthcare industry and patients money for unnecessary treatment, potential harm of antibiotics resistance, and fluid overload in a subset of patients who may get worse with IV fluids, and, worst of all, the cost of delayed diagnosis and medical care to everyone else in the waiting room who may also have a critical illness,” she commented.

“Most of my colleagues would tell you that the sepsis flags tend to err on ‘The Boy Who Cried Wolf’ side of things and that alarm fatigue can ultimately backfire — but once in a while you get a flag that makes you think twice, and that is a good thing,” Faust said. “You have to be vigilant and resist the genuine dangers of alarm fatigue around these sepsis flags and try not to just click through the umpteenth low-yield alert you’ve gotten that week, because sometimes you’re glad that flag popped up.”

In 2023, the CDC issued new guidance for hospitals to improve quality of care for patients with sepsis. The CDC’s Hospital Sepsis Program Core Elements recommends rapid screening to quickly identify cases of sepsis. However, a recent report from the CDC’s National Healthcare Safety Network found that only 65% of hospitals in the U.S. utilize electronic health record-generated alerts based on systemic inflammatory response syndrome criteria. About half (47%) use manual screening and 10% have no standardized process for rapid sepsis identification. Having no standardized approach is more common in smaller hospitals with fewer than 25 beds.

Twenty-two studies, enrolling 19,580 adults, met inclusion criteria for the systematic review and meta-analysis. Among patients in these studies, 52.8% were from EDs that implemented sepsis alert systems and the remainder comprised control groups with no sepsis alert systems. Electronic alerts were used in about 55% of studies and the remainder used conventional alerts.

Among the 18 studies in the review that evaluated mortality — ranging from in-hospital death up to 30-day mortality — the overall mortality rate was 14%. Among the nine studies that evaluated intensive care unit (ICU) admission rates — with definitions ranging from occurring at any time or within 24 or 48 hours — the overall rate of admission to the ICU was 25%; the risk of ICU admission was not associated with the presence of sepsis alerts.

Eleven studies were from the U.S., and there were two studies each from Australia, Sweden, and Canada. Most of the studies were observational. Researchers determined that 16 studies had an overall low risk of bias, four had moderate risk, and two had serious risks of bias. Publication bias was not observed for mortality rate, hospital length of stay, or ICU admission, the authors wrote.

They noted that the definition of sepsis was not uniform across studies, likely reflecting changes in the definition over time. Most studies were not randomized and therefore prone to confounding factors. Comprehensive data were also lacking on sepsis bundle adherence within the first hour of diagnosis.

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