Pandey Shivansh R, Knack Sarah K S, Driver Brian E, Prekker Matthew E, Scott Nathaniel, Ringstrom Sarah J, Maruggi Ellen, Kaus Olivia, Tordsen Walker, Puskarich Michael A
Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA.
Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA.
Acad Emerg Med. 2025 Mar;32(3):204-215. doi: 10.1111/acem.15074. Epub 2024 Dec 27.
Sepsis remains the leading cause of in-hospital death and one of the costliest inpatient conditions in the United States, while treatment delays worsen outcomes. We sought to determine factors and outcomes associated with a missed emergency physician (EP) diagnosis of sepsis.
We conducted a secondary analysis of a prospective single-center observational cohort of undifferentiated, critically ill medical patients (September 2020-May 2022). EP gestalt of suspicion for sepsis was measured using a visual analog scale (VAS; 0%-100%) at 15 and 60 min post-patient arrival. The primary outcome was an explicit hospital discharge diagnosis of sepsis that was present on arrival. We calculated test characteristics for clinically relevant subgroups and examined factors associated with initial and persistent missed diagnoses. Associations with process (antibiotics) and clinical (mortality) outcomes were assessed after adjusting for severity.
Among 2484 eligible patients, 275 (11%) met the primary outcome. A VAS score of ≥50 (more likely than not of being septic) at 15 min demonstrated sensitivity 0.83 (95% confidence interval [CI] 0.78-0.87) and specificity 0.85 (95% CI 0.83-0.86). Older age, hypoxia, hypotension, renal insufficiency, leukocytosis, and both high and low temperature were significantly associated with lower accuracy due to reduced specificity, but maintained sensitivity. Of 48 (17%) and 23 (8%) missed cases at 15 and 60 min, elevated lactate, leukocytosis, bandemia, and positive urinalysis were more common in the missed sepsis compared to nonsepsis cases. Missed diagnoses were associated with median (interquartile range) delay of 48 (27-64) min in antibiotic administration but were not independently associated with inpatient mortality as risk ratios remained close to 1 across VAS scores.
This prospective single-academic center study identified patient subgroups at risk of impaired diagnostic accuracy of sepsis, with clinicians often overdiagnosing rather than underdiagnosing these groups. Prompt abnormal laboratory test results can "rescue" initial missed diagnoses, serving as potential clinician- and systems-level intervention points to reduce missed diagnoses. Missed diagnoses delayed antibiotics, but not mortality after controlling for severity of illness.
脓毒症仍然是美国住院患者死亡的主要原因，也是最昂贵的住院病症之一，而治疗延迟会使预后恶化。我们试图确定与急诊医生（EP）漏诊脓毒症相关的因素和预后情况。
我们对一个前瞻性单中心观察性队列（2020年9月至2022年5月）中未分化的危重症内科患者进行了二次分析。在患者到达后15分钟和60分钟时，使用视觉模拟量表（VAS；0%-100%）测量EP对脓毒症的怀疑程度。主要结局是出院时明确诊断为入院时即存在的脓毒症。我们计算了临床相关亚组的检验特征，并研究了与初始漏诊和持续性漏诊相关的因素。在调整严重程度后，评估了与治疗过程（抗生素）和临床（死亡率）结局的关联。
在2484例符合条件的患者中，275例（11%）达到主要结局。15分钟时VAS评分≥50（脓毒症可能性较大）显示敏感性为0.83（95%置信区间[CI]0.78-0.87），特异性为0.85（95%CI0.83-0.86）。年龄较大、低氧、低血压、肾功能不全、白细胞增多以及体温过高和过低，由于特异性降低，与较低的诊断准确性显著相关，但敏感性保持不变。在15分钟和60分钟时漏诊的48例（17%）和23例（8%）病例中，与非脓毒症病例相比，脓毒症漏诊病例中乳酸升高、白细胞增多、杆状核细胞增多和尿检阳性更为常见。漏诊与抗生素使用中位延迟（四分位间距）48（27-64）分钟相关，但与住院死亡率无独立关联，因为在不同VAS评分下风险比均接近1。
这项前瞻性单学术中心研究确定了脓毒症诊断准确性受损风险较高的患者亚组，临床医生对这些组的诊断往往是过度诊断而非漏诊。及时出现的异常实验室检查结果可以“挽救 ”初始漏诊，作为潜在的临床医生和系统层面的干预点以减少漏诊。漏诊会延迟抗生素使用，但在控制疾病严重程度后与死亡率无关。
