Physiological parameters, location of infection and organ failure are significant predictors of misdiagnosing severe sepsis

Background

Severe sepsis and septic shock are common disease processes in the critically ill and are associated with substantial morbidity and mortality. The importance of the early identification and diagnosis of severe sepsis has been highlighted by the Surviving Sepsis Guidelines with the aim to provide early and aggressive management in order to improve outcome. In contemporary practice, all clinicians have the responsibility of identifying severe sepsis. Therefore the objectives of this study were to determine whether emergency department and intensive care clinicians could identify and diagnose severe sepsis in those patients in their care within the first 24 hours of admission, and to identify predictors of failing to diagnose sepsis.

Methods

The patient cohort were prospectively screened and enrolled on admission to intensive care within the first 24 hours. Severe sepsis was defined as new-onset acute organ dysfunction, using consensus criteria. Clinical data and physiological parameters were collected prospectively. Diagnosis was based on microbiologically confirmed clinical findings. Clinicians caring for each patient were prospectively surveyed.

Results

All 402 subjects had infection. Infection sites included 52% pneumonia, 17% urinary, 15% abdominal, 6% wound and skin, and 10% isolated organs and bone. Single-organ failure was evident in 21%, 42% had two-organ failure, 29% had three-organ failure and 8% had four-organ failure. Nurses identified sepsis in 141 of the 402 patients (P < 0.001) whereas physicians did so in 265 of the 402 patients (P < 0.05). Misdiagnosis of severe sepsis by the attending nurse or physician was more likely to be associated with pneumonia (odds ratio (OR) = 4.2 (95% confidence interval (CI) = 3.6–4.2), P < 0.01), urinary sepsis (OR = 2.9 (95% CI = 2.6–3.4), P < 0.5), less than three-organ failure (OR = 3.1 (95% CI = 2.4–3.7), P < 0.01), Gram-negative infection (OR = 2.3 (95% CI = 1.6–3.5), P < 0.5) and presenting without fever (OR = 3.5 (95% CI = 3.1–3.9), P < 0.05). Thirty-two percent of clinicians did not know the criteria for severe sepsis and 57% missed the patient diagnosis in their care at that time.

Conclusion

In this study, misdiagnosis of severe sepsis is still an acknowledged problem in meeting the goals of early resuscitation. Protocols and monitoring tools may assist the early identification of severe sepsis so appropriate care can be prioritised and resuscitation implemented early in their admission.