Systematic Review and Meta-Analysis Demonstrates Benefits of Sepsis Alert Systems in Emergency DepartmentsSystematic Review and Meta-Analysis Demonstrates Benefits of Sepsis Alert Systems in Emergency Departments A recent systematic review and meta-analysis published in *JAMA Network Open* has found that the use of sepsis alert systems in emergency departments (EDs) is associated with improved patient outcomes. Key Findings: * Sepsis alert systems were associated with a 19% reduction in mortality compared to control groups. * Length of hospital stay was also shorter for patients treated in EDs with sepsis alerts. * Alerts were also associated with improved adherence to sepsis bundle elements, including time to fluid administration, blood culture, antibiotic administration, and lactate measurement. * Electronic alerts were particularly effective in reducing mortality and improving adherence to blood culture guidelines. Expert Opinions: * Jeremy Faust, MD: Sepsis alert systems facilitate early detection of potential sepsis, which is crucial for better outcomes. * Gillian Schmitz, MD: Sepsis alerts can prevent delayed diagnosis and medical care for patients with serious illnesses. Challenges and Considerations: * Alert fatigue: Overuse of non-specific alerts can lead to desensitization and missed diagnoses. * False positives: A significant proportion of patients who trigger sepsis alerts do not ultimately develop sepsis. * Lack of standardization: Different hospitals use varying definitions and approaches for sepsis screening, leading to inconsistencies in care. CDC Guidelines and Hospital Implementation: * The CDC recommends rapid screening to identify sepsis cases. * However, only about 65% of U.S. hospitals use electronic health record-generated sepsis alerts, and many smaller hospitals lack standardized screening processes. Implications: The study provides evidence that sepsis alert systems can be an effective tool for improving patient outcomes in emergency settings. However, it is important to strike a balance between early detection and alert fatigue. Hospitals should implement standardized screening protocols and carefully evaluate the effectiveness of their alert systems.
A systematic review and meta-analysis has found that sepsis alert systems used in emergency departments improve patient outcomes, including reduced risk of death and shorter hospital stays.
The analysis found that sepsis warning systems were associated with a 19% lower mortality (RR 0.81, 95% CI 0.71-0.91), Yeon Joo Lee, MD, of Seoul National University Bundang Hospital in Seongnam, South Korea, and colleagues reported in JAMA Network Opened.
The length of hospital stay was also shorter in EDs where sepsis alert systems were used (standardized mean difference -0.15, 95% CI -0.20 to -0.11).
A subanalysis of data showed that alerts were also associated with improved adherence to sepsis bundle elements, including shorter time to fluid administration, blood culture, antibiotic administration, and lactate measurement. Notably, electronic alerts were associated with reduced mortality (RR 0.78, 95% CI 0.67-0.92) and adherence to blood culture guidelines (RR 1.14, 95% CI 1.03-1.27), while non-electronic alert systems were not associated with these outcomes.
Other meta-analyses have shown mixed results for ED sepsis alert systems on patient outcomes, the authors noted.
“If we’ve learned anything over the last 25 years, it’s that recognizing potential sepsis is the key to better outcomes. From there, it’s less clear,” said Jeremy Faust, MD, an emergency physician at Brigham and Women’s Hospital in Boston and MedPage Today’s chief editor.
He noted that previous randomized trials and other studies have shown that adherence to sepsis bundles often does not lead to better outcomes. “What those studies have shown is that if we have good sepsis screening tools in place — early and continuously — we can detect cases earlier, which is especially critical in the most severe cases,” Faust emphasized.
Studies like this shouldn’t be interpreted in isolation, said Gillian Schmitz, MD, past president of the American College of Emergency Physicians, who was not involved in the analysis. MedPage Today. She pointed to a retrospective study that found that 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 full of undifferentiated patients,” Schmitz said. “The benefit of these alerts is that patients who really have sepsis are identified earlier,” she said.
“But the cost of this is that as many as 75% of patients who activate the alarm do not ultimately develop sepsis. This costs the healthcare system and patients money for unnecessary treatments, potential harm from antibiotic resistance and fluid retention in some patients who may become more ill from IVs. And, worst of all, the cost of delayed diagnosis and medical care for everyone in the waiting room who may also be seriously ill,” she said.
“Most of my colleagues would tell you that the sepsis flags tend to wander into ‘The Boy Who Cried Wolf’ and that alert fatigue can ultimately backfire — but every once in a while you get a flag that makes you think twice, and that’s okay,” Faust said. “You have to be vigilant and resist the real dangers of alert fatigue around these sepsis flags and try not to just click through yet another low-yield alert that you’ve gotten that week, because sometimes you’re glad that flag showed up.”
In 2023, the CDC released new guidelines for hospitals to improve the 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 U.S. hospitals use 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. The lack of a standardized approach is more common in smaller hospitals with fewer than 25 beds.
Twenty-two studies, including 19,580 adults, met the inclusion criteria for the systematic review and meta-analysis. Of the patients in these studies, 52.8% came from EDs that implemented sepsis alert systems and the remainder were control groups without sepsis alert systems. Electronic alerts were used in approximately 55% of the studies and the remainder used conventional alerts.
Of the 18 studies in the review that assessed mortality – ranging from in-hospital death to 30-day mortality – the overall mortality rate was 14%. Of the nine studies that assessed intensive care unit (ICU) admission rates – with definitions ranging from occurring at any time or within 24 or 48 hours – the overall ICU admission rate was 25%; the risk of ICU admission was not associated with the presence of sepsis reports.
Eleven studies were from the US, and two studies were from Australia, Sweden and Canada. Most studies were observational. Researchers found that 16 studies had an overall low risk of bias, four had a moderate risk and two had a serious risk of bias. Publication bias was not observed for mortality, length of hospital stay or ICU admission, the authors wrote.
They noted that the definition of sepsis was not uniform across studies, likely reflecting changes in definition over time. Most studies were not randomized and therefore susceptible to confounding factors. Comprehensive data were also lacking on sepsis bundle adhesion within the first hour after diagnosis.
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Katherine Kahn is a staff writer at MedPage Today, covering infectious diseases. She has been a medical writer for more than 15 years.
Disclosures
The research was funded by a grant from Seoul National University Bundang Hospital.
Lee and other study authors reported no conflicts of interest.
Schmitz reported no conflicts of interest.
Primary source
JAMA Network Opened
Citation: Kim HJ, et al “Sepsis Alert Systems, Mortality, and Adherence to Medication in Emergency Departments: A Systematic Review and Meta-Analysis” JAMA Netw Open 2024; DOI: 10.1001/jamanetworkopen.2024.22823.
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