The Undeniable Link Between Sepsis and Clinical Deterioration

In their latest multicenter study in Critical Care Explorations, the research team led by Dr. Matthew Churpek at the University of Wisconsin, undertook an ambitious chart review of 4,000 high-risk inpatient encounters across four health systems, using eCART to identify those patients.¹ The goal was to delineate the primary causes of clinical deterioration in hospitalized patients and what corresponding workup and treatment those patients received.

Sepsis emerged as the most common cause of clinical deterioration, accounting for 41% of confirmed events, with complete blood counts, chest x-rays, and cultures being the most common diagnostics ordered (47%, 42% and 40%, respectively). Antimicrobials were the most common medication intervention (46% of events), followed by fluid bolus (34%). The other causes of deterioration trailed in comparison to sepsis, with arrhythmias accounting for 19% of deteriorations as the second most common.

The study underscores the critical importance of early sepsis recognition and management in patients deemed to be at increased risk of deterioration and suggests that the current siloed approach to treating sepsis and managing deterioration is fundamentally flawed.  Sepsis and deterioration are not two different problems but rather one and the same, with septic patients at high risk of deterioration and deteriorating patients at high risk of being septic. The large volume of sepsis patients among deteriorating ones may also explain why general early warning scores, like eCART and NEWS, are often more efficient at identifying septic patients than traditional sepsis tools, like SIRS and qSOFA.²

This is why our approach at AgileMD focuses on identifying the patients most likely to deteriorate and then screening those patients for sepsis more frequently. For example, rather than screening all patients for sepsis every shift or relying on a sepsis alert that fires indiscriminately once a day, we advocate using an EHR integrated clinical pathway to screen only those at elevated risk of deterioration but doing so every 4 hours. The net impact is a much smaller and more efficient workload (since fewer sepsis screens are required and each is more likely to be positive) and a standardized workflow for patients suspected to be septic.

_References

_{1. Churpek MM, Ingebritsen R, Carey KA, et al. Causes, Diagnostic Testing, and Treatments Related to Clinical Deterioration Events Among High-Risk Ward Patients. Crit Care Explor. 2024;6(10):e1161. ‍}

_{2. Churpek MM, Snyder A, Sokol S, Pettit NN, Edelson DP. Investigating the Impact of Different Suspicion of Infection Criteria on the Accuracy of Quick Sepsis-Related Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and Early Warning Scores. Crit Care Med. 2017 Nov;45(11):1805-1812.}