Characteristics and outcomes of patients assessed for suspected sepsis the emergency department

Characteristics and outcomes of patients assessed for suspected sepsis the emergency department | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Characteristics and outcomes of patients assessed for suspected sepsis the emergency department Charlotte Dempsey, Jonathan Burcham, Sophie Damianopoulos, Stephen Macdonald This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9004278/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Background Structured sepsis screening and management tools are recommended. Evaluation of their effectiveness is limited by spectrum bias, with apparent improvements in outcomes due to capturing a broader population with overall lower baseline risk. The aim was to determine the true incidence of sepsis and septic shock and outcomes among patients assessed for suspected sepsis in an adult tertiary hospital Emergency Department (ED). Methods A retrospective observational study identified patients with suspected sepsis admitted via the Emergency Department (ED) during the calendar years 2019 and 2020. Patients were subsequently classified into four groups: infection, sepsis, septic shock and non-infection using standardised objective criteria. Baseline characteristics, processes of care and clinical outcomes were compared between groups. Results Five hundred and ninety-five patients were assessed for suspected sepsis in the ED. These were subsequently classified as 211 (34%) with infection, 266 (46%) with sepsis, 58 (10%) with septic shock, and 60 (10%) with an alternative diagnosis. Rates of organ support, intensive care admission and mortality varied significantly between groups. Conclusions An ED sepsis screening program identifies patients with a range of clinical phenotypes, with 44% of patients misclassified. Measuring the effectiveness of sepsis recognition tools based on those assessed for suspected sepsis will generate misleading results. Standardised confirmation of sepsis is required to adjust for baseline risk and generate credible results to drive quality improvements, and inform policy-making and resource allocation. emergency sepsis infectious diseases quality of care outcomes Introduction Sepsis is a significant global health problem, recognised as a Global Health Priority by the World Health Organisation( 1 , 2 ). Despite reductions in mortality in recent decades ( 3 ), there is a substantial burden of morbidity among survivors ( 4 ). Prompt recognition and treatment are important elements in achieving the optimal clinical outcome for patients presenting with sepsis ( 5 , 6 ). Most sepsis cases are community-acquired, and the emergency department (ED) has a critical role in identifying and managing sepsis at the point of presentation. The early features of sepsis can be non-specific, and it can be difficult to recognise and diagnose. Many health systems have introduced sepsis screening and treatment pathways. While associated with improvements in quality-of-care metrics, demonstrating improvements in clinical outcomes is more difficult ( 7 , 8 ). In particular, without objective confirmation of a sepsis diagnosis, misclassification bias may lead to erroneous conclusions about the impact of interventions in quality reporting and observational research studies ( 9 ). We sought to evaluate the characteristics of a cohort of patients admitted with suspected sepsis in the ED at a single adult tertiary hospital. This coincided with the introduction of a sepsis screening tool and initial management guideline. A ‘Code Sepsis’ response was triggered in the ED by clinical features and physiological thresholds with activation of a sepsis pathway. The sepsis screening tool was designed to be sensitive for sepsis and septic shock. We hypothesised that activation of the ED sepsis pathway would therefore identify patients with a range of illness severities, as well as patients subsequently diagnosed with a condition other than infection. Methods Design and setting This was a retrospective chart review of patients admitted via the ED with suspected sepsis during 2019 and 2020. RPH is an adult tertiary ED (annual census 82,000) and major trauma referral hospital for the state of Western Australia. As a result of national and state border closures, Western Australia did not experience a significant number of COVID-19 presentations during 2020. Participants Participants were those admitted from ED for suspected sepsis, defined as Activation of a ‘Code-Sepsis’ call and Collection of blood cultures AND IV antibiotic administration in the ED Patients who were transferred to the ED from another hospital, or who were discharged home or transferred to another health facility, were excluded. Study Groups Patients were retrospectively classified into one of four groups based upon all available clinical information, including the hospital discharge summary. We used an explicit objective methodology to classify cases into four groups: 1) Infection without Sepsis; 2) Sepsis; 3) Septic Shock; and 4) a non-infection diagnosis. Classification of Sepsis and Septic shock was based on the Sepsis-3 criteria ( 10 ), i.e. Sepsis was defined as infection plus an increase in Sequential Organ Failure Assessment (SOFA) score of two or more points at presentation. Septic shock was a requirement for vasopressors or a systolic blood pressure of 2mmol/L. Approvals The study was approved as a quality activity, and as such, the requirement for human research ethics committee approval or participant consent was waived. The work was carried out in accordance with the National Health and Medical Research Council Statement on Ethical Conduct in Human Research. Data and outcomes Data were collected from hospital administrative and laboratory systems and paper medical records. Data were entered into a REDCap database ( 11 ). Baseline data included patient age and sex, mode of arrival to ED, prior living status (independent, residential care), Australasian Triage Score (ATS) category, Charlson Comorbidity Score (CCS), Sequential Organ Failure Assessment (SOFA) Score at baseline, and at 24 hours, 48 hours, and 72 hours post admission. Process-of-care metrics were time from triage to IV antibiotic administration, measurement of lactate, collection of adequate blood cultures (defined as at least two sets), and volume of intravenous (IV) resuscitation fluid administered in the ED. Documentation of a limitation-of-care decision was also captured, typically where comorbid illness or frailty precluded invasive interventions such as intubation. Service and clinical outcome measures collected were admission to intensive care, duration of stay, in-hospital mortality and unplanned readmission to hospital within 30 days. Analysis Participant characteristics were summarised using descriptive statistics. All analyses were performed using Stata 15.1 (College Station, TX, USA). Results During the two-year study period, a total of 726 patients were assessed for suspected sepsis. Inter-hospital transfers, patients not admitted to hospital, or where data were unavailable were excluded (131) leaving a total of 595 cases for analysis in the present study. Overall characteristics of the cohort are shown in Table 1 . Table 1 Baseline characteristics of cohort (N = 595) Age (years) 67 (48, 78) Sex N (%) M 357 (60) F 239 (40) Mode of arrival N (%) Ambulance 399 (67) Private Transport 187 (31) Other 10 ( 2 ) ATS N (%) 1 45 ( 7 ) 2 309 (52) 3 204 (35) 4/5 38 ( 6 ) Prior Living status N (%) Independent 493 (83) Residential Care 76 ( 13 ) NFA 19 ( 3 ) Other 8 ( 1 ) Charlson Score 2 (0, 5) Temperature ( O C) 38.1+/-1.4 Pulse rate (beats/min) 107 +/-24 Respirations (resp/min) 24+/-7 SBP (mmHg) 101 +/-23 GCS 15 ( 14 , 15 ) Source of infection N (%) Respiratory 157 ( 26 ) Urinary 145 ( 24 ) Skin/soft tissue 95 ( 16 ) Abdo/pelvis 56 ( 9 ) Other 35 ( 6 ) Unknown 108 ( 18 ) ATS Australian Triage Score; NFA No Fived Address; SBP Systolic Blood Pressure; GCS Glasgow Coma Scale. The majority of patients arrived by ambulance, with over half being assigned a high triage score of 1 or 2. The vast majority were of independent prior living status. The most common presumed source of infection was respiratory, followed by urinary tract and skin/soft tissue. Table 2 shows the characteristics, processes of care and outcomes by sepsis classification. Patients were classified as follows; Infection 211 (34%), sepsis 266 (46%), septic shock 58 (10%) and non-infection diagnosis 60 (10%). Overall, 53 patients (9%) died. Rates of ICU admission and mortality differed significantly between groups (both P < 0.001). There were no differences in length of hospital stay or rates of representation to hospital. Table 2 Characteristics, processes of care and outcomes by sepsis classification N (%) Infection Sepsis Septic Shock Other 211 (34) 266 (46) 58 ( 10 ) 60 ( 10 ) SOFA Score 0 (0,1) 3 ( 2 , 4 ) 7 ( 5 , 9 ) 1 (0,4) Lactate 1.8 +/-1.0 2.4 +/-1.6 5.3 +/-3.1 2.9+/-3.7 Time to AB (mins) 108 (71,183) 88 (51,145) 67 (45,92) 117 (63,233) 2 sets cultures N (%) 167 (79) 208 (78) 41 (71) 48 (80) Lactate done N (%) 129 (61) 231 (87) 57 (98) 40 (67) IV Fluid volume (ml) 1011 +/-870 1900 +/-1265 2489 +/-1545 1339 +/-1149 Care limitation N (%) 24 ( 11 ) 70 ( 26 ) 18 (30) 7 ( 12 ) ICU admit N (%) 1 (< 1) 52 ( 19 ) 41 (68) 4 ( 7 ) ICU LOS (hrs) 37 (37, 37) 51 (26,87) 66 (28, 141) 66 (40,75) Hosp LOS (days) 4 ( 2 , 6 ) 5 ( 3 , 8 ) 6 ( 4 , 13 ) 4 ( 3 , 8 ) Intubated N (%) 0 (0) 2 (< 1) 11 ( 18 ) 2 (#) Vasopressors N (%) 0 (0) 46 ( 17 ) 41 (68) 2 ( 3 ) New RRT N (%) 0 (0) 4 ( 1 ) 7 ( 12 ) 0 (0) Representation N (%) 44 ( 21 ) 65 ( 25 ) 12 ( 18 ) 13 ( 22 ) Died N 6 26 16 5 Died % (95% CI) 3 ( 1 – 6 ) 10 ( 6 – 14 ) 27 (17–41) 9 ( 3 – 19 ) SOFA Sequential Organ Failure Assessment; AB Antibiotics; IV Intravenous; ICU Intensive Care Unit; LOS Length of Stay; RRT Renal Replacement Therapy. Summary data are medians (interquartile range) or means +/- standard deviation. Discussion This single centre retrospective chart review of patients admitted from the ED of an adult tertiary hospital with suspected sepsis found a range of clinical phenotypes and associated illness severity. Only 56% of patients met objective criteria for sepsis or septic shock. One third were diagnosed with infection without meeting the Sepsis 3 threshold for organ dysfunction, while one in ten were ultimately assigned a non-infection diagnosis. Processes of care showed reasonable compliance with recommended best practice guidelines, particularly the collection of multiple sets of blood cultures and the administration of intravenous fluids. Admission rates to the ICU and mortality were significantly different between groups. While rates of representation and length of hospital stay did not differ, this may be explained by the competing effect of mortality. The finding that around 1 in 5 patients returned to hospital within 30 days is consistent with epidemiological data from Australia ( 12 ). Strengths of this study include the collection of a comprehensive data set and the classification of cases using prespecified objective criteria to determine a final diagnosis of sepsis. Limitations are the single-centre and the retrospective design of the study. As a result, data collectors were not blinded. The study coincided with the introduction of a programme for sepsis recognition and management in the ED, and no comparator data were available for the period before this. The results may not be generalisable to other healthcare settings. Prompt recognition and treatment of sepsis is an important element in optimising patient outcomes. These concepts are described in international practice guidelines such as the Surviving Sepsis Campaign ( 13 ). Delivering recommended treatment is contingent on recognising sepsis. In the ED environment, the presentation of sepsis can be non-specific and difficult to recognise in its early stages, and a structured approach to recognition is required. Sepsis is a clinical diagnosis based upon acute organ dysfunction in the setting of infection, which can often only be confirmed subsequently ( 14 ). In previous research analysis of 13567 suspected sepsis patients admitted to the hospital with suspected sepsis between 2009 and 2013 found introduction of a sepsis screening program led to reductions in processes of care as well as rates of admission to ICU and mortality ( 8 ). Other research found the introduction of an ED sepsis screening tool and treatment bundle led to improvement in compliance with process of care indicators as well as an observed reduction in mortality. The Australian Sepsis Clinical Care Standards include the use of a sepsis pathway ( 15 ). However evaluation of the impact on patient-centred outcomes using before-and-after designs risks spectrum bias due to changes in sepsis coding profile arising from improved awareness and documentation. Without standardised adjudication of diagnosis and adjustment for baseline risk it is difficult to determine to what extent observed improvements in outcome are affected by the inclusion of a lower risk population in the post-intervention group. The concept of a structured approach to the management of sepsis and septic shock has become established ( 16 , 17 ). Studies from the USA, Canada and the United Kingdom have found ED sepsis alerts improve timeliness of treatment for presumed sepsis ( 18 – 21 ). On the other hand, there is a lack clear evidence supporting a relationship between the timing of antibiotic administration and outcome across the broad population of patients treated for suspected sepsis ( 22 ). Additionally, undue emphasis on sepsis treatment mandates may have unintended consequences by altering clinical priorities ( 23 , 24 ). Notwithstanding these concerns, in New York, the use of a sepsis pathway since 2013 has led to over 200 hospitals to contribute to a state-wide sepsis registry. This robust and granular dataset allows for risk-adjusted longitudinal analyses of compliance and outcomes and has found reductions in sepsis mortality among both adult and children associated with the mandated sepsis bundles and reporting systems ( 6 ). Future research should focus on the impact of sepsis recognition tools and initial treatment pathways using robust granular datasets to confirm the diagnosis of sepsis and adjust for baseline risk. Sepsis screening and treatment tools should be the entry point into a comprehensive and coordinated approach to sepsis care across the whole patient journey ( 25 ). This includes primary and pre-hospital care through to discharge and rehabilitation. This will support robust data collection focused on outcomes for quality assurance and benchmarking purposes ( 26 ). Electronic data capture offers opportunities to improve the accuracy of sepsis recognition using machine learning ( 27 ). However, a practical and reproducible standardised clinical definition of sepsis is needed to train these models and to assess their utility as decision support for the clinician at the bedside. Conclusion A structured approach to sepsis recognition in the ED identifies patients with a spectrum of risk, including those with non-sepsis infection and with a non-sepsis diagnosis. This has important implications for assessing the quality of care and clinical outcomes. Confirmation of sepsis and adjustment for baseline risk are necessary for accurate performance measurement and benchmarking. Declarations Funding statement This work was undertaken within operational budgets, and no funding was received for the study Author Contribution SM, JB and CD conceived the study, developed the audit tool and obtained the required approvals. CD and SD undertook data extraction. CD and SM undertook the analysis and drafted the paper. All authors reviewed the paper for intellectual content and approved the version for submission. Data Availability Data will be made available upon reasonable request References Rudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, et al. Global, regional, and national sepsis incidence and mortality, 1990–2017: analysis for the Global Burden of Disease Study. Lancet (London England). 2020;395(10219):200–11. Reinhart K, Daniels R, Kissoon N, Machado FR, Schachter RD, Finfer S. Recognizing Sepsis as a Global Health Priority - A WHO Resolution. N Engl J Med. 2017;377(5):414–7. Kaukonen KM, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000–2012. JAMA. 2014;311(13):1308–16. Thompson K, Taylor C, Jan S, Li Q, Hammond N, Myburgh J, et al. Health-related outcomes of critically ill patients with and without sepsis. Intensive Care Med. 2018;44(8):1249–57. Im Y, Kang D, Ko RE, Lee YJ, Lim SY, Park S, et al. Time-to-antibiotics and clinical outcomes in patients with sepsis and septic shock: a prospective nationwide multicenter cohort study. Crit Care. 2022;26(1):19. Seymour CW, Gesten F, Prescott HC, Friedrich ME, Iwashyna TJ, Phillips GS, et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med. 2017;376(23):2235–44. Venkatesh B, Schlapbach L, Mason D, Wilks K, Seaton R, Lister P, et al. Impact of 1-hour and 3-hour sepsis time bundles on patient outcomes and antimicrobial use: A before and after cohort study. Lancet Reg Health West Pac. 2022;18:100305. Burrell AR, McLaws ML, Fullick M, Sullivan RB, Sindhusake D. SEPSIS KILLS: early intervention saves lives. Med J Aust. 2016;204(2):e731–7. Pham A, Cummings M, Lindeman C, Drummond N, Williamson T. Recognizing misclassification bias in research and medical practice. Fam Pract. 2019;36(6):804–7. Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A, et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762–74. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inf. 2009;42:377–81. Care ACSQH. National Sepsis Program Extension, Epidemiology Report, A national analysis of the sepsis patient journey in Australian public hospital admitted care. Sydney: ACSQHC; 2025. Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021;49(11):e1063–143. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801–10. Hwang MI, Bond WF, Powell ES. Sepsis Alerts in Emergency Departments: A Systematic Review of Accuracy and Quality Measure Impact. West J Emerg Med. 2020;21(5):1201–10. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368–77. Investigators P, Rowan KM, Angus DC, Bailey M, Barnato AE, Bellomo R, et al. Early, Goal-Directed Therapy for Septic Shock - A Patient-Level Meta-Analysis. N Engl J Med. 2017;376(23):2223–34. Hayden GE, Tuuri RE, Scott R, Losek JD, Blackshaw AM, Schoenling AJ, et al. Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED. Am J Emerg Med. 2016;34(1):1–9. Gatewood MO, Wemple M, Greco S, Kritek PA, Durvasula R. A quality improvement project to improve early sepsis care in the emergency department. BMJ Qual Saf. 2015;24(12):787–95. McGregor C. Improving time to antibiotics and implementing the Sepsis 6. BMJ Qual Improv Rep. 2014;2(2). Khowaja AR, Willms AJ, Krause C, Carriere S, Ridout B, Kennedy C, et al. The Return on Investment of a Province-Wide Quality Improvement Initiative for Reducing In-Hospital Sepsis Rates and Mortality in British Columbia, Canada. Crit Care Med. 2022;50(4):e340–50. Weinberger J, Rhee C, Klompas M. A Critical Analysis of the Literature on Time-to-Antibiotics in Suspected Sepsis. J Infect Dis. 2020;222(Suppl 2):S110–8. Rhee C, Gohil S, Klompas M. Regulatory mandates for sepsis care–reasons for caution. N Engl J Med. 2014;370(18):1673–6. Singer M, Inada-Kim M, Shankar-Hari M. Sepsis hysteria: excess hype and unrealistic expectations. Lancet (London England). 2019;394(10208):1513–4. Australian Commission of Safety and Quality in Healthcare. Sepsis Clinical Care Standard. Sydney: ACSQHC; 2021. Klompas M, Rhee C, Singer M. The Importance of Shifting Sepsis Quality Measures From Processes to Outcomes. JAMA. 2023;329(7):535–6. Adams R, Henry KE, Sridharan A, Soleimani H, Zhan A, Rawat N, et al. Prospective, multi-site study of patient outcomes after implementation of the TREWS machine learning-based early warning system for sepsis. Nat Med. 2022;28(7):1455–60. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 Apr, 2026 Reviews received at journal 31 Mar, 2026 Reviews received at journal 30 Mar, 2026 Reviews received at journal 28 Mar, 2026 Reviews received at journal 27 Mar, 2026 Reviewers agreed at journal 23 Mar, 2026 Reviewers agreed at journal 20 Mar, 2026 Reviewers agreed at journal 20 Mar, 2026 Reviewers agreed at journal 18 Mar, 2026 Reviewers invited by journal 18 Mar, 2026 Editor invited by journal 05 Mar, 2026 Editor assigned by journal 03 Mar, 2026 Submission checks completed at journal 03 Mar, 2026 First submitted to journal 01 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Despite reductions in mortality in recent decades (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), there is a substantial burden of morbidity among survivors (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Prompt recognition and treatment are important elements in achieving the optimal clinical outcome for patients presenting with sepsis (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMost sepsis cases are community-acquired, and the emergency department (ED) has a critical role in identifying and managing sepsis at the point of presentation. The early features of sepsis can be non-specific, and it can be difficult to recognise and diagnose. Many health systems have introduced sepsis screening and treatment pathways. While associated with improvements in quality-of-care metrics, demonstrating improvements in clinical outcomes is more difficult (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In particular, without objective confirmation of a sepsis diagnosis, misclassification bias may lead to erroneous conclusions about the impact of interventions in quality reporting and observational research studies (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe sought to evaluate the characteristics of a cohort of patients admitted with suspected sepsis in the ED at a single adult tertiary hospital. This coincided with the introduction of a sepsis screening tool and initial management guideline. A \u0026lsquo;Code Sepsis\u0026rsquo; response was triggered in the ED by clinical features and physiological thresholds with activation of a sepsis pathway. The sepsis screening tool was designed to be sensitive for sepsis and septic shock. We hypothesised that activation of the ED sepsis pathway would therefore identify patients with a range of illness severities, as well as patients subsequently diagnosed with a condition other than infection.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign and setting\u003c/h2\u003e \u003cp\u003eThis was a retrospective chart review of patients admitted via the ED with suspected sepsis during 2019 and 2020. RPH is an adult tertiary ED (annual census 82,000) and major trauma referral hospital for the state of Western Australia. As a result of national and state border closures, Western Australia did not experience a significant number of COVID-19 presentations during 2020.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eParticipants were those admitted from ED for suspected sepsis, defined as\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eActivation of a \u0026lsquo;Code-Sepsis\u0026rsquo; call and\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCollection of blood cultures AND IV antibiotic administration in the ED\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003ePatients who were transferred to the ED from another hospital, or who were discharged home or transferred to another health facility, were excluded.\u003c/p\u003e\n\u003ch3\u003eStudy Groups\u003c/h3\u003e\n\u003cp\u003ePatients were retrospectively classified into one of four groups based upon all available clinical information, including the hospital discharge summary. We used an explicit objective methodology to classify cases into four groups: 1) Infection without Sepsis; 2) Sepsis; 3) Septic Shock; and 4) a non-infection diagnosis. Classification of Sepsis and Septic shock was based on the Sepsis-3 criteria (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), i.e. Sepsis was defined as infection plus an increase in Sequential Organ Failure Assessment (SOFA) score of two or more points at presentation. Septic shock was a requirement for vasopressors or a systolic blood pressure of \u0026lt;\u0026thinsp;90mmHg, despite at least one litre of intravenous fluid resuscitation, along with a blood lactate of \u0026gt;2mmol/L.\u003c/p\u003e\n\u003ch3\u003eApprovals\u003c/h3\u003e\n\u003cp\u003e The study was approved as a quality activity, and as such, the requirement for human research ethics committee approval or participant consent was waived. The work was carried out in accordance with the National Health and Medical Research Council Statement on Ethical Conduct in Human Research.\u003c/p\u003e\n\u003ch3\u003eData and outcomes\u003c/h3\u003e\n\u003cp\u003eData were collected from hospital administrative and laboratory systems and paper medical records. Data were entered into a REDCap database (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Baseline data included patient age and sex, mode of arrival to ED, prior living status (independent, residential care), Australasian Triage Score (ATS) category, Charlson Comorbidity Score (CCS), Sequential Organ Failure Assessment (SOFA) Score at baseline, and at 24 hours, 48 hours, and 72 hours post admission. Process-of-care metrics were time from triage to IV antibiotic administration, measurement of lactate, collection of adequate blood cultures (defined as at least two sets), and volume of intravenous (IV) resuscitation fluid administered in the ED. Documentation of a limitation-of-care decision was also captured, typically where comorbid illness or frailty precluded invasive interventions such as intubation. Service and clinical outcome measures collected were admission to intensive care, duration of stay, in-hospital mortality and unplanned readmission to hospital within 30 days.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eParticipant characteristics were summarised using descriptive statistics. All analyses were performed using Stata 15.1 (College Station, TX, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the two-year study period, a total of 726 patients were assessed for suspected sepsis. Inter-hospital transfers, patients not admitted to hospital, or where data were unavailable were excluded (131) leaving a total of 595 cases for analysis in the present study. Overall characteristics of the cohort are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of cohort (N\u0026thinsp;=\u0026thinsp;595)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (48, 78)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e357 (60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e239 (40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMode of arrival N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmbulance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e399 (67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate Transport\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e187 (31)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eATS N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e309 (52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e204 (35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior Living status N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndependent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e493 (83)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidential Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNFA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharlson Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0, 5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTemperature (\u003csup\u003eO\u003c/sup\u003eC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.1+/-1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulse rate (beats/min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107 +/-24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespirations (resp/min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24+/-7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBP (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101 +/-23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSource of infection N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e157 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145 (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkin/soft tissue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdo/pelvis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e108 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eATS Australian Triage Score; NFA No Fived Address; SBP Systolic Blood Pressure; GCS Glasgow Coma Scale.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe majority of patients arrived by ambulance, with over half being assigned a high triage score of 1 or 2. The vast majority were of independent prior living status. The most common presumed source of infection was respiratory, followed by urinary tract and skin/soft tissue.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the characteristics, processes of care and outcomes by sepsis classification. Patients were classified as follows; Infection 211 (34%), sepsis 266 (46%), septic shock 58 (10%) and non-infection diagnosis 60 (10%). Overall, 53 patients (9%) died. Rates of ICU admission and mortality differed significantly between groups (both P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There were no differences in length of hospital stay or rates of representation to hospital.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics, processes of care and outcomes by sepsis classification\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSepsis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSeptic Shock\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e211 (34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e266 (46)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSOFA Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (0,4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLactate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.8 +/-1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.4 +/-1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.3 +/-3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.9+/-3.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to AB (mins)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e108 (71,183)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88 (51,145)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67 (45,92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e117 (63,233)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 sets cultures N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e167 (79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e208 (78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48 (80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLactate done N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129 (61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e231 (87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57 (98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40 (67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV Fluid volume (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1011 +/-870\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1900 +/-1265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2489 +/-1545\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1339 +/-1149\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCare limitation N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU admit N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (\u0026lt;\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU LOS (hrs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (37, 37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (26,87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66 (28, 141)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e66 (40,75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHosp LOS (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntubated N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (\u0026lt;\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (#)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVasopressors N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNew RRT N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRepresentation N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDied N\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDied % (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10 CR11 CR12 CR13\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (17\u0026ndash;41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eSOFA Sequential Organ Failure Assessment; AB Antibiotics; IV Intravenous; ICU Intensive Care Unit; LOS Length of Stay; RRT Renal Replacement Therapy. Summary data are medians (interquartile range) or means +/- standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e This single centre retrospective chart review of patients admitted from the ED of an adult tertiary hospital with suspected sepsis found a range of clinical phenotypes and associated illness severity. Only 56% of patients met objective criteria for sepsis or septic shock. One third were diagnosed with infection without meeting the Sepsis 3 threshold for organ dysfunction, while one in ten were ultimately assigned a non-infection diagnosis.\u003c/p\u003e \u003cp\u003e Processes of care showed reasonable compliance with recommended best practice guidelines, particularly the collection of multiple sets of blood cultures and the administration of intravenous fluids. Admission rates to the ICU and mortality were significantly different between groups. While rates of representation and length of hospital stay did not differ, this may be explained by the competing effect of mortality. The finding that around 1 in 5 patients returned to hospital within 30 days is consistent with epidemiological data from Australia (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStrengths of this study include the collection of a comprehensive data set and the classification of cases using prespecified objective criteria to determine a final diagnosis of sepsis. Limitations are the single-centre and the retrospective design of the study. As a result, data collectors were not blinded. The study coincided with the introduction of a programme for sepsis recognition and management in the ED, and no comparator data were available for the period before this. The results may not be generalisable to other healthcare settings.\u003c/p\u003e \u003cp\u003ePrompt recognition and treatment of sepsis is an important element in optimising patient outcomes. These concepts are described in international practice guidelines such as the Surviving Sepsis Campaign (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Delivering recommended treatment is contingent on recognising sepsis. In the ED environment, the presentation of sepsis can be non-specific and difficult to recognise in its early stages, and a structured approach to recognition is required. Sepsis is a clinical diagnosis based upon acute organ dysfunction in the setting of infection, which can often only be confirmed subsequently (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn previous research analysis of 13567 suspected sepsis patients admitted to the hospital with suspected sepsis between 2009 and 2013 found introduction of a sepsis screening program led to reductions in processes of care as well as rates of admission to ICU and mortality (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Other research found the introduction of an ED sepsis screening tool and treatment bundle led to improvement in compliance with process of care indicators as well as an observed reduction in mortality. The Australian Sepsis Clinical Care Standards include the use of a sepsis pathway (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). However evaluation of the impact on patient-centred outcomes using before-and-after designs risks spectrum bias due to changes in sepsis coding profile arising from improved awareness and documentation. Without standardised adjudication of diagnosis and adjustment for baseline risk it is difficult to determine to what extent observed improvements in outcome are affected by the inclusion of a lower risk population in the post-intervention group.\u003c/p\u003e \u003cp\u003eThe concept of a structured approach to the management of sepsis and septic shock has become established (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Studies from the USA, Canada and the United Kingdom have found ED sepsis alerts improve timeliness of treatment for presumed sepsis (\u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). On the other hand, there is a lack clear evidence supporting a relationship between the timing of antibiotic administration and outcome across the broad population of patients treated for suspected sepsis (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Additionally, undue emphasis on sepsis treatment mandates may have unintended consequences by altering clinical priorities (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Notwithstanding these concerns, in New York, the use of a sepsis pathway since 2013 has led to over 200 hospitals to contribute to a state-wide sepsis registry. This robust and granular dataset allows for risk-adjusted longitudinal analyses of compliance and outcomes and has found reductions in sepsis mortality among both adult and children associated with the mandated sepsis bundles and reporting systems (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFuture research should focus on the impact of sepsis recognition tools and initial treatment pathways using robust granular datasets to confirm the diagnosis of sepsis and adjust for baseline risk. Sepsis screening and treatment tools should be the entry point into a comprehensive and coordinated approach to sepsis care across the whole patient journey (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This includes primary and pre-hospital care through to discharge and rehabilitation. This will support robust data collection focused on outcomes for quality assurance and benchmarking purposes (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Electronic data capture offers opportunities to improve the accuracy of sepsis recognition using machine learning (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). However, a practical and reproducible standardised clinical definition of sepsis is needed to train these models and to assess their utility as decision support for the clinician at the bedside.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eA structured approach to sepsis recognition in the ED identifies patients with a spectrum of risk, including those with non-sepsis infection and with a non-sepsis diagnosis. This has important implications for assessing the quality of care and clinical outcomes. Confirmation of sepsis and adjustment for baseline risk are necessary for accurate performance measurement and benchmarking.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding statement\u003c/h2\u003e \u003cp\u003eThis work was undertaken within operational budgets, and no funding was received for the study\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSM, JB and CD conceived the study, developed the audit tool and obtained the required approvals. CD and SD undertook data extraction. CD and SM undertook the analysis and drafted the paper. All authors reviewed the paper for intellectual content and approved the version for submission.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData will be made available upon reasonable request\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, et al. Global, regional, and national sepsis incidence and mortality, 1990\u0026ndash;2017: analysis for the Global Burden of Disease Study. Lancet (London England). 2020;395(10219):200\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReinhart K, Daniels R, Kissoon N, Machado FR, Schachter RD, Finfer S. Recognizing Sepsis as a Global Health Priority - A WHO Resolution. N Engl J Med. 2017;377(5):414\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaukonen KM, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000\u0026ndash;2012. JAMA. 2014;311(13):1308\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThompson K, Taylor C, Jan S, Li Q, Hammond N, Myburgh J, et al. Health-related outcomes of critically ill patients with and without sepsis. Intensive Care Med. 2018;44(8):1249\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIm Y, Kang D, Ko RE, Lee YJ, Lim SY, Park S, et al. Time-to-antibiotics and clinical outcomes in patients with sepsis and septic shock: a prospective nationwide multicenter cohort study. Crit Care. 2022;26(1):19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeymour CW, Gesten F, Prescott HC, Friedrich ME, Iwashyna TJ, Phillips GS, et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med. 2017;376(23):2235\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVenkatesh B, Schlapbach L, Mason D, Wilks K, Seaton R, Lister P, et al. Impact of 1-hour and 3-hour sepsis time bundles on patient outcomes and antimicrobial use: A before and after cohort study. Lancet Reg Health West Pac. 2022;18:100305.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurrell AR, McLaws ML, Fullick M, Sullivan RB, Sindhusake D. SEPSIS KILLS: early intervention saves lives. Med J Aust. 2016;204(2):e731\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePham A, Cummings M, Lindeman C, Drummond N, Williamson T. Recognizing misclassification bias in research and medical practice. Fam Pract. 2019;36(6):804\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A, et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)\u0026mdash;A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inf. 2009;42:377\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCare ACSQH. National Sepsis Program Extension, Epidemiology Report, A national analysis of the sepsis patient journey in Australian public hospital admitted care. Sydney: ACSQHC; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEvans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021;49(11):e1063\u0026ndash;143.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSinger M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHwang MI, Bond WF, Powell ES. Sepsis Alerts in Emergency Departments: A Systematic Review of Accuracy and Quality Measure Impact. West J Emerg Med. 2020;21(5):1201\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInvestigators P, Rowan KM, Angus DC, Bailey M, Barnato AE, Bellomo R, et al. Early, Goal-Directed Therapy for Septic Shock - A Patient-Level Meta-Analysis. N Engl J Med. 2017;376(23):2223\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHayden GE, Tuuri RE, Scott R, Losek JD, Blackshaw AM, Schoenling AJ, et al. Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED. Am J Emerg Med. 2016;34(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGatewood MO, Wemple M, Greco S, Kritek PA, Durvasula R. A quality improvement project to improve early sepsis care in the emergency department. BMJ Qual Saf. 2015;24(12):787\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGregor C. Improving time to antibiotics and implementing the Sepsis 6. BMJ Qual Improv Rep. 2014;2(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhowaja AR, Willms AJ, Krause C, Carriere S, Ridout B, Kennedy C, et al. The Return on Investment of a Province-Wide Quality Improvement Initiative for Reducing In-Hospital Sepsis Rates and Mortality in British Columbia, Canada. Crit Care Med. 2022;50(4):e340\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeinberger J, Rhee C, Klompas M. A Critical Analysis of the Literature on Time-to-Antibiotics in Suspected Sepsis. J Infect Dis. 2020;222(Suppl 2):S110\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRhee C, Gohil S, Klompas M. Regulatory mandates for sepsis care\u0026ndash;reasons for caution. N Engl J Med. 2014;370(18):1673\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSinger M, Inada-Kim M, Shankar-Hari M. Sepsis hysteria: excess hype and unrealistic expectations. Lancet (London England). 2019;394(10208):1513\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAustralian Commission of Safety and Quality in Healthcare. Sepsis Clinical Care Standard. Sydney: ACSQHC; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKlompas M, Rhee C, Singer M. The Importance of Shifting Sepsis Quality Measures From Processes to Outcomes. JAMA. 2023;329(7):535\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdams R, Henry KE, Sridharan A, Soleimani H, Zhan A, Rawat N, et al. Prospective, multi-site study of patient outcomes after implementation of the TREWS machine learning-based early warning system for sepsis. Nat Med. 2022;28(7):1455\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"emergency, sepsis, infectious diseases, quality of care, outcomes","lastPublishedDoi":"10.21203/rs.3.rs-9004278/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9004278/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eStructured sepsis screening and management tools are recommended. Evaluation of their effectiveness is limited by spectrum bias, with apparent improvements in outcomes due to capturing a broader population with overall lower baseline risk. The aim was to determine the true incidence of sepsis and septic shock and outcomes among patients assessed for suspected sepsis in an adult tertiary hospital Emergency Department (ED).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective observational study identified patients with suspected sepsis admitted via the Emergency Department (ED) during the calendar years 2019 and 2020. Patients were subsequently classified into four groups: infection, sepsis, septic shock and non-infection using standardised objective criteria. Baseline characteristics, processes of care and clinical outcomes were compared between groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFive hundred and ninety-five patients were assessed for suspected sepsis in the ED. These were subsequently classified as 211 (34%) with infection, 266 (46%) with sepsis, 58 (10%) with septic shock, and 60 (10%) with an alternative diagnosis. Rates of organ support, intensive care admission and mortality varied significantly between groups.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAn ED sepsis screening program identifies patients with a range of clinical phenotypes, with 44% of patients misclassified. Measuring the effectiveness of sepsis recognition tools based on those assessed for suspected sepsis will generate misleading results. Standardised confirmation of sepsis is required to adjust for baseline risk and generate credible results to drive quality improvements, and inform policy-making and resource allocation.\u003c/p\u003e","manuscriptTitle":"Characteristics and outcomes of patients assessed for suspected sepsis the emergency department","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-20 14:28:42","doi":"10.21203/rs.3.rs-9004278/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-06T05:23:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-31T21:41:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-30T15:53:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-29T01:06:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-27T14:21:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"259175240854493223088289794273443252367","date":"2026-03-23T23:41:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"256444865825705741840064361946216628964","date":"2026-03-20T14:48:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"109358246468697228590376845237330446901","date":"2026-03-20T13:29:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"43437940870628821288205288150006175219","date":"2026-03-19T00:30:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-18T09:53:20+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-05T08:08:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-03T10:44:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-03T10:43:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Emergency Medicine","date":"2026-03-01T23:59:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ff722e4a-ea49-4caa-a010-48ae811c1eed","owner":[],"postedDate":"March 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-21T01:38:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-20 14:28:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9004278","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9004278","identity":"rs-9004278","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}