title: Longer time to antibiotics and higher mortality among septic patients with non-specific presentations--a cross sectional study of Emergency Department patients indicating that a screening tool may improve identification.
abstract: BACKGROUND
  The presentation of sepsis is varied and our hypotheses were that septic patients with non-specific presentations such as decreased general condition (DGC) have a less favourable outcome, and that a screening tool could increase identification of these patients. We aimed to: 1) assess time to antibiotics and in-hospital mortality among septic patients with ED chief complaint DGC, as compared with septic patients with other ED chief complaints, and 2) determine whether a screening tool could improve identification of septic patients with non-specific presentations such as DGC.
  
  
  METHODS
  Cross sectional study comparing time to antibiotics (Mann Whitney and Kaplan-Meier tests), and in-hospital mortality (logistic regression), between 61 septic patients with ED chief complaint DGC and 516 septic patients with other ED chief complaints. The sensitivity and specificity of the modified Robson screening tool was compared with that of ED doctor clinical judgment (McNemar's two related samples test) among 122 patients presenting to the ED with chief complaint DGC, of which 61 were discharged with ICD code sepsis.
  
  
  RESULTS
  Septic patients presenting to the ED with the chief complaint DGC had a longer median time to antibiotics (05:26 h:minutes; IQR 4:00-10:40, vs. 03:56 h:minutes; IQR 2:21-7:32) and an increased in-hospital mortality (crude OR = 4.01; 95% CI, 2.19-7.32), compared to septic patients with other ED chief complaints. This association remained significant when adjusting for sex, age, priority, comorbidity and fulfilment of the Robson score (OR 4.31; 95% CI, 2.12-8.77). The modified Robson screening tool had a higher sensitivity (63.0 vs. 24.6%, p < 0.001), but a lower specificity (68.3 vs. 100.0%, p < 0.001), as compared to clinical judgment.
  
  
  CONCLUSIONS
  This is, to the best of our knowledge, the first study comparing outcome of septic patients according to ED chief complaint. Septic patients presenting with a non-specific ED presentation, here exemplified as the chief complaint DGC, have a less favourable outcome. Our results indicate that implementation of a screening tool may increase the identification of septic patients.
  
  
  CONCLUSIONS
  The results indicate that septic patients presenting with ED chief complaint DGC constitute a vulnerable patient group with delayed time to antibiotics and high in-hospital mortality. Furthermore, the results support that implementation of a screening tool may be beneficial to improve identification of these patients.
authors.affiliation: Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sjukhusbacken 10, SE 118 83, Stockholm, Sweden. ulrika.wallgren@sll.se.|Fisksätra Vårdcentral (Primary Health Care Center), Fisksätra torg 20, SE 133 41, Saltsjöbaden, Sweden. ulrika.wallgren@sll.se.
authors.forename: Ulrika Margareta
authors.initials: UM
authors.lastname: Wallgren
authors.affiliation: Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sjukhusbacken 10, SE 118 83, Stockholm, Sweden. viktor.antonsson@stud.ki.se.
authors.forename: Viktor Erik
authors.initials: VE
authors.lastname: Antonsson
authors.affiliation: Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sjukhusbacken 10, SE 118 83, Stockholm, Sweden. maaret.castren@hus.fi.|Department of Emergency Medicine and Services, Helsinki University Hospital and Helsinki University, Haartmaninkatu 4, PL 340, 00029 HUS, Helsinki, Finland. maaret.castren@hus.fi.
authors.forename: Maaret Kaarina
authors.initials: MK
authors.lastname: Castrén
authors.affiliation: Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sjukhusbacken 10, SE 118 83, Stockholm, Sweden. lisa.kurland@ki.se.|Section of Emergency Medicine, Södersjukhuset, Sjukhusbacken 10, SE 118 83, Stockholm, Sweden. lisa.kurland@ki.se.
authors.forename: Lisa
authors.initials: L
authors.lastname: Kurland
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D042241:Early Diagnosis; D004636:Emergency Service, Hospital; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D012680:Sensitivity and Specificity; D012772:Shock, Septic / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality; D013997:Time Factors
chemical_list: D000900:Anti-Bacterial Agents