title: Predictors of early progression to severe sepsis or shock among emergency department patients with nonsevere sepsis.
abstract: BACKGROUND
  Progression from nonsevere sepsis-i.e., sepsis without organ failure or shock-to severe sepsis or shock among emergency department (ED) patients has been associated with significant mortality. Early recognition in the ED of those who progress to severe sepsis or shock during their hospital course may improve patient outcomes. We sought to identify clinical, demographic, and laboratory parameters that predict progression to severe sepsis, septic shock, or death within 96 h of ED triage among patients with initial presentation of nonsevere sepsis.
  
  
  METHODS
  This is a retrospective cohort of patients presenting to a single urban academic ED from November 2008 to October 2010. Patients aged 18 years or older who met criteria for sepsis and had a lactate level measured in the ED were included. Patients were excluded if they had any combination of the following: a systolic blood pressure <90 mmHg upon triage, an initial whole blood lactate level ≥4 mmol/L, or one or more of a set of predefined signs of organ dysfunction upon initial assessment. Disease progression was defined as the development of any combination of the aforementioned conditions, initiation of vasopressors, or death within 96 h of ED presentation. Data on predefined potential predictors of disease progression and outcome measures of disease progression were collected by a query of the electronic medical record and via chart review. Logistic regression was used to assess associations of potential predictor variables with a composite outcome measure of sepsis progression to organ failure, hypotension, or death.
  
  
  RESULTS
  In this cohort of 582 ED patients with nonsevere sepsis, 108 (18.6 %) experienced disease progression. Initial serum albumin <3.5 mg/dL (OR 4.82; 95 % CI 2.40-9.69; p < 0.01) and a diastolic blood pressure <52 mmHg at ED triage (OR 4.59; 95 % CI 1.57-13.39; p < 0.01) were independently associated with disease progression to severe sepsis or shock within 96 h of ED presentation. There were no deaths within 96 h of ED presentation.
  
  
  CONCLUSIONS
  In our patient cohort, serum albumin <3.5 g/dL and an ED triage diastolic blood pressure <52 mmHg independently predict early progression to severe sepsis or shock among ED patients with presumed sepsis.
authors.affiliation: Department of Medicine, Emory University School of Medicine, 1648 Pierce Dr NE, Atlanta, GA, 30307, USA. andre.holder@emory.edu.|Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Grady Memorial Hospital, 80 Jesse Hill Jr. Drive SE, Rm 2D012, Atlanta, GA, 30303, USA. andre.holder@emory.edu.
authors.forename: Andre L
authors.initials: AL
authors.lastname: Holder
authors.affiliation: Beacon Health System, Elkhart General Hospital, 600 East Blvd, Elkhart, IN, 46514, USA. dr.namita84@gmail.com.
authors.forename: Namita
authors.initials: N
authors.lastname: Gupta
authors.affiliation: Department of Radiology, Emory University School of Medicine, 1648 Pierce Dr NE, Atlanta, GA, 30307, USA. elizabeth.lulaj@emory.edu.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Lulaj
authors.affiliation: Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210th Street, Rosenthal Red Zone, Room 2nd Floor, Bronx, NY, 10467, USA. miriam.furgiuele@gmail.com.
authors.forename: Miriam
authors.initials: M
authors.lastname: Furgiuele
authors.affiliation: Department of Emergency Medicine, Kingston Hospital, 396 Broadway, Kingston, NY, 12401, USA. idalyhidalgo@gmail.com.
authors.forename: Idaly
authors.initials: I
authors.lastname: Hidalgo
authors.affiliation: Department of Emergency Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, 1400 Pelham Parkway South, 1B-25, Bronx, NY, 10461, USA. michael.jones@nbhn.net.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Jones
authors.affiliation: Department of Emergency Medicine, Saint Francis Hospital and Medical Center, 114 Woodland Street, Hartford, CT, 06105, USA. erdocjolly@yahoo.com.
authors.forename: Tiphany
authors.initials: T
authors.lastname: Jolly
authors.affiliation: Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210th Street, Rosenthal Red Zone, Room 2nd Floor, Bronx, NY, 10467, USA. gennisp@gmail.com.
authors.forename: Paul
authors.initials: P
authors.lastname: Gennis
authors.affiliation: Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210th Street, Rosenthal Red Zone, Room 2nd Floor, Bronx, NY, 10467, USA. adrienne.birnbaum@nbhn.net.
authors.forename: Adrienne
authors.initials: A
authors.lastname: Birnbaum
keywords: Disease progression; Nonsevere sepsis; Organ dysfunction; Predictors; Sepsis progression