Emergency Department observational data in The Netherlands

With this prospectively registered data (2011 - 2016) of three emergency departments in the Netherlands research was done to adress the question whether older sepsis patients present at the Emergency Department with a higher disease severity and to adress the question whether older patients receive an equal quality of care

Initial disease severity and quality of care of emergency department sepsis patients who are older or younger than 70 years of age

<div><p>Objective</p><p>Due to atypical symptom presentation older patients are more prone to delayed sepsis recognition. We investigated whether initial disease severity <i>before</i> emergency department (ED) treatment (including treatable acute organ dysfunction), quality of ED sepsis care and the impact on mortality was different between patients older and younger than 70 years. If differences exist, improvements are needed for ED management of older patients at risk for sepsis.</p><p>Methods</p><p>In this observational multicenter study, ED patients who were hospitalized with a suspected infection were stratified by age <70 and ≥70 years. The presence of treatable and potentially reversible acute organ dysfunction was measured by the RO components of the Predisposition, Infection, Response and Organ dysfunction (PIRO) score, reflecting acute sepsis-related organ dysfunction developed <i>before</i> ED presentation. Quality of care, as assessed by the full compliance with nine quality performance measures and the standardized mortality ratio (SMR: observed/expected in-hospital mortality), was compared between older and younger patients.</p><p>Results</p><p>The RO-components of the PIRO score were 8 (interquartile range; 4–9) in the 833 older patients, twice as high as the 4 (2–8; P<0.001) in the 1537 younger patients. However, full compliance with all nine quality performance measures was achieved in 34.2 (31.0–37.4)% of the older patients, not higher than the 33.0 (30.7–35.4)% in younger patients (P = 0.640). In-hospital mortality was 9.2% (95%-CI, 7.3–11.2) in patients ≥70, twice as high as the 4.6% (3.6–5.6) in patients <70 years, resulting in an SMR (in study period) of ~0.7 in both groups (P>0.05).</p><p>Conclusion</p><p>Older sepsis patients are sicker at ED presentation but are not treated more expediently or reliably despite their extra acuity The presence of twice as much treatable acute organ dysfunction <i>before</i> ED treatment suggests that acute organ dysfunction is recognized relatively late by general practitioners or patients in the out of hospital setting.</p></div

Quality of care as assessed by achievement of quality performance measures in the groups <70 and ≥70 years of age.

<p>Quality of care as assessed by achievement of quality performance measures in the groups <70 and ≥70 years of age.</p

Comparison of disease severity at ED presentation (before ED treatment) between patients <70 and patients ≥70 years of age.

<p>Comparison of disease severity at ED presentation (before ED treatment) between patients <70 and patients ≥70 years of age.</p

Illustration of the problem.

<p>With increasing age, both sepsis incidence and treatable organ dysfunction increase. However, quality of care, as assessed by full compliance to all nine quality performance measures, remains the same. *The increasing sepsis incidence, is according to an epidemiological study by Angus et al. [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0185214#pone.0185214.ref003" target="_blank">3</a>]</p

Patient characteristics of patients in groups younger and older than 70 years.

<p>Patient characteristics of patients in groups younger and older than 70 years.</p

Multivariable logistic regression analysis for in-hospital mortality.

<p>Multivariable logistic regression analysis for in-hospital mortality.</p

Additional file 4: of The most commonly used disease severity scores are inappropriate for risk stratification of older emergency department sepsis patients: an observational multi-centre study

Sensitivity analyses showing that exclusion of older patients with acute organ dysfunction or “Do Not Resuscitate (DNR) status” from the older group resulted in similar area under the curves (AUCs) of all disease severity scores. (DOCX 13 kb