Triage and flow management in sepsis

Abstract

Background: Sepsis is a major public health problem, with a growing incidence and mortality rates still close to 30% in severe cases. The speed and adequacy of the treatment administered in the first hours of sepsis, particularly access to intensive care, are important to reduce mortality. This study compared the triage strategies and intensive care rationing between septic patients and patients with other indications of intensive care. This study included all patients with signs for intensive care, enrolled in the intensive care management system of a Brazilian tertiary public emergency hospital, from January 1, 2010, to December 31, 2016. The intensivist periodically evaluated the requests, prioritizing them according to a semi-quantitative scale. Demographic data, Charlson Comorbidity Index (CCI), Sequential Organ Failure Assessment (SOFA), and quick SOFA (qSOFA), as well as surgical interventions, were used as possible confounding factors in the construction of incremental logistic regression models for prioritization and admission to intensive care outcomes. Results: The study analyzed 9195 ICU requests; septic patients accounted for 1076 cases (11.7%), 293 (27.2%) of which were regarded as priority 1. Priority 1 septic patients were more frequently hospitalized in the ICU than nonseptic patients (52.2% vs. 34.9%, p < 0.01). Septic patients waited longer for the vacancy, with a median delay time of 43.9 h (interquartile range 18.2-108.0), whereas nonseptic patients waited 32.5 h (interquartile range 11.5-75.8)-p < 0.01. Overall mortality was significantly higher in the septic group than in the group of patients with other indications for intensive care (72.3% vs. 39.8%, p < 0.01). This trend became more evident after the multivariate analysis, and the mortality odds ratio was almost three times higher in septic patients (2.7, 2.3-3.1). Conclusion: Septic patients had a lower priority for ICU admission and longer waiting times for an ICU vacancy than patients with other critical conditions. Overall, this implied a 2.7-fold increased risk of mortality in septic patients.