Perhaps no group of clinicians knows more about diagnosing and treating sepsis than emergency physicians. We routinely identify patients with sepsis and administer the crucial, lifesaving early care that our patients need to stand the best chance of pulling through. And yet, for the better part of this century, the major expert bodies in emergency medicine have not been leaders in producing clinical guidelines and policies on sepsis. Certainly, some key individuals have been important players, but the major documents that, for all intents and purposes, set the standards of care for the detection and treatment of sepsis have come from groups other than emergency physicians. Until now.
Explore This IssueACEP Now: Vol 40 – No 05 – May 2021
With the recent publication of “Early Care of Adults with Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report,” by Yealy and colleagues in the Annals of Emergency Medicine, emergency physicians as a whole have finally stepped up to the plate.1 And it’s a home run.
The document provides up-to-date guidance on a variety of key clinical questions. Is there one single best way to detect sepsis? No, but there are many good ones. Relying on one only, especially a low-bar threshold that trips sepsis flags too liberally, does not help patients. Which patients need antibiotics immediately, and which can be evaluated and tested first? The focus is on identifying patients with septic shock. These are the patients who urgently need antibiotics and source control when appropriate. Do we really need to give all patients 30 cc per kilogram of bodyweight of intravenous fluids? No. Many can receive that bolus, but clinician judgment is needed, and no one specific volume of fluids is “the right amount.” Can we use peripheral vasopressors? Yes, if the intravenous line is a good one. What about steroids? They can be used but need not be used routinely. How about adjuncts like vitamins? They are not recommended. These and many other key questions are addressed.
There are three takeaways that bear emphasis. First, the report contradicts major swaths of the Centers for Medicare and Medicaid Services (CMS) SEP-1 core quality measure, which has been in effect since 2015. It will be interesting to see whether CMS will be able to continue to keep the measure active in light of both the ACEP guideline and a position paper published earlier this year by the Infectious Diseases Society of America by Rhee and colleagues, which shares many of the same concepts.2 Second, the document is authoritative in its scope and depth. It covers an impressive number of issues and provides a much-needed review of the relevant literature. But as important is the process by which this document came to be. (I had the opportunity to be present for the task force’s deliberations in Dallas in early 2020, though I was not a part of the committee.) Emergency physician expertise was at the core of these recommendations. However, ACEP was wise to include participation from a wide variety of other expert bodies, including other EM societies, representation from peer-group bodies ranging from infectious diseases, critical care, and nursing to EMS and hospitalists. That the final report was endorsed by so many of these organizations, including the Society of Hospital Medicine and the Society of Critical Care Medicine, speaks to the value and rigor that are found in the resulting manuscript.
Emergency physicians have always been on the ground treating patients with sepsis. At long last, the collective expertise and experience of emergency physicians are reflected in the medical literature. Certainly, the evidence will evolve. But now, we are leading the way in developing that evidence, interpreting it, and implementing it. This will lead to better patient outcomes and improved systems for identifying and treating sepsis patients both now and in the future.