Hospital toolkit for adult sepsis surveillance
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      Sepsis is a clinical syndrome defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.1 A study using clinical data estimated 1.7 million cases of sepsis in 2014 in the U.S., which likely contribute to over 270,000 deaths.2 Patients who survive sepsis often suffer long-term physical, psychological, and cognitive disabilities.

      Because there is no confirmatory diagnostic test, the diagnosis of sepsis requires clinical judgment based on evidence of infection and organ dysfunction. A 1991 consensus conference established a clinical definition based on the patient’s systemic inflammatory response syndrome (SIRS) to infection (later referred to as Sepsis-1)3, and these clinical criteria were expanded in 2001 in the Sepsis-2 criteria.4 In response to increasing understanding

      of sepsis pathobiology, a task force updated the clinical definitions in 20161, and in Sepsis-3, defined sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection”, with clinical guidelines defining organ dysfunction as acute change in total Sequential Organ Failure Assessment (SOFA) score ≥2 points consequent to the infection.1

      The updated clinical definitions are critical for identifying patients at risk for sepsis and further complications, but there is also a need to have a definition that can be used to track sepsis. Different definitions for sepsis are needed for different purposes, which could include clinical care, research, surveillance, and quality improvement and audit.5,6 For example, a sepsis definition optimized for public health surveillance would prioritize reliability and validity across healthcare facilities, and low measurement burden. However timeliness may be less of a priority because such definitions would be used retrospectively and not be intended for clinical management of individual patients.5,6

      Prior to 2017, U.S. national estimates of sepsis burden primarily relied on the use of administrative codes, which have consistently demonstrated increasing incidence and decreasing mortality.7 Administrative codes are also frequently used in sepsis quality initiatives, including Centers for Medicare & Medicaid Services Early Management Bundle, Severe Sepsis/Septic Shock (SEP-1). However, studies have demonstrated that coding for sepsis has steadily increased over the past decade, yet coding for the most common underlying infections has been stable or decreasing.8 These analyses demonstrate that coding practices are likely vulnerable to biases from increasing sepsis awareness and financial incentives (higher reimbursement for sepsis coding), and therefore unreliable for surveillance purposes.8

      In 2017, a CDC Prevention Epicenters-funded consortium published results of a study which used a new definition for sepsis based on objective clinical data elements conceptually analogous to Sepsis-3. This definition was optimized for surveillance directly from electronic health records across over 400 facilities, and displayed superior sensitivity and similar specificity compared to administrative codes when using Sepsis-3 criteria determined by medical record reviews as a gold standard.2 Furthermore, this definition demonstrated that national sepsis incidence and outcomes (combination of death and discharge to hospice) were stable from 2009-2014, in contrast to administrative codes which showed increasing incidence and decreasing mortality, but are fundamentally confounded by increasing sepsis awareness, coding bias, and financial incentives.


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