In what is almost certainly news only to quality improvement administrators, this newly published work out of Australia and New Zealand confirms what most already knew: the Systemic Inflammatory Response Syndrome criteria are only modestly associated with severe sepsis.
This is a retrospective evaluation of 13 years of data from the Australia and New Zealand Intensive Care Society Adult Patient Database, comprising routinely collected quality-assurance data. Of 1,171,797 patients admitted to adult ICUs, 109,663 were identified as having both an infection and organ failure – the general, clinical definition of severe sepsis. First, the good news: over the 13 year study period, mortality dropped substantially – from over 30% down to close to 15%. Then, the bad news: 12.1% of patients in the severe sepsis cohort manifested 0 or 1 SIRS criteria. Mortality was lower in SIRS-negative severe sepsis, but hardly trivial at 16.1% during the study period, compared with 24.5% in the SIRS-positive patients.
So, the traditional SIRS-criteria definition of severe sepsis, previously thought to have at least sensitivity at expense of specificity will miss 1 in 8 patients with organ failure and an underlying infection. Considering only approximately 1/3rd of patients with two or more SIRS criteria in the Emergency Department have an underlying infection, the utility of these criteria is substantially less reliable than previously thought. Sadly, I’m certain many of you are suffering under SIRS criteria-based alerts in your Electronic Health Record – and, if such alerts are introducing cognitive biases by decreased vigilance and alert fatigue, it ought to be obvious we’re simply harming ourselves and patients.
“Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis”
http://www.nejm.org/doi/full/10.1056/NEJMoa1415236