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Comparison of Two Sepsis Recognition Methods in a Pediatric Emergency Department
Fran Balamuth1,2, Elizabeth R Alpern3, Robert W Grundmeier1,4
1Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Insights
An electronic alert system showed higher sensitivity for identifying pediatric severe sepsis and septic shock than physician judgment alone. However, physician judgment offered greater specificity in this critical pediatric emergency department study.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Informatics
- Critical Care
Background:
- Severe sepsis and septic shock are life-threatening conditions in children.
- Early and accurate identification is crucial for timely intervention and improved outcomes.
- Current methods rely on clinical expertise, which may have limitations in sensitivity or specificity.
Purpose of the Study:
- To compare the effectiveness of physician judgment against an electronic algorithmic alert for identifying severe sepsis/septic shock in pediatric patients.
- To evaluate the diagnostic test characteristics of each method.
Main Methods:
- Observational cohort study of pediatric patients (older than 56 days) presenting with fever or hypothermia.
- Real-time clinical evaluation by emergency department (ED) team.
- Retrospective application of an electronic algorithmic alert for sepsis identification.
- Comparison of sensitivity, specificity, and receiver operating characteristic (ROC) curves.
Main Results:
- The electronic algorithmic alert demonstrated higher sensitivity (92.1%) compared to physician judgment (72.7%) in identifying severe sepsis/septic shock.
- Physician judgment exhibited higher specificity (99.5%) than the algorithmic alert (83.4%).
- A combined approach (physician judgment or algorithmic alert) improved sensitivity to 96.6% with 83.3% specificity.
Conclusions:
- Electronic algorithmic alerts are more sensitive but less specific than physician judgment for recognizing pediatric severe sepsis/septic shock.
- The choice of sepsis recognition method should align with institutional priorities regarding sensitivity versus specificity.
- Findings support the potential integration of algorithmic alerts to enhance sepsis detection in pediatric EDs.
Objectives:
The objective was to compare the effectiveness of physician judgment and an electronic algorithmic alert to identify pediatric patients with severe sepsis/septic shock in a pediatric emergency department (ED).
Methods:
This was an observational cohort study of patients older than 56 days with fever or hypothermia. All patients were evaluated for potential sepsis in real time by the ED clinical team. An electronic algorithmic alert was retrospectively applied to identify patients with potential sepsis independent of physician judgment. The primary outcome was the proportion of patients correctly identified with severe sepsis/septic shock defined by consensus criteria. Test characteristics were determined and receiver operating characteristic (ROC) curves were compared.
Results:
Of 19,524 eligible patient visits, 88 patients developed consensus-confirmed severe sepsis or septic shock. Physician judgment identified 159 and the algorithmic alert identified 3,301 patients with potential sepsis. Physician judgment had sensitivity of 72.7% (95% confidence interval [CI] = 72.1% to 73.4%) and specificity of 99.5% (95% CI = 99.4% to 99.6%); the algorithmic alert had sensitivity of 92.1% (95% CI = 91.7% to 92.4%) and specificity of 83.4% (95% CI = 82.9% to 83.9%) for severe sepsis/septic shock. There was no significant difference in the area under the ROC curve for physician judgment (0.86, 95% CI = 0.81 to 0.91) or the algorithm (0.88, 95% CI = 0.85 to 0.91; p = 0.54). A combination method using either positive physician judgment or an algorithmic alert improved sensitivity to 96.6% and specificity to 83.3%. A sequential approach, in which positive identification by the algorithmic alert was then confirmed by physician judgment, achieved 68.2% sensitivity and 99.6% specificity. Positive and negative predictive values for physician judgment versus algorithmic alert were 40.3% versus 2.5% and 99.88% versus 99.96%, respectively.
Conclusions:
The electronic algorithmic alert was more sensitive but less specific than physician judgment for recognition of pediatric severe sepsis and septic shock. These findings can help to guide institutions in selecting pediatric sepsis recognition methods based on institutional needs and priorities.
