Clinical Outcomes for Emergency Department Presentations of Sepsis Managed on a Clinical Pathway: A Systematic Review...

Background: Sepsis is a time-critical condition requiring early recognition and intervention. Many emergency departments (EDs) have adopted clinical pathways to standardise sepsis care; however, the impact of these pathways on patient outcomes remains unclear. Methods: A systematic review and meta-analysis was conducted in November 2024 searching PubMed, Embase, and Scopus. Studies were included if they assessed the impact of a clinical pathway on adult or paediatric patients with sepsis presenting to the ED. Results: Thirty-three studies were included, of which the majority were retrospective cohort designs and were rated serious overall risk of bias. Pathway implementation was associated with faster time to antibiotics across all subgroups (135 min before vs. 93 min after; MD -43 min, p < 0.001). In-hospital mortality appeared reduced in the primary analysis (RD -2.4%, p = 0.032); however, this finding was fragile under sensitivity analysis and was not observed in prospective or randomised designs. The apparent reduction in hospital length of stay was driven by paediatric and low- and middle-income country studies and was non-significant when restricted to adult studies. ICU admission rate, ED length of stay, and time to IV fluid resuscitation were not significantly reduced. Conclusions: ED sepsis pathway implementation is associated with improved time to antibiotics across clinical settings and populations. Current evidence is insufficient to demonstrate a reduction in mortality; the apparent signal in retrospective studies is attributable to secular improvements in sepsis care and asymmetric patient identification rather than a true pathway effect. Future research should prioritise prospective controlled studies with standardised screening methods, time zero definitions and control of confounding variables.