Performance of NEWS2, RETTS, clinical judgment and the Predict Sepsis screening tools with respect to identification of sepsis among ambulance patients with suspected infection: a prospective cohort study

Ulrika M Wallgren, Jan Sjölin, Hans Järnbert-Pettersson, Lisa Kurland, Ulrika M Wallgren, Jan Sjölin, Hans Järnbert-Pettersson, Lisa Kurland

Abstract

Background: There is little evidence of which sepsis screening tool to use in the ambulance setting. The primary aim of the current study was to compare the performance of NEWS2 (National Early Warning score 2) and RETTS (Rapid Emergency Triage and Treatment System) with respect to identification of sepsis among ambulance patients with clinically suspected infection. The secondary aim was to compare the performance of the novel Predict Sepsis screening tools with that of NEWS2, RETTS and clinical judgment.

Methods: Prospective cohort study of 323 adult ambulance patients with clinically suspected infection, transported to hospitals in Stockholm, during 2017/2018. The sensitivity, specificity, and AUC (Area Under the receiver operating Curve) were calculated and compared by using McNemar´s test and DeLong's test.

Results: The prevalence of sepsis in the current study population was 44.6% (144 of 323 patients). No significant difference in AUC was demonstrated between NEWS2 ≥ 5 and RETTS ≥ orange. NEWS2 ≥ 7 demonstrated a significantly greater AUC than RETTS red. The Predict Sepsis screening tools ≥ 2 demonstrated the highest sensitivity (range 0.87-0.91), along with RETTS ≥ orange (0.83), but the lowest specificity (range 0.39-0.49). The AUC of NEWS2 (0.73) and the Predict Sepsis screening tools (range 0.75-0.77) was similar.

Conclusions: The results indicate that NEWS2 could be the better alternative for sepsis identification in the ambulance, as compared to RETTS. The Predict Sepsis screening tools demonstrated a high sensitivity and AUCs similar to that of NEWS2. However, these results need to be interpreted with caution as the Predict Sepsis screening tools require external validation.

Trial registration: ClinicalTrials.gov, NCT03249597. Registered 15 August 2017-Retrospectively registered, https://ichgcp.net/clinical-trials-registry/NCT03249597 .

Keywords: Emergency care; Emergency medical services; Prehospital; Screening; Sepsis.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
ROC curves for models without cut-offs and sepsis*. ROC, Receiver Operating Characteristic Curve; NEWS2, National Early Warning Score 2; RETTS, Rapid Emergency Triage and Treatment System. *ROC curves based on sum of scores for NEWS2 and the Predict Sepsis screening tools, with respect to outcome sepsis
Fig. 2
Fig. 2
ROC curves for models with specific cut-offs and sepsis*. ROC, Receiver Operating Characteristic Curve; NEWS2, National Early Warning Score 2; RETTS, Rapid Emergency Triage and Treatment System. *ROC curves for all the models, with specific cut-offs, with respect to outcome sepsis

References

    1. Mouncey PR, Osborn TM, Power GS, Harrison DA, Sadique MZ, Grieve RD, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372(14):1301–1311. doi: 10.1056/NEJMoa1500896.
    1. Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, Pike F, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683–1693. doi: 10.1056/NEJMoa1401602.
    1. Peake SL, Delaney A, Bailey M, Bellomo R, Cameron PA, Cooper DJ, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371(16):1496–1506. doi: 10.1056/NEJMoa1404380.
    1. Henriksen DP, Laursen CB, Jensen TG, Hallas J, Pedersen C, Lassen AT. Incidence rate of community-acquired sepsis among hospitalized acute medical patients-a population-based survey. Crit Care Med. 2015;43(1):13–21. doi: 10.1097/CCM.0000000000000611.
    1. Wallgren UM, Castren M, Svensson AE, Kurland L. Identification of adult septic patients in the prehospital setting: a comparison of two screening tools and clinical judgment. Eur J Emerg Med Off J Eur Soc Emerg Med. 2014;21(4):260–265. doi: 10.1097/MEJ.0000000000000084.
    1. Wallgren UM, Antonsson VE, Castren MK, Kurland L. Longer time to antibiotics and higher mortality among septic patients with non-specific presentations—a cross sectional study of Emergency Department patients indicating that a screening tool may improve identification. Scand J Trauma Resuscit Emerg Med. 2016;24(1):1. doi: 10.1186/s13049-015-0193-0.
    1. Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589–1596. doi: 10.1097/01.CCM.0000217961.75225.E9.
    1. Ferrer R, Artigas A, Suarez D, Palencia E, Levy MM, Arenzana A, et al. Effectiveness of treatments for severe sepsis: a prospective, multicenter, observational study. Am J Respir Crit Care Med. 2009;180(9):861–866. doi: 10.1164/rccm.200812-1912OC.
    1. Gaieski DF, Mikkelsen ME, Band RA, Pines JM, Massone R, Furia FF, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med. 2010;38(4):1045–1053. doi: 10.1097/CCM.0b013e3181cc4824.
    1. Ferrer R, Martin-Loeches I, Phillips G, Osborn TM, Townsend S, Dellinger RP, et al. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med. 2014;42(8):1749–1755. doi: 10.1097/CCM.0000000000000330.
    1. Studnek JR, Artho MR, Garner CL, Jr., Jones AE. The impact of emergency medical services on the ED care of severe sepsis. Am J Emerg Med. 2010.
    1. Wang HE, Weaver MD, Shapiro NI, Yealy DM. Opportunities for emergency medical services care of sepsis. Resuscitation. 2010;81(2):193–197. doi: 10.1016/j.resuscitation.2009.11.008.
    1. Robson W, Nutbeam T, Daniels R. Sepsis: a need for prehospital intervention? Emerg Med J. 2009;26(7):535–538. doi: 10.1136/emj.2008.064469.
    1. Ljungström L. En utmaning till infektionsläkare: Gör omhändertagandet av patienter med akut svår bakteriell infektion (SBI) lika bra som omhändertagandet av akuta koronara syndrom! Infektionsläkaren. 2005;4.
    1. Bayer O, Schwarzkopf D, Stumme C, Stacke A, Hartog CS, Hohenstein C, et al. An early warning scoring system to identify septic patients in the prehospital setting: the PRESEP score. Acad Emerg Med Off J Soc Acad Emerg Med. 2015;22(7):868–871. doi: 10.1111/acem.12707.
    1. Polito CC, Isakov A, Yancey AH, 2nd, Wilson DK, Anderson BA, Bloom I, et al. Prehospital recognition of severe sepsis: development and validation of a novel EMS screening tool. Am J Emerg Med. 2015;33(9):1119–1125. doi: 10.1016/j.ajem.2015.04.024.
    1. Baez AA, Cochon L. Acute care diagnostics collaboration: assessment of a bayesian clinical decision model integrating the prehospital sepsis score and point-of-care lactate. Am J Emerg Med. 2016;34(2):193–196. doi: 10.1016/j.ajem.2015.10.007.
    1. Hunter CL, Silvestri S, Ralls G, Stone A, Walker A, Papa L. A prehospital screening tool utilizing end-tidal carbon dioxide predicts sepsis and severe sepsis. Am J Emerg Med. 2016;34(5):813–819. doi: 10.1016/j.ajem.2016.01.017.
    1. Johansson N, Spindler C, Valik J, Vicente V. Developing a decision support system for patients with severe infection conditions in pre-hospital care. Int J Infect Dis Off Publ Int Soc Infect Dis. 2018;72:40–48. doi: 10.1016/j.ijid.2018.04.4321.
    1. Physicians RCo. National Early Warning Score (NEWS) 2-Standardising the assessment of acute-illness severity in the NHS, Updated report of a working party December 2017. 19 December 2017. : Royal College of Physicians; 2017.
    1. Widgren BR, Jourak M. Medical emergency triage and treatment system (METTS): a new protocol in primary triage and secondary priority decision in emergency medicine. J Emerg Med. 2011;40(6):623–628. doi: 10.1016/j.jemermed.2008.04.003.
    1. Mellhammar L, Linder A, Tverring J, Christensson B, Boyd JH, Åkesson P, et al. Scores for sepsis detection and risk stratification - construction of a novel score using a statistical approach and validation of RETTS. PLoS ONE. 2020;15(2):e0229210. doi: 10.1371/journal.pone.0229210.
    1. Magnusson CA-O, Herlitz J, Karlsson T, Jiménez-Herrera M, Axelsson C, Magnusson CAO, et al. The performance of the EMS triage (RETTS-p) and the agreement between the field assessment and final hospital diagnosis: a prospective observational study among children < 16 years. LID – 500 Initial assessment, level of care and outcome among children who were seen by emergency medical services: a prospective observational study. LID. 2019;88:1471–2431.
    1. Rosenqvist M, Bengtsson-Toni M, Tham J, Lanbeck P, Melander O, Åkesson P. Improved outcomes after regional implementation of sepsis alert: a novel triage model. Crit Care Med. 2020;48(4):484–490. doi: 10.1097/CCM.0000000000004179.
    1. Mellhammar L, Linder A, Tverring J, Christensson B, Boyd JH, Sendi P, et al. NEWS2 is superior to qSOFA in detecting sepsis with organ dysfunction in the Emergency Department. J Clin Med. 2019;8(8):1128. doi: 10.3390/jcm8081128.
    1. Suffoletto B, Frisch A, Prabhu A, Kristan J, Guyette FX, Callaway CW. Prediction of serious infection during prehospital emergency care. Prehosp Emerg Care Off J Natl Assoc EMS Phys Natl Assoc State EMS Directors. 2011;15(3):325–330.
    1. Wallgren UM, Sjölin J, Järnbert-Pettersson H, Kurland L. The predictive value of variables measurable in the ambulance and the development of the Predict Sepsis screening tools: a prospective cohort study. Scand J Trauma Resuscit Emerg Med. 2020;28(1):59. doi: 10.1186/s13049-020-00745-6.
    1. Ulf Kanfjäll CaSAA. Annual ambulance assignments Samariten Ambulans AB Stockholm. Samariten Ambulans AB; 2019.
    1. Årsrapport 2017 Prehospitala verksamheter i SLL Sect. 4.1 and 6.2 (2017).
    1. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3) JAMA. 2016;315(8):801–810. doi: 10.1001/jama.2016.0287.
    1. Pullyblank A, Tavaré A, Little H, Redfern E, le Roux H, Inada-Kim M, et al. Implementation of the National Early Warning Score in patients with suspicion of sepsis: evaluation of a system-wide quality improvement project. Br J Gen Pract. 2020;70(695):e381–e388. doi: 10.3399/bjgp20X709349.
    1. Richard Lowry P. VassarStats; Clinical Research Calculators, Calculator 1. VassarStats: Website for Statistical Computation2019 []. Available from: .
    1. World Medical Association Declaration of Helsinki Ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191–2194. doi: 10.1001/jama.2013.281053.
    1. Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou PP, Irwig L, et al. STARD 2015: an updated list of essential items for reporting diagnostic accuracy studies. Clin Chem. 2015;61(12):1446–1452. doi: 10.1373/clinchem.2015.246280.
    1. Wattanasit P, Khwannimit B. Comparison the accuracy of early warning scores with qSOFA and SIRS for predicting sepsis in the emergency department. Am J Emerg Med. 2020.
    1. Rosenqvist M, Fagerstrand E, Lanbeck P, Melander O, Akesson P. Sepsis alert—a triage model that reduces time to antibiotics and length of hospital stay. Infect Dis (London, England) 2017;49(7):507–513.
    1. Medicinska behandlingsriktlinjer för ambulanssjukvården 2020. Vårdgivarguiden: Falck, Samariten Ambulans AB, AISAB, Region Stockholm; 2020.
    1. Sterling SA, Miller WR, Pryor J, Puskarich MA, Jones AE. The impact of timing of antibiotics on outcomes in severe sepsis and septic shock: a systematic review and meta-analysis. Crit Care Med. 2015;43(9):1907–1915. doi: 10.1097/CCM.0000000000001142.
    1. Singer M. Antibiotics for sepsis: does each hour really count, or is it incestuous amplification? Am J Respir Crit Care Med. 2017;196(7):800–802. doi: 10.1164/rccm.201703-0621ED.
    1. Levy MM, Evans LE, Rhodes A. The surviving sepsis campaign bundle: 2018 update. Crit Care Med. 2018;46(6):997–1000. doi: 10.1097/CCM.0000000000003119.

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