Practice pattern survey - winter/influenza season and sepsis workups...

[SERENITY NOW]

I'm curious what everyone's local practice pattern is.  Where I trained, it seemed to be that our gestalt would trump the sirs criteria.  If we thought that it was strep throat/influenza/etc, we could just leave it at that regardless of the vitals and SIRS criteria.  At my new ED several people are saying that SIRS + any infection = automatic sepsis workup in patients who are 18+ basically regardless of the situation.  When I'm on my fast track shifts, with so much pressure to keep things efficient, I'm really worried about having to order a bunch of unnecessary blood tests all in the name of "sepsis compliance" really slowing everything down.  I've been trying to look up any national recommendations to support getting around this practice but I can't seem to find any.  I'm curious what its like for you all, and if you know of any resources out there relating to this topic.    

 

Please take the survey questions associated with this thread.  In all questions, assume that the patient doesn't look critically ill / "sick" -- more geared towards the lower to moderate acuity patients we are most likely to be seeing.  I realize that there are more considerations for all of these patients, like CXRs, strep/influenza testing, etc... but really I've found that the big branching point for us in fast track is whether or not a patient will require blood work (with an upset nurse and 2 hour stay) vs no blood work (with happy nurse and <1 hr stay), so that is where the questions boil down to.  

[EMEDPA]

Sounds like a triage issue. no one potentially septic should be sent to FT. that should be the expectation and all the walking well with flu/influenza/colds should not be expected to get septic workups.

[kmash]

I seemed to go with the majority.  Clinical picture is huge and I was taught to never discharge persistent tachycardia.  

[narcan]

I've seen it done both ways. Personally, it's still history, physical and gestalt. SIRS criteria is overly sensitive, but a good screening tool for the triage nurses and a good way to make sure you think about sepsis in every patient with an illness. There is definitely a direct correlation though between age, comorbidites and how much of a workup I do. Remember that old people are always full of badness.

But if they're young, healthyish and look like they have strep throat, I just give them steroids +/- antibiotics depending on their CENTOR score and my exam. One of these days I'm going to miss myocarditis, but it's incredibly hard to catch, so that's why I always have very clear return precaution discussions with every patient and document that. I tell them that just because we're discharging you now doesn't mean you won't need to come back later, that I expect you to do well, but you need to be vigilant at home and return immediately if getting worse despite treatment.

One thing to consider regarding your current ED: if patients meet SIRS criteria, hospitals can bill for a sepsis workup. Do you work in a for-profit institution? Perhaps one owned by HCA? If so, that's probably your answer. In either case, ask your medical director or SP what he wants you to do when you work in fast track because surely they want those patients moved expeditiously.