Epidemiology of the Systemic Inflammatory Response Syndrome (SIRS) in the Emergency Department

Introduction: Consensus guidelines recommend sepsis screening for adults with systemic inflammatory response syndrome (SIRS), but the epidemiology of SIRS among adult emergency department (ED) patients is poorly understood. Recent emphasis on cost-effective, outcomes-based healthcare prompts the evaluation of the performance of large-scale efforts such as sepsis screening. We studied a nationally representative sample to clarify the epidemiology of SIRS in the ED and subsequent category of illness. Methods: This was a retrospective analysis of ED visits by adults from 2007 to 2010 in the National Hospital Ambulatory Medical Care Survey (NHAMCS). We estimated the incidence of SIRS using initial ED vital signs and a Bayesian construct to estimate white blood cell count based on test ordering. We report estimates with Bayesian modified credible intervals (mCIs). Results: We used 103,701 raw patient encounters in NHAMCS to estimate 372,844,465 ED visits over the 4-year period. The moderate estimate of SIRS in the ED was 17.8% (95% mCI: 9.7 to 26%). This yields a national moderate estimate of approximately 16.6 million adult ED visits with SIRS per year. Adults with and without SIRS had similar demographic characteristics, but those with SIRS were more likely to be categorized as emergent in triage (17.7% versus 9.9%, p<0.001), stay longer in the ED (210 minutes versus 153 minutes, p<0.0001), and were more likely to be admitted (31.5% versus 12.5%, p<0.0001). Infection accounted for only 26% of SIRS patients. Traumatic causes of SIRS comprised 10% of presentations; other traditional categories of SIRS were rare. Conclusion: SIRS is very common in the ED. Infectious etiologies make up only a quarter of adult SIRS cases. SIRS may be more useful if modified by clinician judgment when used as a screening test in the rapid identification and assessment of patients with the potential for sepsis. [West J Emerg Med. 2014;15(3):329–336.]

[1]  D. Angus,et al.  Variation in sepsis care: a wake-up call , 2003, Critical care.

[2]  D. Mannino,et al.  The epidemiology of sepsis in the United States from 1979 through 2000. , 2003, The New England journal of medicine.

[3]  John L Moran,et al.  Robust meta-analytic conclusions mandate the provision of prediction intervals in meta-analysis summaries. , 2012, Journal of clinical epidemiology.

[4]  A. Raftery,et al.  Inference for Deterministic Simulation Models: The Bayesian Melding Approach , 2000 .

[5]  Jeffrey P. Green,et al.  Emergency Department Presentation of the Pediatric Systemic Inflammatory Response Syndrome , 2013, Pediatric emergency care.

[6]  Richard Beale,et al.  The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis , 2010, Intensive Care Medicine.

[7]  D. Bates,et al.  The association of sepsis syndrome and organ dysfunction with mortality in emergency department patients with suspected infection. , 2006, Annals of emergency medicine.

[8]  David W Bates,et al.  Mortality in Emergency Department Sepsis (MEDS) score: A prospectively derived and validated clinical prediction rule* , 2003, Critical care medicine.

[9]  A Modification for Bayesian Credible Intervals , 2006 .

[10]  R. Bone,et al.  Toward an epidemiology and natural history of SIRS (systemic inflammatory response syndrome) , 1992, JAMA.

[11]  Jesús Blanco,et al.  Incidence, organ dysfunction and mortality in severe sepsis: a Spanish multicentre study , 2008, Critical care.

[12]  P. Ziprin,et al.  Systematic review of discharge coding accuracy. , 2012, Journal of public health.

[13]  K. Inman,et al.  Sepsis, SIRS and infection , 1995, Intensive Care Medicine.

[14]  W. Knaus,et al.  Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. 1992. , 2009, Chest.

[15]  Derek C. Angus,et al.  National estimates of severe sepsis in United States emergency departments , 2007, Critical care medicine.

[16]  M. Bullard,et al.  Revisions to the Canadian Emergency Department Triage and Acuity Scale implementation guidelines. , 2004, CJEM.

[17]  M. Pasquale,et al.  Epidemiology of sepsis in patients with traumatic injury , 2004, Critical care medicine.

[18]  Yu‐Chu Shen,et al.  Factors associated with closures of emergency departments in the United States. , 2011, JAMA.

[19]  D. Bates,et al.  Resource Utilization Among Patients With Sepsis Syndrome , 2003, Infection Control &#x0026; Hospital Epidemiology.

[20]  Fergus Laughridge,et al.  The future of emergency care in the United States health system. , 2006, Annals of emergency medicine.

[21]  A. Gray,et al.  The epidemiology of adults with severe sepsis and septic shock in Scottish emergency departments , 2012, Emergency Medicine Journal.

[22]  G. Pugliese,et al.  Severe Streptococcus pyogenes Infections, United Kingdom, 2003–2004 , 2008, Emerging infectious diseases.

[23]  Sumita Sinha,et al.  Seasonal variation in the epidemiology of sepsis* , 2007, Critical care medicine.

[24]  Dear SIRS: it's time to return to sepsis as we have known it. , 2006, Annals of emergency medicine.

[25]  Munish Goyal,et al.  Validation of the Mortality in Emergency Department Sepsis (MEDS) score in patients with the systemic inflammatory response syndrome (SIRS)* , 2008, Critical care medicine.

[26]  Rolf Rossaint,et al.  Epidemiology of sepsis in Germany: results from a national prospective multicenter study , 2007, Intensive Care Medicine.

[27]  S. Trzeciak.  National Study of Emergency Department Visits for Sepsis, 1992 to 2001Strehlow MC, Emond SD, Shapiro NI, et al (Stanford Univ, Palo Alto, Calif; Beth Israel Deaconess Med Ctr, Boston; Massachusetts Gen Hosp, Boston) Ann Emerg Med 48:326–331, 2006§ , 2007 .

[28]  L. McCaig,et al.  Understanding and interpreting the National Hospital Ambulatory Medical Care Survey: key questions and answers. , 2012, Annals of emergency medicine.

[29]  James Mountford,et al.  Toward an outcomes-based health care system: a view from the United Kingdom. , 2010, JAMA.

[30]  D. Bates,et al.  Severe sepsis: variation in resource and therapeutic modality use among academic centers , 2003, Critical care.

[31]  D. Pittet,et al.  The natural history of the systemic inflammatory response syndrome (SIRS). A prospective study. , 1995, JAMA.

[32]  J. Younger,et al.  Prospective trial of real-time electronic surveillance to expedite early care of severe sepsis. , 2011, Annals of emergency medicine.

[33]  John F. Hurdle,et al.  Measuring diagnoses: ICD code accuracy. , 2005, Health services research.

[34]  R. Niska,et al.  National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. , 2010, National health statistics reports.

[35]  R. Bone,et al.  To SIRS with love. , 1998, Critical care medicine.

[36]  G. Clermont,et al.  Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care , 2001, Critical care medicine.

[37]  Derek C. Angus,et al.  Epidemiology of sepsis: An update , 2001, Critical care medicine.

[38]  J. T. ter Maaten,et al.  The value of the clinical impression in recognizing and treating sepsis patients in the emergency department , 2012, European journal of emergency medicine : official journal of the European Society for Emergency Medicine.

[39]  Christian Genest,et al.  Combining Probability Distributions: A Critique and an Annotated Bibliography , 1986 .

[40]  C. Brun-Buisson,et al.  EPISEPSIS: a reappraisal of the epidemiology and outcome of severe sepsis in French intensive care units , 2004, Intensive Care Medicine.

[41]  A. Whippy,et al.  Kaiser Permanente's performance improvement system, part 3: multisite improvements in care for patients with sepsis. , 2011, Joint Commission journal on quality and patient safety.

[42]  I. L. Cohen.  Guidelines for the use of innovative therapies in sepsis. , 1993, Critical care medicine.

[43]  Joseph B. Kadane,et al.  An application of robust Bayesian analysis to a medical experiment , 1994 .

[44]  J. Lowes,et al.  The systemic inflammatory response syndrome as a predictor of bacteraemia and outcome from sepsis. , 1996, QJM : monthly journal of the Association of Physicians.

[45]  A. Scott,et al.  The Analysis of Categorical Data from Complex Sample Surveys: Chi-Squared Tests for Goodness of Fit and Independence in Two-Way Tables , 1981 .

[46]  C. Camargo,et al.  National study of emergency department visits for sepsis, 1992 to 2001. , 2006, Annals of emergency medicine.

[47]  Nathan Shapiro,et al.  Shock Index and Early Recognition of Sepsis in the Emergency Department: Pilot Study , 2013, The western journal of emergency medicine.