The Presentation, Pace, and Profile of Infection and Sepsis Patients Hospitalized Through the Emergency Department: An Exploratory Analysis

Abstract

To characterize the signs and symptoms of sepsis, compare them with those from simple infection and other emergent conditions and evaluate their association with hospital outcomes.

Design setting participants and intervention: A multicenter, retrospective cohort study of 408,377 patients hospitalized through the emergency department from 2012 to 2017 with sepsis, suspected infection, heart failure, or stroke. Infected patients were identified based on Sepsis-3 criteria, whereas noninfected patients were identified through diagnosis codes.

Measurements and main results: Signs and symptoms were identified within physician clinical documentation in the first 24 hours of hospitalization using natural language processing. The time of sign and symptom onset prior to presentation was quantified, and sign and symptom prevalence was assessed. Using multivariable logistic regression, the association of each sign and symptom with four outcomes was evaluated: sepsis versus suspected infection diagnosis, hospital mortality, ICU admission, and time of first antibiotics (> 3 vs ≤ 3 hr from presentation). A total of 10,825 signs and symptoms were identified in 6,148,348 clinical documentation fragments. The most common symptoms overall were as follows: dyspnea (35.2%), weakness (27.2%), altered mental status (24.3%), pain (23.9%), cough (19.7%), edema (17.8%), nausea (16.9%), hypertension (15.6%), fever (13.9%), and chest pain (12.1%). Compared with predominant signs and symptoms in heart failure and stroke, those present in infection were heterogeneous. Signs and symptoms indicative of neurologic dysfunction, significant respiratory conditions, and hypotension were strongly associated with sepsis diagnosis, hospital mortality, and intensive care. Fever, present in only a minority of patients, was associated with improved mortality (odds ratio, 0.67, 95% CI, 0.64-0.70; p < 0.001). For common symptoms, the peak time of symptom onset before sepsis was 2 days, except for altered mental status, which peaked at 1 day prior to presentation.

Conclusions: The clinical presentation of sepsis was heterogeneous and occurred with rapid onset prior to hospital presentation. These findings have important implications for improving public education, clinical treatment, and quality measures of sepsis care.

Keywords: electronic health record; infection; mortality; outcomes; sepsis.

Figure 1.

Frequency of the top 30 most common presenting signs and symptoms among patients hospitalized from the emergency department stratified by cohort: sepsis (left), suspected infection (left center), heart failure (right center), and stroke (right). Bars are colored by the symptom frequency in the cohort, grouped as: greater than 15% (dark gray), 5–15% (light gray), and less than 5% (white). Dyspnea was present in 81.4% of heart failure patients (rightward arrow). Sepsis and suspected infection were defined based on Sepsis-3 specifications. AMS = altered mental status

Figure 2.

Bubble plot of adjusted odds ratios for sepsis versus suspected infection (y-axis) and hospital mortality (x-axis) among common signs and symptoms (sepsis frequency ≥ 3%) in infected patients. Bubble size is indicative of frequency, ranging from tremor and hypotension (3.0%) to pain (30.2%). Only symptoms with a p ≤ 0.001 for at least one outcome are included. Red dashed lines indicate odds ratios of 1 for both axes. AMS = altered mental status.

Figure 3.

Bubble plots of adjusted odds ratios for ICU admission (y-axis) and time to first antibiotic greater than 3 hr (x-axis) in sepsis for common signs and symptoms (sepsis frequency ≥ 3%). Bubble size is indicative of frequency, ranging from hypotension (2.9%) to pain (30.3%). Only symptoms with a p ≤ 0.001 for at least one outcome are included. Red dashed lines indicate odds ratios of 1 for both axes. AMS = altered mental status.

Figure 4.

Histogram of reported time of symptom onset prior to sepsis presentation for the top 12 most common signs and symptoms in sepsis. Time of symptom onset is defined as acute (< 7 d) or subacute (≥ 7 d, truncated at 7 d), with day 0 representing the day of emergency department (ED) presentation. The frequency of subacute hypertension was 78.3%. The peak duration of acute symptom onset was 2 d for all symptoms, except altered mental status which had peak symptoms onset of 1 d before ED presentation.