Early recognition and treatment of sepsis are crucial for improving patient outcomes, leading to clinical guidelines recommending sepsis screening programmes. However, evidence supporting these programmes is limited. Observational studies suggest screening improves care processes, such as timely lactate measurement and antibiotic administration, and may reduce mortality. However, small randomised trials have shown mixed results. Screening may also increase antibiotic use and the risk of multidrug-resistant infections.
A recent research priority led to the SCREEN trial, which evaluated whether electronic sepsis screening using the qSOFA score could reduce 90-day in-hospital mortality compared to no screening.
A trial was conducted across five hospitals in Saudi Arabia, where 45 hospital wards were randomised into nine sequences of five wards each. Sepsis screening was implemented in 2-month intervals. The study took place from October 1, 2019, to July 31, 2021, with follow-up until October 29, 2021.
An electronic alert based on the qSOFA score was integrated into the medical record, initially in silent mode and later activated to a revealed mode for sepsis screening.
The primary outcome was 90-day in-hospital mortality, with 11 secondary outcomes, including code blue activation, vasopressor use, kidney replacement therapy, multidrug-resistant infections, and Clostridioides difficile.
Among 60,055 patients, 29,442 were in the screening group and 30,613 in the no screening group. The median age was 59 years, with 51% male. Alerts were triggered in 14.6% of patients in the screening group and 17.6% in the no screening group.
Within 12 hours of the alert, the screening group was more likely to have serum lactate tested and intravenous fluids ordered. Electronic screening led to a lower 90-day in-hospital mortality and reduced vasopressor use and multidrug-resistant organisms. However, it increased code blue activations, kidney replacement therapy, and C. difficile infections.
The alert identified high-risk patients, and physicians assessed sepsis in one-third of cases. Mortality reduction was observed in both patients with and without documented infections, suggesting the screening's benefit was not limited to sepsis. The alert led to more frequent lactate measurements and fluid orders within the first 12 hours. There was no significant increase in body fluid cultures or antibiotic orders within this period, likely due to prior treatment. Communication between nurses and the medical team after an alert might have improved care coordination.
The study also noted potential unintended consequences, such as antibiotic overuse, increased kidney replacement therapy, and higher rates of C. difficile infections. The increase in code blue activations is unclear, but it may not reflect an actual rise in cardiac arrests.
Electronic sepsis screening, compared to no screening, significantly reduced in-hospital 90-day mortality among hospitalised ward patients. Overall, the screening appeared beneficial, though certain factors, such as contamination and changes in antibiotic use, might have influenced the results. The study raised questions about whether some outcomes, like kidney therapy and C. difficile, might be linked to changes in antibiotic treatment patterns.
Source: JAMA
Image Credit: iStock
