Knack SKS, Scott N, Driver BE, et al. Early Physician Gestalt Versus Usual Screening Tools for the Prediction of Sepsis in Critically Ill Emergency Patients. Ann Emerg Med. 2024 Mar 25:S0196-0644(24)00099-4. doi: 10.1016/j.annemergmed.2024.02.009. (Original study)

STUDY OBJECTIVE: Compare physician gestalt to existing screening tools for identifying sepsis in the initial minutes of presentation when time-sensitive treatments must be initiated.

METHODS: This prospective observational study conducted with consecutive encounter sampling took place in the emergency department (ED) of an academic, urban, safety net hospital between September 2020 and May 2022. The study population included ED patients who were critically ill, excluding traumas, transfers, and self-evident diagnoses. Emergency physician gestalt was measured using a visual analog scale (VAS) from 0 to 100 at 15 and 60 minutes after patient arrival. The primary outcome was an explicit sepsis hospital discharge diagnosis. Clinical data were recorded for up to 3 hours to compare Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), quick SOFA (qSOFA), Modified Early Warning Score (MEWS), and a logistic regression machine learning model using Least Absolute Shrinkage and Selection Operator (LASSO) for variable selection. The screening tools were compared using receiver operating characteristic analysis and area under the curve calculation (AUC).

RESULTS: A total of 2,484 patient-physician encounters involving 59 attending physicians were analyzed. Two hundred seventy-five patients (11%) received an explicit sepsis discharge diagnosis. When limited to available data at 15 minutes, initial VAS (AUC 0.90; 95% confidence interval [CI] 0.88, 0.92) outperformed all tools including LASSO (0.84; 95% CI 0.82 to 0.87), qSOFA (0.67; 95% CI 0.64 to 0.71), SIRS (0.67; 95% 0.64 to 0.70), SOFA (0.67; 95% CI 0.63 to 0.70), and MEWS (0.66; 95% CI 0.64 to 0.69). Expanding to data available at 60 minutes did not meaningfully change results.

CONCLUSION: Among adults presenting to an ED with an undifferentiated critical illness, physician gestalt in the first 15 minutes of the encounter outperformed other screening methods in identifying sepsis.

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Discipline Area Score
Emergency Medicine 6 / 7
Comments from MORE raters

Emergency Medicine rater

This single-center study investigated how well physicians could identify sepsis compared with several tools. Physicians were better than SOFA, MEWS, etc. at predicting sepsis measured at 15 minutes persisting to an hour. This is not surprising for several reasons: 1. This is an extremely high-performing center (the results are unlikely to be generalizable); 2. These sepsis tools are not designed to diagnose sepsis - they are mainly prognostic; 3. Recent studies show that these tools when used for diagnosis and are positive, may be more accurate at predicting the absence of sepsis. (https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2781307). Summary: Physicians are pretty good at picking up on sepsis, especially if they have a lot of training and support.

Emergency Medicine rater

Very interesting methodology! Despite being a single-center prospective study, this report reinforces the importance of clinical gestalt in the emergency department and the positive related outcomes.

Emergency Medicine rater

An excellent and timely article showing physician gestalt is superior to the standard guidelines for detecting clinically significant sepsis.
Comments from EvidenceAlerts subscribers

Dr. Stanley Schwartz (5/1/2024 4:56 PM)

This surprises me and doesn't surprise me. Docs who have experience with treating patients with sepsis recognize what we used to call "do-bad" patients. There's something about early sepsis that triggers that sixth sense. (And there's a sense of personal affirmation when the lab and blood cultures confirm that sixth sense.)