• Gideon Latten, Kirsten Hensgens, de BontEefje G P MEGPMFamily Medicine, Maastricht University, Research Institute CAPHRI, Maastricht, Limburg, The Netherlands., MurisJean W MJWM0000-0002-8780-476XFamily Medicine, Maastricht University, Research Institute CAPHRI, Maastricht, Limburg, The Netherlands., CalsJochen W LJWLFamily Medicine, Maastricht University, Research Institute CAPHRI, Maastricht, Limburg, The Netherlands., and Patricia Stassen.
• Emergency Department, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands g.latten@zuyderland.nl.
• BMJ Open. 2020 Jul 19; 10 (7): e036276.

ObjectiveTo investigate the documentation of sepsis and a sense of urgency throughout the acute care chain.DesignProspective cohort study.SettingEmergency department (ED) in a large district hospital in Heerlen, The Netherlands.ParticipantsParticipants included patients ≥18 years with suspected sepsis who visited the ED during out-of-hours between September 2017 and January 2018 (n=339) and had been referred by a general practitioner and/or transported by ambulance. We defined suspected sepsis as suspected or proven infection and the presence of ≥2 quick Sepsis-related Organ Failure Assessment and/or ≥2 Systemic Inflammatory Response Syndrome criteria.Outcome MeasuresWe analysed how often sepsis and a sense of urgency were documented in the prehospital and ED medical records. A sense of urgency was considered documented when a medical record suggested the need of immediate assessment by a physician in the ED. We described documentation patterns throughout the acute care chain and investigated whether documentation of sepsis or a sense of urgency is associated with adverse outcomes (intensive care admission/30-day all-cause mortality).ResultsSepsis was documented in 16.8% of medical records and a sense of urgency in 22.4%. In 4.1% and 7.7%, respectively, sepsis and a sense of urgency were documented by all involved professionals. In patients with an adverse outcome, sepsis was documented more often in the ED than in patients without an adverse outcome (47.9% vs 13.7%, p<0.001).ConclusionsOur study shows that in prehospital and ED medical records, sepsis and a sense of urgency are documented in one out of five patients. In only 1 out of 20 patients sepsis or a sense of urgency is documented by all involved professionals. It is possible that poor documentation causes harm, due to delayed diagnosis or treatment. Hence, it could be important to raise awareness among professionals regarding the importance of their documentation.© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

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