LAUSR

The term sepsis commonly evokes a critically ill patient with multiorgan failure who requires immediate and aggressive lifesaving care. In the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), sepsis is defined conceptually as “life-threatening organ dysfunction caused by a dysregulated host response to infection.”1(p801) The Sepsis-3 task force recommended operationalizing this definition as suspected infection and a concurrent increase in the Sequential Organ Failure Assessment (SOFA) score by 2 or more points. A growing body of work is making it increasingly clear, however, that these clinical criteria identify many patients with mild infections that respond quickly to treatment in addition to individuals with life-threatening critical illness.2 Peltan and colleagues3 reported the prevalence, characteristics, and outcomes of adult patients with sepsis who were discharged alive from the emergency departments (EDs) of 4 hospitals in Utah. The investigators used detailed electronic health record data to identify 12 333 ED patients with suspected infection (defined as the collection of a clinical culture and administration of intravenous antibiotics) and organ dysfunction (defined as an increase in SOFA score by 2 or more points higher than baseline), in accordance with Sepsis-3.1 Peltan and colleagues3 found that 16.1% of patients who met the sepsis criteria were discharged alive from the ED. Similar observations have previously been reported. A national study of ED visits between 2009 and 2011 that defined sepsis using diagnosis codes and/or clinical criteria reported that approximately 20% of patients with sepsis did not require inpatient admission.4 Another study reported that, among 67 733 patients with sepsis diagnosis who were admitted to 110 US hospitals, 1 in 10 were discharged alive within 3 days.5 The analysis by Peltan and colleagues3 expands on these studies by providing the clinical characteristics and 30-day outcomes of patients with sepsis who were discharged from the ED. These patients tended to be younger and less severely ill compared with those who were admitted to the hospital, with fewer perturbations in their vital signs, milder organ dysfunction, and higher rates of arrival by private vehicle over ambulance. Two-thirds had urinary infections, whereas those who were admitted to the hospital more commonly had pulmonary or intra-abdominal infections. The 30-day mortality rate in patients who were discharged was only 0.9% compared with 8.3% in those who were hospitalized. Although both crude and risk-adjusted 30-day mortality rates were lower in patients with sepsis who were discharged from the ED vs admitted to the hospital, Peltan and colleagues3 recognized the massive potential for residual confounding and were careful not to overstate these findings as support for routine outpatient sepsis management. Rather, the authors concluded that most ED clinicians synthesize the entire constellation of objective and subjective clinical data to appropriately triage patients who are at low risk for poor outcomes to outpatient followup care. These observations can be interpreted in 1 of 2 ways. They can be seen as evidence that we should broaden our mental models of sepsis to include mild transient illnesses in addition to severe infections that lead to critical illness. Alternatively, they can prompt us to reconsider how best to operationalize the Sepsis-3 conceptual definition. The first interpretation has major implications for epidemiologic surveillance given that most previous studies have described sepsis incidence, characteristics, and outcomes using either hospital discharge diagnosis codes or electronic clinical criteria that are generated exclusively during inpatient care. For example, the clinical surveillance definition used in a 2017 Centers for Disease Control and Prevention–sponsored study that generated annual estimates of sepsis incidence and mortality in + Related article