Validation of a 'Usual Care' Model for Vasopressor Initiation in a Cohort of Emergency Department Patients with Sepsis.

ABSTRACT

Usual care regarding vasopressor (VP) initiation is ill-defined. We aimed to further validate a quantitative model for usual care in the Emergency Department (ED) regarding the timing of VP initiation in sepsis. We retrospectively studied a cohort of adult critically-ill ED patients who also received antibiotics in the ED. We applied a multivariable model previously developed from another patient cohort which distinguishes between time points at which patients were or were not subsequently started on a continuous VP infusion. The model has six independently significant predictors (respiratory rate, Glasgow Coma Scale score, systolic blood pressure, SpO2, administered intravenous fluids, and elapsed time). The outcome was initiation of VP infusion, either within the ED or within 6 hours after leaving the ED. We applied the model to all time points, beginning when all model input parameters were first available for a given patient, and ending when either VP were first started, or the patient left the ED. Out of 55,963 adult ED patients during the two-year study interval, we identified 1,629 who met our inclusion criteria. The area under the receiver operating characteristic curve was 0.81 for all patients, and 0.72 for the subset with at least one hypotensive blood pressure measurement. At a model threshold with sensitivity and specificity 0.74 and 0.74, respectively, the median advance detection time was 170.5 minutes (IQR 53 - 363).