Complex Sepsis Presentations, SEP-1 Compliance, and Outcomes.

Summary

In 590 ED sepsis patients, noncompliance with SEP-1 was associated with older age, higher comorbidity burden, septic shock, organ dysfunction, atypical presentations, and concurrent noninfectious illness. While SEP-1 compliance correlated with lower crude mortality, the association disappeared after adjusting for illness severity and clinical complexity.

Key Findings

• SEP-1 noncompliance associated with older age, higher comorbidity (Elixhauser >20), septic shock, kidney dysfunction, thrombocytopenia, nonfebrile presentation, impaired mental status, and concurrent noninfectious illnesses.
• SEP-1 compliance associated with lower crude hospital mortality (11.9% vs 16.1%), but no significant difference after adjusting sequentially for demographics/comorbidities, infection source, severity, and complexity (final AOR 1.08; 95% CI 0.61–1.91).
• Clinical complexity factors were more prevalent in noncompliant cases, suggesting confounding of SEP-1–mortality associations in prior observational studies.

Clinical Implications

Hospitals should interpret SEP-1 metrics in context, incorporate complexity markers into quality dashboards, and prioritize tailored pathways for atypical or concurrent noninfectious presentations.

Limitations

• Retrospective design with potential misclassification and residual confounding; moderate sample size from academic centers may limit generalizability.
• SEP-1 adjudication and complexity measures depend on documentation quality and abstraction accuracy.

Future Directions

Develop risk-adjusted sepsis quality metrics incorporating complexity markers; test tailored care pathways for atypical presentations in pragmatic trials.