Sepsis is important, but there is more

Dear Editor,

We eagerly read the article on the computerised protocol for comprehensive management of sepsis and the report of an early identification system, recently published in your journal.¹ The article as a whole is very interesting, since it serves as an example of the importance of systems promoting interdepartmental cooperation, with the participation of the intensive care department and the use of technology and electronic resources as reported in this study.

However, the article reflected a very particular local effort adapted to its setting which no doubt required a great deal of work on the part of the participating teams. We would like to note that they used a specific scale to detect a decline in vital signs which they themselves had designed and which has been neither verified nor validated. In addition, the study only featured patients with sepsis. Systems to aid in detecting all types of patients at risk or with clinical deterioration who may benefit from early care may be more pertinent. For this purpose, there is the Early Warning Score (EWS)² and other slightly modified scales that use groups from Spain.³ These scales have been verified and validated and they are international in scope.

We believe that early detection of clinical deterioration should take a much more holistic and innovative approach. Such an approach might involve applying the process to the healthcare setting and more specifically to critical care medicine. In addition, it might be designed using techniques for continuous improvement, such as the Lean or Six Sigma system, as has been reported by authors in our field.⁴

The limitations section of the study cites only an inability to compare clinical courses among patients not consulted. We feel that, as a strategy to improve future efforts involving their process, the researchers should take into account that their electronic consultation system features little involvement of surgical departments as opposed to medical departments, a great deal of involvement of the intensive care department (since, as they recognise, it was managed in that department), and very little involvement of vital sign warning systems.

Therefore, while we appreciate the significant contributions made by the article in question, we feel that warning systems must unify warning criteria among different associations and use validated systems, with vital signs and even laboratory parameters that aid in early detection, not only of patients with sepsis, but of all patients at risk of developing a critical condition. This innovative overall concept of an “ICU without walls” is becoming increasingly widespread, particularly in intensive care medicine departments,⁵ and is forming part of a new way of organising current health systems in general and the process of the critically ill patient in particular.⁶