Sepsis Guideline Adherence in the Emergency Department: The Grey Zone of Early Infection - A retrospective observational study

Abstract

Background Many patients presenting to the emergency department (ED) with systemic infection remain in a diagnostic “grey zone,” where sepsis is suspected but not definitive. Evidence on adherence to guideline-recommended sepsis management in this population is limited. We evaluated adherence to sepsis guidelines and its association with the National Early Warning Score (NEWS).

Methods We conducted an observational study in the ED of the Medical University of Vienna (May 2022–May 2025). Adult patients with systemic infection who were suspected of having/developing sepsis and required intermediate or intensive care were included. Patients were identified through antibiotic administration, clinical scoring, chart review and stratified by NEWS. Outcomes included the proportion ultimately diagnosed with sepsis, timeliness of sepsis-related interventions, in-hospital transfer patterns and 30- and 90-day survival. The ethics approval number is 1591/2025.

Results Among 16,134 patients requiring intermediate or intensive care, 1,472 had systemic infection, of whom 527 ultimately met sepsis criteria. Higher NEWS was associated with faster lactate measurement, more aggressive fluid resuscitation and increased vasopressor use. Despite this, approximately one-third of patients received broad-spectrum antibiotics within 60 minutes. 8,067 patients were initially admitted to general wards; 99 were transferred to intermediate care and 232 required intensive care unit admission. 30- and 90-day survival declined progressively with increasing NEWS. Overall, 527 patients met SOFA ≥2 criteria and received earlier fluids and more frequent norepinephrine administration. Similar trends were observed using MEWS.

Conclusions In ED patients with systemic infection and higher NEWS values identified those requiring earlier and more aggressive sepsis management. However, timely delivery of key interventions remained suboptimal. Frequent clinical deterioration and escalation of care highlight the importance of structured early risk assessment and optimized ED workflows.