Factors Influencing Clinical Deterioration in Persons with Sepsis


  • Patiporn Bunyaphatkun RN, PhD Candidate, Joint Program between Faculty of Nursing and Ramathibidi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
  • Siriorn Sindhu RN, DNS, Associate Professor, Faculty of Nursing, Mahidol University, Thailand
  • Patricia M. Davidson RN, PhD, School of Nursing, Johns Hopkins University, USA
  • Ketsarin Utriyaprasit RN, PhD, Nursing, Associate Professor, Faculty of Nursing, Mahidol University, Thailand
  • Chukiat Viwatwongkasem Associate Professor, Department of Biostatistics, Faculty of Public Health, Mahidol University, Thailand
  • Wittaya Chartbunchachai MD, Dip.,Thai Board of Surgery, Director of Trauma Center and Critical Care, Khon Kaen Hospital, Khon Kaen, Thailand


Clinical deterioration, Emergency care, Influencing factors, Sepsis, Shock, Thailand


                  Sepsis is a common problem in patients in emergency rooms that need proper management within 72 hours to prevent clinical deterioration. The objective of this study was to determine factors influencing the clinical deterioration of persons with sepsis. A descriptive correlation study was conducted from September 2014 to February 2015 at 11 hospitals in  central Thailand. Recruited into the study were 172 participants presenting with > 2 criteria of systemic inflammatory response syndrome without white blood cell count and shock index >1 at triage, and diagnosed with infectious disease at the 11 emergency departments. Data were collected through interviews, physical examinations and reviewing patients’ charts and were analyzed using descriptive statistics and binary logistic regression.
               Results showed that symptoms of clinical deterioration manifested in 59.3% of participants. Over 40% demonstrated failure of the circulatory system occurred among 77.5% participants within 24 hours of emergency department arrival. Factors influencing clinical deterioration were higher severity of illness, incomplete triage practices and non-achieved performance of sepsis resuscitation bundle. These factors explained 22% of the variance of clinical deterioration. The implications for nursing practice in improving sepsis care are provision of triage training, development of sepsis fast track, and encouragement of compliances with triage assessment protocols and sepsis resuscitation bundle.


1. World Sepsis Day. Fact Sheet Sepsis September 2013. [cited 2014 March 4]. Available from: https://www. world-sepsis-day.org/CONTENTPIC/2015_WSD_ FactSheet_long_English.

2. Mahavanakul W, Nickerson EK, Srisomang P, Teparrukkul P, Lorvinitnun P, Wongyingsinn M, et al. Feasibility of modified surviving sepsis campaign guidelines in a resourcerestricted setting based on a cohort study of severe S. aureus sepsis. PLoS One. 2012;7(2):e29858.

3. Kaukonen KM, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 20002012. JAMA. 2014;311(13):1308-16.

4. Abraham E, Singer M. Mechanisms of sepsis-induced organ dysfunction. Crit Care Med. 2007;35(10):2408-16.

5. Levy MM, Macias WL, Vincent JL, Russell JA, Silva E, Trzaskoma B, et al. Early changes in organ function predict eventual survival in severe sepsis. Crit Care Med. 2005; 33(10):2194-201.

6. Vosylius S, Sipylaite J, Ivaskevicius J. Sequential organ failure assessment score as the determinant of outcome for patients with severe sepsis. Croat Med J. 2004;45(6):715-20.

7. Glickman SW, Cairns CB, Otero RM, Woods CW, Tsalik EL, Langley RJ, et al. Disease progression in hemodynamically stable patients presenting to the emergency department with sepsis. Acad Emerg Med. 2010;17(4):383-90.

8. Tsai JC-H, Cheng C-W, Weng S-J, Huang C-Y, Yen DH-T, Chen H-L. Comparison of Risks Factors for Unplanned ICU Transfer after ED Admission in Patients with Infections and Those without Infections. The Scientific World Journal. 2014;2014:10.

9. Lu TC, Tsai CL, Lee CC, Ko PC, Yen ZS, Yuan A, et al. Preventable deaths in patients admitted from emergency department. Emerg Med J. 2006;23(6):452-5.

10. Wang HE, Weaver MD, Shapiro NI, Yealy DM. Opportunities for Emergency Medical Services care of sepsis. Resuscitation. 2010;81(2):193-7.

11. Shapiro NI, Wolfe RE, Moore RB, Smith E, Burdick E, Bates DW. Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule. Crit Care Med. 2003;31(3):670-5.

12. Freitas FG, Salomao R, Tereran N, Mazza BF, Assuncao M, Jackiu M, et al. The impact of duration of organ dysfunction on the outcome of patients with severe sepsis and septic shock. Clinics. 2008;63(4):483-8.

13. Yurkova I, Wolf L. Under-triage as a significant factor affecting transfer time between the emergency department and the intensive care unit. J Emerg Nurs. 2011;37(5):491-6.

14. Kim JH, Hong SK, Kim KC, Lee MG, Lee KM, Jung SS, et al. Influence of full-time intensivist and the nurse-to-patient ratio on the implementation of severe sepsis bundles in Korean intensive care units. J Crit Care. 2012;27(4):414 e11-21.

15. Champunot R, Kamsawang, N., Tuandoung, P., & Tansuphaswasdikul, S. Saving 500 Lives Campaign: another way to improve the mortality rate of patients with severe sepsis and septic shock. Poster presented in sepsis 2012. Critical Care. 2012;16(Suppl 3):P105.

16. Angkasekwinai N, Rattanaumpawan P, Thamlikitkul V. Epidemiology of sepsis in Siriraj Hospital 2007. J Med Assoc Thai. 2009;92 Suppl 2:S68-78.

17. Razzak JA, Kellermann AL. Emergency medical care in developing countries: is it worthwhile? Bull World Health Organ. 2002;80(11):900-5.

18. Herlitz J, Wireklintsundstrom B, Bang A, Berglund A, Svensson L, Blomstrand C. Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities. Scand J Trauma Resusc Emerg Med. 2010;18:48.

19. Larsen GY, Mecham N, Greenberg R. An Emergency Department Septic Shock Protocol and Care Guideline for Children Initiated at Triage. Pediatrics. 2011;127(6): e1585-e92.

20. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39(2):165-228.

21. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Intensive Care Med. 2003;29(4):530-8.

22. Herlitz J, Bang A, Wireklint-Sundstrom B, Axelsson C, Bremer A, Hagiwara M, et al. Suspicion and treatment of severe sepsis. An overview of the prehospital chain of care. Scand J Trauma Resusc Emerg Med. 2012;20:42.

23. Jordan HT, Prapasiri P, Areerat P, Anand S, Clague B, Sutthirattana S, et al. A comparison of population-based pneumonia surveillance and health-seeking behavior in two provinces in rural Thailand. Int J Infect Dis. 2009; 13(3):355-61.

24. Begier EM, Sockwell D, Branch LM, Davies-Cole JO, Jones LH, Edwards L, et al. The National Capitol Region’s Emergency Department syndromic surveillance system: do chief complaint and discharge diagnosis yield different results? Emerg Infect Dis. 2003;9(3):393-6.

25. Westphal GA, Koenig A, Caldeira Filho M, Feijo J, de Oliveira LT, Nunes F, et al. Reduced mortality after the implementation of a protocol for the early detection of severe sepsis. J Crit Care. 2011;26(1):76-81.

26. Gilboy N, Tanabe P, Travers D, Rosenau AM. Emergency Severity Index (ESI) A Triage Tool for Emergency Department Care Version 4: Implementation Handbook 2012 [cited 2014 May 18]. Available from https://www. ahrq.gov/professionals/systems/hospital/esi/esihandbk.

27. Nguyen HB, Kuan WS, Batech M, Shrikhande P, Mahadevan M, Li CH, et al. Outcome effectiveness of the severe sepsis resuscitation bundle with addition of lactate clearance as a bundle item: a multi-national evaluation. Crit Care. 2011; 15(5):R229.

28. Hanzelka KM, Yeung SC, Chisholm G, Merriman KW, Gaeta S, Malik I, et al. Implementation of modified early-goal directed therapy for sepsis in the emergency center of a comprehensive cancer center. Support Care Cancer. 2013; 21(3):727-34.

29. Bone RC, Grodzin CJ, Balk RA. Sepsis: a new hypothesis for pathogenesis of the disease process. Chest. 1997; 112(1):235-43.

30. Berger T, Green J, Horeczko T, Hagar Y, Garg N, Suarez A, et al. Shock index and early recognition of sepsis in the emergency department: pilot study. West J Emerg Med. 2013;14(2):168-74.

31. Hsieh FY. Sample size tables for logistic regression. Stat Med. 1989;8(7):795-802.

32. Bellomo R, Goldsmith D, Uchino S, Buckmaster J, Hart G, Opdam H, et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med. 2004;32(4):916-21.

33. Cretikos M, Chen J, Hillman K, Bellomo R, Finfer S, Flabouris A, et al. The objective medical emergency team activation criteria: a case-control study. Resuscitation. 2007;73(1): 62-72.

34. Rady MY, Smithline HA, Blake H, Nowak R, Rivers E. A comparison of the shock index and conventional vital signs to identify acute, critical illness in the emergency department. Ann Emerg Med. 1994;24(4):685-90.

35. Wira CR, Francis MW, Bhat S, Ehrman R, Conner D, Siegel M. The shock index as a predictor of vasopressor use in emergency department patients with severe sepsis. West J Emerg Med. 2014;15(1):60-6.

36. Cheng AC, Buising KL. Delayed administration of antibiotics and mortality in patients with community-acquired pneumonia. Ann Emerg Med. 2009;53(5):618-24.

37. National Institute of Emergency Medicine. Guidelines to follow the rules, criteria and procedures to sort and prioritize emergency care at the emergency room, according to the Emergency Medical Board. Nonthaburi: National Institute of Emergency Medicine; 2015.

38. Vegt AE, Holman M, ter Maaten JC. The value of the clinical impression in recognizing and treating sepsis patients in the emergency department. Eur J Emerg Med. 2012; 19(6):373-8.

39. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-10.

40. Power GS, Harrison DA, Mouncey PR, Osborn TM, Harvey SE, Rowan KM. The Protocolised Management in Sepsis (ProMISe) trial statistical analysis plan. Crit Care Resusc. 2013;15(4):311-7.




How to Cite

Bunyaphatkun P, Sindhu S, Davidson PM, Utriyaprasit K, Viwatwongkasem C, Chartbunchachai W. Factors Influencing Clinical Deterioration in Persons with Sepsis. PRIJNR [Internet]. 2017 May 5 [cited 2023 Dec. 9];21(2):135-47. Available from: https://he02.tci-thaijo.org/index.php/PRIJNR/article/view/71287



Original paper