If free open access medical education (#FOAMed) has a single greatest strength, it is that it cuts the gap between knowledge acquisition and knowledge translation significantly. February proved that once again.

First, The New England Journal of Medicine (NEJM) announced that metrics for all articles published since July 2010 will now be available to everyone, not just authors. This will actually give FOAM a boost. Even a superficial browsing of its newly updated @NEJM website, NEJM, demonstrates that the articles that received Twitter attention were more likely to have substantially higher page views. While formal studies to assess that contention will be necessary, it will now be easier than ever to do so. Further, it was immediately apparent that some—though not all—articles in NEJM receive fewer page views than many popular FOAM blog posts and podcasts. If this is the case for the leading medical journal in the world, that contrast will certainly be magnified in the lesser-read journals. This will continue to underscore the importance of FOAM quality. Some, like Teresa Chan, MD (TChanMD), of CanadiEM (formally), will likely see this as further evidence that some formal structures in the FOAM movement seeking to assure quality are important, if not necessary. (See her much discussed article “Waves of FOAM” on CanadiEM.) Others like Scott Weingart, MD, FCCM (@emcrit), argue that the massive number of FOAM site visits ensures its own quality in ways that even journals can’t match. Active FOAM audiences frequently catch mistakes large and small, and they have a direct line to the content creators, who are likely to make corrections and comments instantly.

But the biggest news in #FOAMed was, once again, sepsis. After months of anticipation, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine announced their new consensus definitions of sepsis on Feb. 22 from its 45th annual critical care conference, held in Orlando, Florida (#CCC45 on Twitter). To say that the new sepsis definitions went viral would be an understatement. Of the 15,000 tweets, by far the most buzz centered around the new sepsis definitions, known as Sepsis 3 and published in The Journal of the American Medical Association (JAMA). An online debate erupted within minutes of the announcement.

The new definitions, which have not been endorsed by ACEP, define sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection.”¹ The criteria for organ dysfunction are defined as any acute increase in the Sequential/Sepsis Related Organ Dysfunction Scale (SOFA). However, because a SOFA scale involves a significant slew of laboratory results, the committee sought to develop a proxy that would help emergency and prehospital providers identify at-risk patients. Thus, from retrospective chart data, the quickSOFA, or qSOFA, was derived. qSOFA is meant to replace systemic inflammatory response syndrome (SIRS), which was deemed unhelpful for identifying sepsis patients and criticized both for being too big a net while having significant holes in it, causing some septic patients to escape notice. Further, unlike SIRS, the qSOFA score can be calculated in triage without laboratory results. To have a “positive” qSOFA, a patient must have two of the following: respiratory rate ≥22, altered mental status (defined as a Glasgow Coma Scale ≤13), and a systolic blood pressure ≤100 mm HG. In the newly published, albeit retrospective, studies, qSOFA outperformed SIRS in detecting patients at risk of having life-threatening organ dysfunction due to infection. Septic shock was also redefined as the “subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.” After identifying the cohort of patients in the medical records who were most likely to die, the clinical criteria were derived. This “reverse engineering” was done in order to develop a tool that clinicians could use to help risk-stratify patients.

Of the 15,000 tweets, by far the most buzz centered around the new sepsis definitions, known as Sepsis 3 and published in The Journal of the American Medical Association. An online debate erupted within minutes of the announcement.

Of the various aspects of the new definitions, the biggest attention getter online has certainly been the qSOFA score. My podcast cohost Lauren Westafer, DO, MPH (@LWestafer, @FOAMpodcast), immediately tweeted a JPEG of a silhouetted man in a hat with the three qSOFA criteria listed. That’s “HAT” for hypotension, altered mental status, and tachypnea. Not bad. Not to be outdone though, Natalie May, MBChB, MPHe, MCEM, FCEM (@_NMay), of the St. Emlyn’s emergency medicine blog in Manchester, UK, tweeted a JPEG of the DC Comics bat signal: “the BAT score: Blood pressure, AMS, Tachypnoea.” Oh, the British with their extra vowels.

Others commenters, however, were less enthusiastic about the new definitions and criteria. Intensivist Flavia Machado, MD, PhD (@FlaviaSepsis), tweeted a JPEG summing up her feelings: “Keep Calm and Don’t Change Sepsis Definitions.” In a link to a statement from the Latin American Sepsis Institute (LASI), Dr. Machado and others in low- and middle-resource settings expressed concern that the new definitions might not have enough sensitivity. The 19 coauthors also expressed concern that the definitions were made without consulting important stakeholder organizations such as LASI. Last year, ACEP lodged a similar complaint regarding the lack of emergency medicine representation on the task force that developed the new definitions.

That being said, uptake of the definitions online seemed brisk and enthusiastic. On his free online medical calculator, MDcalc, Graham Walker, MD (@grahamwalker), rolled out a new SOFA and qSOFA score tool within days of the announcement. Salim Rezaie, MD (@srrezaie), used the relatively new Twitter poll function to ask the #FOAMed community, “Is Sepsis-3/qSOFA/SOFA ready for primetime clinical use?” Out of 139 responses, 22 percent said, “Yes, SIRS is Dead,” 28 percent said, “No, SIRS is NOT dead,” while 50 percent said, “Maybe, Use SIRS & SOFA.” Not a bad start for five days after liftoff.

Dr. Westafer and I also released a 20-minute summary of the definitions on our podcast, FOAMcast. In that episode, we cover how the definitions were made as well as some strengths, weaknesses, criticisms, and defenses of the new definitions.

The conversation will no doubt continue online and likely in person at the 36th International Symposium on Intensive Care and Emergency Medicine, March 15–18, in Brussels, Belgium, so watch for tweets coming from #ISICEM16.

Reference

1. Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA. 2016;315(8):801-810.