Determining the Electronic Signature of Infection in Electronic Health Record Data

Crit Care Med. 2021 Jul 1;49(7):e673-e682. doi: 10.1097/CCM.0000000000004968.


Objectives: Recent sepsis studies have defined patients as "infected" using a combination of culture and antibiotic orders rather than billing data. However, the accuracy of these definitions is unclear. We aimed to compare the accuracy of different established criteria for identifying infected patients using detailed chart review.

Design: Retrospective observational study.

Setting: Six hospitals from three health systems in Illinois.

Patients: Adult admissions with blood culture or antibiotic orders, or Angus International Classification of Diseases infection codes and death were eligible for study inclusion as potentially infected patients. Nine-hundred to 1,000 of these admissions were randomly selected from each health system for chart review, and a proportional number of patients who did not meet chart review eligibility criteria were also included and deemed not infected.

Interventions: None.

Measurements and main results: The accuracy of published billing code criteria by Angus et al and electronic health record criteria by Rhee et al and Seymour et al (Sepsis-3) was determined using the manual chart review results as the gold standard. A total of 5,215 patients were included, with 2,874 encounters analyzed via chart review and a proportional 2,341 added who did not meet chart review eligibility criteria. In the study cohort, 27.5% of admissions had at least one infection. This was most similar to the percentage of admissions with blood culture orders (26.8%), Angus infection criteria (28.7%), and the Sepsis-3 criteria (30.4%). Sepsis-3 criteria was the most sensitive (81%), followed by Angus (77%) and Rhee (52%), while Rhee (97%) and Angus (90%) were more specific than the Sepsis-3 criteria (89%). Results were similar for patients with organ dysfunction during their admission.

Conclusions: Published criteria have a wide range of accuracy for identifying infected patients, with the Sepsis-3 criteria being the most sensitive and Rhee criteria being the most specific. These findings have important implications for studies investigating the burden of sepsis on a local and national level.

MeSH terms

  • Adult
  • Aged
  • Anti-Bacterial Agents / therapeutic use
  • Antibiotic Prophylaxis / statistics & numerical data
  • Blood Culture
  • Chicago / epidemiology
  • Data Accuracy*
  • Electronic Health Records / standards*
  • False Positive Reactions
  • Female
  • Humans
  • Infections / diagnosis
  • Infections / epidemiology*
  • Information Storage and Retrieval / methods*
  • International Classification of Diseases
  • Male
  • Middle Aged
  • Organ Dysfunction Scores
  • Patient Admission / statistics & numerical data
  • Prevalence
  • Retrospective Studies
  • Sensitivity and Specificity
  • Sepsis / diagnosis


  • Anti-Bacterial Agents