Daniel E Leisman1,2,3, Catalina Angel1, Sandra M Schneider2,4, Jason A D'Amore2, John K D'Angelo2, Martin E Doerfler5,6. 1. Icahn School of Medicine at Mount Sinai, New York, New York. 2. Department of Emergency Medicine, Hofstra-Northwell School of Medicine, Hempstead, New York. 3. Global Sepsis Alliance, Jena, Germany. 4. American College of Emergency Physicians, Irving, Texas. 5. Department of Medicine, Hofstra-Northwell School of Medicine, Hempstead, New York. 6. Department of Science Education, Hofstra-Northwell School of Medicine, Hempstead, New York.
Abstract
BACKGROUND: Differences between hospital-presenting sepsis (HPS) and emergency department-presenting sepsis (EDPS) are not well described. OBJECTIVES: We aimed to (1) quantify the prevalence of HPS versus EDPS cases and outcomes; (2) compare HPS versus EDPS characteristics at presentation; (3) compare HPS versus EDPS in process and patient outcomes; and (4) estimate risk differences in patient outcomes attributable to initial resuscitation disparities. DESIGN: Retrospective consecutive-sample cohort. SETTING: Nine hospitals from October 1, 2014, to March 31, 2016. PATIENTS: All hospitalized patients with sepsis or septic shock, as defined by simultaneous (1) infection, (2) ≥2 Systemic Inflammatory Response Syndrome (SIRS) criteria, and (3) ≥1 acute organ dysfunction criterion. EDPS met inclusion criteria while physically in the emergency department (ED). HPS met the criteria after leaving the ED. MEASUREMENTS: We assessed overall HPS versus EDPS contributions to case prevalence and outcomes, and then compared group differences. Process outcomes included 3-hour bundle compliance and discrete bundle elements (eg, time to antibiotics). The primary patient outcome was hospital mortality. RESULTS: Of 11,182 sepsis hospitalizations, 2,509 (22.4%) were hospital-presenting. HPS contributed 785 (35%) sepsis mortalities. HPS had more frequent heart failure (OR: 1.31, CI: 1.18-1.47), renal failure (OR: 1.62, CI: 1.38-1.91), gastrointestinal source of infection (OR: 1.84, CI: 1.48-2.29), euthermia (OR: 1.45, CI: 1.10-1.92), hypotension (OR: 1.85, CI: 1.65-2.08), or impaired gas exchange (OR: 2.46, CI: 1.43-4.24). HPS were admitted less often from skilled nursing facilities (OR: 0.44, CI: 0.32-0.60), had chronic obstructive pulmonary disease (OR: 0.53, CI: 0.36-0.78), tachypnea (OR: 0.76, CI: 0.58-0.98), or acute kidney injury (OR: 0.82, CI: 0.68-0.97). In a propensity-matched cohort (n = 3,844), HPS patients had less than half the odds of 3-hour bundle compliant care (17.0% vs 30.3%, OR: 0.47, CI: 0.40-0.57) or antibiotics within three hours (66.2% vs 83.8%, OR: 0.38, CI: 0.32-0.44) vs EDPS. HPS was associated with higher mortality (31.2% vs 19.3%, OR: 1.90, CI: 1.64-2.20); 23.3% of this association was attributable to differences in initial resuscitation (resuscitation-adjusted OR: 1.69, CI: 1.43-2.00). CONCLUSIONS: HPS differed from EDPS by admission source, comorbidities, and clinical presentation. These patients received markedly less timely initial resuscitation; this disparity explained a moderate proportion of mortality differences.
BACKGROUND: Differences between hospital-presenting sepsis (HPS) and emergency department-presenting sepsis (EDPS) are not well described. OBJECTIVES: We aimed to (1) quantify the prevalence of HPS versus EDPS cases and outcomes; (2) compare HPS versus EDPS characteristics at presentation; (3) compare HPS versus EDPS in process and patient outcomes; and (4) estimate risk differences in patient outcomes attributable to initial resuscitation disparities. DESIGN: Retrospective consecutive-sample cohort. SETTING: Nine hospitals from October 1, 2014, to March 31, 2016. PATIENTS: All hospitalized patients with sepsis or septic shock, as defined by simultaneous (1) infection, (2) ≥2 Systemic Inflammatory Response Syndrome (SIRS) criteria, and (3) ≥1 acute organ dysfunction criterion. EDPS met inclusion criteria while physically in the emergency department (ED). HPS met the criteria after leaving the ED. MEASUREMENTS: We assessed overall HPS versus EDPS contributions to case prevalence and outcomes, and then compared group differences. Process outcomes included 3-hour bundle compliance and discrete bundle elements (eg, time to antibiotics). The primary patient outcome was hospital mortality. RESULTS: Of 11,182 sepsis hospitalizations, 2,509 (22.4%) were hospital-presenting. HPS contributed 785 (35%) sepsismortalities. HPS had more frequent heart failure (OR: 1.31, CI: 1.18-1.47), renal failure (OR: 1.62, CI: 1.38-1.91), gastrointestinal source of infection (OR: 1.84, CI: 1.48-2.29), euthermia (OR: 1.45, CI: 1.10-1.92), hypotension (OR: 1.85, CI: 1.65-2.08), or impaired gas exchange (OR: 2.46, CI: 1.43-4.24). HPS were admitted less often from skilled nursing facilities (OR: 0.44, CI: 0.32-0.60), had chronic obstructive pulmonary disease (OR: 0.53, CI: 0.36-0.78), tachypnea (OR: 0.76, CI: 0.58-0.98), or acute kidney injury (OR: 0.82, CI: 0.68-0.97). In a propensity-matched cohort (n = 3,844), HPS patients had less than half the odds of 3-hour bundle compliant care (17.0% vs 30.3%, OR: 0.47, CI: 0.40-0.57) or antibiotics within three hours (66.2% vs 83.8%, OR: 0.38, CI: 0.32-0.44) vs EDPS. HPS was associated with higher mortality (31.2% vs 19.3%, OR: 1.90, CI: 1.64-2.20); 23.3% of this association was attributable to differences in initial resuscitation (resuscitation-adjusted OR: 1.69, CI: 1.43-2.00). CONCLUSIONS: HPS differed from EDPS by admission source, comorbidities, and clinical presentation. These patients received markedly less timely initial resuscitation; this disparity explained a moderate proportion of mortality differences.
Authors: Anand Kumar; Daniel Roberts; Kenneth E Wood; Bruce Light; Joseph E Parrillo; Satendra Sharma; Robert Suppes; Daniel Feinstein; Sergio Zanotti; Leo Taiberg; David Gurka; Aseem Kumar; Mary Cheang Journal: Crit Care Med Date: 2006-06 Impact factor: 7.598
Authors: Michele Jonsson Funk; Daniel Westreich; Chris Wiesen; Til Stürmer; M Alan Brookhart; Marie Davidian Journal: Am J Epidemiol Date: 2011-03-08 Impact factor: 4.897
Authors: Martin E Doerfler; John D'Angelo; Diane Jacobsen; Mark P Jarrett; Andrea I Kabcenell; Kevin D Masick; Darlene Parmentier; Karen L Nelson; Lori Stier Journal: Jt Comm J Qual Patient Saf Date: 2015-05
Authors: Mitchell M Levy; Mitchell P Fink; John C Marshall; Edward Abraham; Derek Angus; Deborah Cook; Jonathan Cohen; Steven M Opal; Jean-Louis Vincent; Graham Ramsay Journal: Crit Care Med Date: 2003-04 Impact factor: 7.598
Authors: Vincent Liu; Gabriel J Escobar; John D Greene; Jay Soule; Alan Whippy; Derek C Angus; Theodore J Iwashyna Journal: JAMA Date: 2014-07-02 Impact factor: 56.272
Authors: Mitchell M Levy; Andrew Rhodes; Gary S Phillips; Sean R Townsend; Christa A Schorr; Richard Beale; Tiffany Osborn; Stanley Lemeshow; Jean-Daniel Chiche; Antonio Artigas; R Phillip Dellinger Journal: Crit Care Med Date: 2015-01 Impact factor: 7.598
Authors: Russell R Miller; Li Dong; Nancy C Nelson; Samuel M Brown; Kathryn G Kuttler; Daniel R Probst; Todd L Allen; Terry P Clemmer Journal: Am J Respir Crit Care Med Date: 2013-07-01 Impact factor: 21.405
Authors: Christopher W Seymour; Colin R Cooke; Susan R Heckbert; John A Spertus; Clifton W Callaway; Christian Martin-Gill; Donald M Yealy; Thomas D Rea; Derek C Angus Journal: Crit Care Date: 2014-09-27 Impact factor: 9.097
Authors: Jennifer C Ginestra; Rachel Kohn; Rebecca A Hubbard; Andrew Crane-Droesch; Scott D Halpern; Meeta Prasad Kerlin; Gary E Weissman Journal: Ann Am Thorac Soc Date: 2022-09
Authors: Timothy G Buchman; Steven Q Simpson; Kimberly L Sciarretta; Kristen P Finne; Nicole Sowers; Michael Collier; Saurabh Chavan; Ibijoke Oke; Meghan E Pennini; Aathira Santhosh; Marie Wax; Robyn Woodbury; Steve Chu; Tyler G Merkeley; Gary L Disbrow; Rick A Bright; Thomas E MaCurdy; Jeffrey A Kelman Journal: Crit Care Med Date: 2020-03 Impact factor: 7.598
Authors: Timothy G Buchman; Steven Q Simpson; Kimberly L Sciarretta; Kristen P Finne; Nicole Sowers; Michael Collier; Saurabh Chavan; Ibijoke Oke; Meghan E Pennini; Aathira Santhosh; Marie Wax; Robyn Woodbury; Steve Chu; Tyler G Merkeley; Gary L Disbrow; Rick A Bright; Thomas E MaCurdy; Jeffrey A Kelman Journal: Crit Care Med Date: 2020-03 Impact factor: 7.598