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Sepsis Presenting in Hospitals versus Emergency Departments: Demographic, Resuscitation, and Outcome Patterns in a Multicenter Retrospective Cohort
Author(s) -
Leisman Daniel E,
Angel Catalina,
Schneider Sandra M,
D'Amore Jason A,
D'Angelo John K,
Doerfler Martin E
Publication year - 2019
Publication title -
journal of hospital medicine
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.128
H-Index - 65
eISSN - 1553-5606
pISSN - 1553-5592
DOI - 10.12788/jhm.3188
Subject(s) - medicine , sepsis , emergency department , retrospective cohort study , septic shock , resuscitation , cohort , emergency medicine , cohort study , systemic inflammatory response syndrome , psychiatry
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.