Sepsis Presenting in Hospitals versus Emergency Departments: Demographic, Resuscitation, and Outcome Patterns in a Multicenter Retrospective Cohort
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.
© 2019 Society of Hospital Medicine
Sepsis is both the most expensive condition treated and the most common cause of death in hospitals in the United States.1-3 Most sepsis patients (as many as 80% to 90%) meet sepsis criteria on hospital arrival, but mortality and costs are higher when meeting criteria after admission.3-6 Mechanisms of this increased mortality for these distinct populations are not well explored. Patients who present septic in the emergency department (ED) and patients who present as inpatients likely present very different challenges for recognition, treatment, and monitoring.7 Yet, how these groups differ by demographic and clinical characteristics, the etiology and severity of infection, and patterns of resuscitation care are not well described. Literature on sepsis epidemiology on hospital wards is particularly limited.8
This knowledge gap is important. If hospital-presenting sepsis (HPS) contributes disproportionately to disease burdCHFens, it reflects a high-yield population deserving the focus of quality improvement (QI) initiatives. If specific causes of disparities were identified—eg, poor initial resuscitation— they could be specifically targeted for correction. Given that current treatment guidelines are uniform for the two populations,9,10 characterizing phenotypic differences could also have implications for both diagnostic and therapeutic recommendations, particularly if the groups display substantially differing clinical presentations. Our prior work has not probed these effects specifically, but suggested ED versus inpatient setting at the time of initial sepsis presentation might be an effect modifier for the association between several elements of fluid resuscitation and patient outcomes.11,12
We, therefore, conducted a retrospective analysis to ask four sequential questions: (1) Do patients with HPS, compared with EDPS, contribute adverse outcome out of proportion to case prevalence? (2) At the time of initial presentation, how do HPS patients differ from EDPS patients with respect to demographics, comorbidities, infectious etiologies, clinical presentations, and severity of illness (3) If holding observed baseline factors constant, does the physical location of sepsis presentation inherently increase the risk for treatment delays and mortality? (4) To what extent can differences in the likelihood for timely initial treatment between the ED and inpatient settings explain differences in mortality and patient outcomes?
We hypothesized a priori that HPS would reflect chronically sicker patients whom both received less timely resuscitation and who contributed disproportionately frequent bad outcomes. We expected disparities in timely resuscitation care would explain a large proportion of this difference.
METHODS
We performed a retrospective analysis of the Northwell Sepsis Database, a prospectively captured, multisite, real world, consecutive-sample cohort of all “severe sepsis” and septic shock patients treated at nine tertiary and community hospitals in New York from October 1, 2014, to March 31, 2016. We analyzed all patients from a previously published cohort.11
