Sepsis Presenting in Hospitals versus Emergency Departments: Demographic, Resuscitation, and Outcome Patterns in a Multicenter Retrospective Cohort

被引:24
作者
Leisman, Daniel E. [1 ,2 ,3 ]
Angel, Catalina [1 ]
Schneider, Sandra M. [2 ,4 ]
D'Amore, Jason A. [2 ]
D'Angelo, John K. [2 ]
Doerfler, Martin E. [5 ,6 ]
机构
[1] Icahn Sch Med Mt Sinai, New York, NY 10029 USA
[2] Hofstra Northwell Sch Med, Dept Emergency Med, Hempstead, NY 11549 USA
[3] Global Sepsis Alliance, Jena, Germany
[4] Amer Coll Emergency Phys, Irving, TX USA
[5] Hofstra Northwell Sch Med, Dept Med, Hempstead, NY USA
[6] Hofstra Northwell Sch Med, Dept Sci Educ, Hempstead, NY USA
关键词
INTERNATIONAL CONSENSUS DEFINITIONS; REDUCED MORTALITY; SURVIVAL; BUNDLE; CARE; IMPLEMENTATION; INITIATION; ADMISSION; THERAPY; MOTION;
D O I
10.12788/jhm.3188
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
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. (C) 2019 Society of Hospital Medicine
引用
收藏
页码:340 / 348
页数:9
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