Original ContributionLower mortality in sepsis patients admitted through the ED vs direct admission☆,☆☆
Introduction
Sepsis is a broad clinical condition defined by the presence of infection and a systemic inflammatory response and exists along a continuum with severe sepsis and septic shock [1]. It affects more than 750 000 US residents each year and is associated with a mortality rate of up to 50% to 60% once septic shock is present [2], [3].
Specific interventions, including early antibiotics [4], [5] and early goal directed therapy [6], have been shown to reduce mortality in severe sepsis and septic shock. The Institute for Healthcare Improvement and the Surviving Sepsis Campaign advocate an aggressive resuscitation protocol within the first 6 hours of patient presentation [7]. These interventions may be both time and resource intensive, and significant challenges exist to their implementation, including difficulties in diagnosing sepsis and high levels of resources and staff required for appropriate management [8], [9], [10], [11], [12].
Patients suspected of having sepsis present to the hospital and are initially resuscitated in the emergency department (ED) or are admitted directly to the inpatient hospital. It is unclear if the location of initial presentation and sepsis resuscitation impacts mortality. If the location of initial presentation impacts mortality, patients suspected of being critically ill with sepsis should be directed toward this location. We hypothesize that admission through the ED may be associated with lower inpatient mortality rates due to emergency physicians' experience in the diagnosis and treatment of undifferentiated patients and immediate availability of physicians, nurses, and resources to resuscitate septic patients.
The goal of this investigation was to use a large national hospital discharge data set to determine if there was an association between inpatient mortality and route of admission, through the ED or direct admission to the hospital, for patients with a principal diagnosis of sepsis.
Section snippets
Study design
We performed a cross-sectional analysis of the 2008 Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS). The 2008 NIS includes 42 states, representative of approximately 20% of US community hospitals, and is the largest publicly available all-payer inpatient database in the United States. It is provided by the US Agency for Healthcare Research and Quality. Additional detail on the NIS can be found on the Healthcare Cost and Utilization Project Web site (//www.hcup-us.ahrq.gov/
Differences in patient and hospital characteristics
Table 1 displays patient and hospital characteristic differences between patients admitted through the ED vs those admitted directly to the hospital. Fig. 2 demonstrates the range of inpatient overall mortality across all institutions in this sample. There was a significant difference in overall inpatient sepsis mortality by route of admission: 17.1% for patients admitted through the ED and 19.7% for those admitted directly to the hospital (P < .001). A similar unadjusted difference was
Discussion
In this large nationally representative study, we found a 17% lower likelihood of inpatient overall mortality and an 8% lower likelihood of early inpatient mortality for those patients who were admitted through the ED as compared with direct admission to the hospital. Emergency departments face unique challenges in delivering timely resuscitation of critically ill patients, primarily due to rising ED volumes and overcrowded conditions [18]. This study provides support for the valuable role the
References (23)
- et al.
2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference
Crit Care Med
(2003) - et al.
Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: a trend analysis from 1993 to 2003
Crit Care Med
(2007) - et al.
Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care
Crit Care Med
(2001) - et al.
Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock
Crit Care Med
(2006) - et al.
Adequacy of early empiric antibiotic treatment and survival in severe sepsis: experience from the MONARCS trial
Clin Infect Dis
(2004) - et al.
Early goal-directed therapy in the treatment of severe sepsis and septic shock
N Engl J Med
(2001) - et al.
Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008
Intensive Care Med
(2008) - Reade MC, Huang DT, Bell D, Coats TJ, Cross AM, Moran JL, et al. Variability in management of early severe sepsis....
- et al.
Practice and perception—a nationwide survey of therapy habits in sepsis
Crit Care Med
(2008) - et al.
Barriers to implementing protocol-based sepsis resuscitation in the emergency department—results of a national survey
Crit Care Med
(2007)
Implementing early goal-directed therapy in the emergency setting: the challenges and experiences of translating research innovations into clinical reality in academic and community settings
Acad Emerg Med
Cited by (24)
Discharge Against Medical Advice After Hospitalization for Sepsis: Predictors, 30-Day Readmissions, and Outcomes
2023, Journal of Emergency MedicineImpact of multimorbidity and frailty on adverse outcomes among older delayed discharge patients: Implications for healthcare policy
2022, Health PolicyCitation Excerpt :Past works have also discussed the potential impacts associated with the direct readmission compared to the readmission via ED (e.g., reducing ED overcrowding and increasing the delays in initial evaluation) [61]. Accordingly, these two modes of admission could lead to different adverse outcomes [62], supporting the idea of separating these two means of readmissions. We assessed the sensitivity of our results to various configurations of the readmission variable.
Multi-Stakeholder Informed Guidelines for Direct Admission of Children to Hospital
2018, Journal of PediatricsUrgent Care as Intermediary Care: How Inbound and Outbound Transport Can Enhance Care of Community-Based Pediatric Emergencies
2017, Clinical Pediatric Emergency MedicineCitation Excerpt :The potential risk is that children are admitted to a unit requiring a higher level of care than can be provided, or without all necessary diagnostic testing that might be more easily accomplished in an ED. Specific studies examining the safety of direct admissions by comparing outcomes to those transferred through the ED for conditions including pneumonia and sepsis have had variable results.51,52 Such transfers require that the receiving physician have a degree of confidence in the sending team’s assessment.
Pitfalls in the Treatment of Sepsis
2017, Emergency Medicine Clinics of North AmericaIn reply:
2016, Annals of Emergency Medicine
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This work has been presented at the Academy Health Annual Meeting in Boston, MA, in June 2010 and at the ACEP Scientific Assembly in Las Vegas, ND, in September 2010.
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Dr Powell and Dr Khare were supported by National Research Service Award postdoctoral fellowship grants through the Institute for Healthcare Studies at Northwestern University under institutional awards from the Agency for Healthcare Research and Quality (T-32 HS 000078 and F-32 HS 17876-01).