Original Contribution
Lower mortality in sepsis patients admitted through the ED vs direct admission,☆☆

https://doi.org/10.1016/j.ajem.2011.01.011Get rights and content

Abstract

Purpose

Early aggressive resuscitation in patients with severe sepsis decreases mortality but requires extensive time and resources. This study analyzes if patients with sepsis admitted through the emergency department (ED) have lower inpatient mortality than do patients admitted directly to the hospital.

Procedures

We performed a cross-sectional analysis of hospitalizations with a principal diagnosis of sepsis in institutions with an annual minimum of 25 ED and 25 direct admissions for sepsis, using data from the 2008 Nationwide Inpatient Sample. Analyses were controlled for patient and hospital characteristics and examined the likelihood of either early (2-day postadmission) or overall inpatient mortality.

Findings

Of 98 896 hospitalizations with a principal diagnosis of sepsis, from 290 hospitals, 80,301 were admitted through the ED and 18 595 directly to the hospital. Overall sepsis inpatient mortality was 17.1% for ED admissions and 19.7% for direct admissions (P < .001). Overall early sepsis mortality was 6.9%: 6.8% for ED admissions and 7.4% for direct admissions (P = .005). Emergency department patients had a greater proportion of comorbid conditions, were more likely to have Medicaid or be uninsured (12.5% vs 8.4%; P < .001), and were more likely to be admitted to urban, large bed-size, or teaching hospitals (P < .001). The risk-adjusted odds ratio for overall mortality for ED admissions was 0.83 (95% confidence interval, 0.80-0.87) and 0.92 for early mortality (95% confidence interval, 0.86-0.98), as compared with direct admissions to the hospital.

Conclusion

Admission for sepsis through the ED was associated with lower early and overall inpatient mortality in this large national sample.

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

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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.

    ☆☆

    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).

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