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Sepsis Care Improved in the ED

Author Information (click to view)

Rahul K. Khare, MD, MS FACEP

Assistant Director of Operations
Assistant Professor, Department of Emergency Medicine
Institute for Healthcare Studies
Northwestern University Feinberg School of Medicine
Northwestern Memorial Hospital

Rahul K. Khare, MD, MS FACEP, has indicated to Physician’s Weekly that he has received grants/research aid from the AHRQ (K08 HS019005). 

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Rahul K. Khare, MD, MS FACEP (click to view)

Rahul K. Khare, MD, MS FACEP

Assistant Director of Operations
Assistant Professor, Department of Emergency Medicine
Institute for Healthcare Studies
Northwestern University Feinberg School of Medicine
Northwestern Memorial Hospital

Rahul K. Khare, MD, MS FACEP, has indicated to Physician’s Weekly that he has received grants/research aid from the AHRQ (K08 HS019005). 

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Patients who present with sepsis are either admitted through the ED or directly to the hospital. Because of the time sensitivity of treating this condition, how patients are admitted can have a significant impact on outcomes.
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Sepsis is a life-threatening condition that requires immediate medical attention. The condition occurs when the body’s overwhelming immune response to infection triggers widespread inflammation that drops blood pressure and may lead to shock. Each year, about 750,000 people in the United States get sepsis, and it’s increasingly affecting the elderly population. When patients receive appropriate care in a timely fashion, the death rate associated with sepsis decreases substantially. However, if these patients go into shock, as many as 50% will die from it.

Patients can present with sepsis in many ways and are either admitted through the ED or directly admitted to the hospital. While early aggressive resuscitation in patients with severe sepsis can decrease mortality, this requires extensive time and resources (see also, Procalcitonin: A Biomarker for Early Sepsis Intervention). In the February 2011 American Journal of Emergency Medicine, Emilie Powell, MD, MBA, my colleagues, and I had a study published in which we analyzed if patients with sepsis admitted through the ED have lower inpatient mortality than those admitted directly to the hospital .

Comparing Inpatient Mortality for Sepsis

In our analysis, we analyzed 2008 data from the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample from the AHRQ. The cross-sectional analysis examined hospitalizations with a principal diagnosis of sepsis in institutions with an annual minimum of 25 ED and 25 direct admissions for sepsis. The study controlled for patient and hospital characteristics. We also assessed the likelihood of early inpatient mortality—defined as within 2 days of the admission—and overall inpatient mortality. Nearly 100,000 hospitalizations with a principal diagnosis of sepsis were examined from 290 hospitals.

Because of the time sensitivity of treating sepsis, how these patients are admitted for treatment can have an impact on outcomes.

Our study found that 80,301 of all sepsis hospitalizations assessed were admitted through the ED, and 18,595 were directly admitted to the hospital. The overall sepsis inpatient mortality was 17.1% for ED admissions, compared with 19.7% for direct admissions. Overall early sepsis mortality was 6.9%, but favored ED admissions (6.8%) over direct admissions (7.4%). The better mortality rates observed in ED admissions occurred even though these patients:

Had a greater proportion of comorbid conditions.
Were more likely to have Medicaid or be uninsured.
Were more likely to be admitted to urban, large bed-size, or teaching hospitals.

Overall, patients who were admitted through the ED were 17% less likely to die from sepsis and 8% less likely to die within 2 days of admission from sepsis when compared with direct admissions to the hospital. The lower mortality rate could be due to EDs being more aggressive in early sepsis resuscitation, having an infrastructure to deal with time-sensitive diseases such as sepsis, and having readily available antibiotics for immediate treatment of the infection (see also, A Quality Improvement Strategy to Reduce Infection Rates). The combination of these elements is crucial for providing recommended treatments to patients with sepsis.

Suspected Sepsis Should Go to the ED

An important point to stress from our study is the valuable role that the often-overcrowded ED plays in providing sepsis care and early resuscitation. Because of the time sensitivity of treating sepsis, how these patients are admitted for treatment can have an impact on outcomes. Given the more favorable mortality rates we observed in the ED, patients who are suspected of having sepsis should be directed to go to the ED for treatment first instead of being admitted to a hospital floor. Any delays to the best available treatment could result catastrophically for these patients.

Readings & Resources (click to view)

Powell ES, Khare RK, Courtney MD, Feinglass J. Lower mortality in sepsis patients admitted through the ED vs direct admission. Am J Emerg Med. 2011 Feb 26 [Epub ahead of print]. Available at: http://www.sciencedirect.com/science/article/pii/S0735675711000209.

Puskarich MA, Trzeciak S, Shapiro NI, et al; on behalf of the Emergency Medicine Shock Research Network (EMSHOCKNET). Outcomes of patients undergoing early sepsis resuscitation for cryptic shock compared with overt shock. Resuscitation. 2011;821289-1293.

Stoneking L, Denninghoff K, Deluca L, et al. Sepsis bundles and compliance with clinical guidelines. J Intensive Care Med. 2011;26:172-182.

Jones AE, Troyer JL, Kline JA. Cost-effectiveness of an emergency department-based early sepsis resuscitation protocol. Crit Care Med. 2011;39:1306-1312.

Winterbottom F, Seoane L, Sundell E, et al. Improving sepsis outcomes for acutely ill adults using interdisciplinary order sets. Clin Nurse Spec. 2011;25:180-185.

1 Comment

  1. First, no one with sepsis should be admitted to a floor. The ICU is the only rational option. Granted an ICU in a small local hospital is not ideal as resources and skill levels may be wanting. Second, PLEASE admit me to a teaching hospital, where the latest medical advances will be employed in my care – just please don’t turn me over to the intern or the first year!! I want a practioner who has some mileage under his or her scrubs. I know that ex-ICU nurses, like me, rank just behind surgeons on the worst patient list, but that’s life – and death.
    I think the reason the poor and uninsured end up in the teaching hospitals in greater numbers is the location of the hospitals and this population’s lack of contact with primary care practioners. For better or worse, this population tends to use the ED for primary care, which has been the case since I worked in the ED in the ’70s. I guess in this case, it works to their benefit.

    Reply

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