Elsevier

Journal of Critical Care

Volume 30, Issue 1, February 2015, Pages 78-84
Journal of Critical Care

Sepsis / Acute Kidney Injury
Epidemiology and outcomes in patients with severe sepsis admitted to the hospital wards,☆☆

https://doi.org/10.1016/j.jcrc.2014.07.012Get rights and content

Abstract

Purpose

The purpose of this study was to detail the trajectory and outcomes of patients with severe sepsis admitted from the emergency department to a non–intensive care unit (ICU) setting and identify risk factors associated with adverse outcomes.

Material and methods

This was a single-center retrospective cohort study conducted at a tertiary, academic hospital in the United States between 2005 and 2009. The primary outcome was a composite outcome of ICU transfer within 48 hours of admission and/or 28-day mortality.

Results

Of 1853 patients admitted with severe sepsis, 841 (45%) were admitted to a non-ICU setting, the rate increased over time (P < .001), and 12.5% of these patients were transferred to the ICU within 48 hours and/or died within 28 days. In multivariable models, age (P < .001), an oncology diagnosis (P < .001), and illness severity as measured by Acute Physiologic and Chronic Health Evaluation II (P = .04) and high (≥ 4 mmol/L) initial serum lactate levels (P = .005) were associated with the primary outcome.

Conclusions

Patients presenting to the emergency department with severe sepsis were frequently admitted to a non-ICU setting, and the rate increased over time. Of 8 patients admitted to the hospital ward, one was transferred to the ICU within 48 hours and/or died within 28 days of admission. Factors present at admission were identified that were associated with adverse outcomes.

Introduction

Severe sepsis is common, costly, and frequently, life altering [1], [2], [3], [4], [5], [6], [7]. Severe sepsis afflicts as many as 3 000 000 adults in the United States annually and results in an estimated 750 000 deaths [4]. It is estimated that most patients with severe sepsis are admitted through the emergency department (ED) [2], [3], [4]. As a leading cause of morbidity and mortality internationally, epidemiological studies of severe sepsis have focused on those patients admitted to the intensive care unit (ICU) [8], [9], [10].

Because there is a wide spectrum of disease severity at presentation, ranging from single organ dysfunction to multisystem organ dysfunction that results in death, many patients with severe sepsis will be admitted to a non-ICU setting [1], [7]. Although it is known that patients transferred from the hospital ward to the ICU are more likely to die than patients admitted directly to the ICU from the ED [11], and the sepsis population appears to be especially vulnerable [12], [13], little is known about the epidemiology and outcomes of patients admitted to the wards with severe sepsis.

We conducted an observational cohort study to examine the epidemiology of this understudied patient population. We describe the trajectory of care and the frequency of adverse outcomes in severe sepsis cases admitted to the hospital ward at a single center over 5 years. We hypothesized that admission to a non-ICU setting would increase over time and that we could identify clinical factors present at presentation associated with adverse outcomes, including death.

Section snippets

Materials and methods

This retrospective observational cohort study was reviewed by the Institutional Review Board at the University of Pennsylvania. The study was approved with an exemption for obtaining informed consent.

Baseline characteristics for ICU and hospital ward admissions

Of 1853 patients with severe sepsis admitted through the ED, 841 (45.4%; 95% confidence interval [CI], 43.1, 47.7) were admitted to the hospital ward (Fig. 1). As shown in Table 1, compared with patients admitted to an ICU setting, patients admitted to a non-ICU setting were younger (P < .001), less severely ill (P < .001), had fewer comorbidities (P < .001), were more likely to present with a genitourinary (P < .001) or soft tissue source of infection (P = .002), were less likely to present

Discussion

In this retrospective cohort study conducted over 5 years, we found that patients presenting to the hospital through the ED with severe sepsis were frequently admitted to a non-ICU setting, and the rate increased over time. Once admitted to a non-ICU setting, adverse outcomes, defined as transfer to the ICU within 48 hours and/or 28-day mortality, occurred in 1 of 8 patients. Factors associated with adverse outcomes included patient age, oncologic diagnosis, and illness severity upon

References (46)

  • C. Guerra et al.

    Risk factors for dementia after critical illness in elderly medicare beneficiaries

    Crit Care

    (2012)
  • H.E. Wang et al.

    National estimates of severe sepsis in United States emergency departments

    Crit Care Med

    (2007)
  • C. Brun-Buisson et al.

    EPISEPSIS: a reappraisal of the epidemiology and outcome of severe sepsis in French intensive care units

    Intensive Care Med

    (2004)
  • C. Alberti et al.

    Epidemiology of sepsis and infection in ICU patients from an international multicentre cohort study

    Intensive Care Med

    (2002)
  • C. Brun-Buisson et al.

    Incidence, risk factors and outcome of severe sepsis and septic shock in adults: a multicenter prospective study in intensive care units

    JAMA

    (1995)
  • V. Liu et al.

    Adverse outcomes associated with delayed intensive care unit transfers in an integrated healthcare system

    J Hosp Med

    (2012)
  • M.K. Delgado et al.

    Risk factors for unplanned transfer to intensive care within 24 hours of admission from the emergency department in an integrated healthcare system

    J Hosp Med

    (2013)
  • M.E. Mikkelsen et al.

    Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock

    Crit Care Med

    (2009)
  • D.F. Gaieski et al.

    Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department

    Crit Care Med

    (2010)
  • S.A. Whittaker et al.

    Severe sepsis cohorts derived from claims-based strategies appear to be biased toward a more severely ill patient population

    Crit Care Med

    (2013)
  • M.E. Mikkelsen et al.

    The epidemiology of acute respiratory distress syndrome in patients presenting to the emergency department with severe sepsis

    Shock

    (2013)
  • M.M. Levy et al.

    2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference

    Crit Care Med

    (2003)
  • E. Rivers et al.

    Early goal-directed therapy in the treatment of severe sepsis and septic shock

    N Engl J Med

    (2001)
  • Cited by (33)

    • Differential roles of comorbidity burden and functional status in elderly and non-elderly patients with infections in general wards

      2020, Journal of the Formosan Medical Association
      Citation Excerpt :

      The more severe form of the infectious diseases, namely sepsis, is associated with a substantial risk of mortality and morbidity, often requires intensive care management, and draws a lot of research attention.3 However, patients admitted to the general wards with a main diagnosis of infectious diseases may still carry a non-negligible risk of death.4–6 Thus, further investigations into this patient population in terms of epidemiology, clinical features, treatment outcomes and prognostic factors will provide better understanding and management of infectious diseases across the severity spectrum.

    • Helpful Only When Elevated: Initial Serum Lactate in Stable Emergency Department Patients with Sepsis Is Specific, but Not Sensitive for Future Deterioration

      2018, Journal of Emergency Medicine
      Citation Excerpt :

      While many patients with severe sepsis or septic shock will require critical care in the intensive care unit (ICU), some patients are stable enough for management on the wards. However, patients who subsequently deteriorate on the wards and then require ICU admission have worse outcomes than those who are admitted directly to the ICU from the ED (3–5). It is therefore important to identify patients at risk of short-term deterioration at an early stage (6).

    • Clinical predictors of early death from sepsis

      2017, Journal of Critical Care
      Citation Excerpt :

      Univariate testing did not detect significant differences in the rates or rapidity of critical therapeutic interventions among patients experiencing early death; whereas failure to normalize serum lactate (persistent lactate elevation), initial pH, and early blood culture positivity were significant predictors of early death in the univariate analysis. While some of these factors are known to predict in-hospital mortality or increased ICU lengths of stay in sepsis [6,14,15] to our knowledge this is the first study to associate these clinical features with mortality within the first 24 h of presentation of sepsis. These findings may have implications for risk stratification of patients with severe sepsis or septic shock in addition to early identification of those in whom aggressive management may be needed to decrease risk of death or inform alternative goals of care.

    • Pitfalls in the Treatment of Sepsis

      2017, Emergency Medicine Clinics of North America
      Citation Excerpt :

      In the surgical quality literature, unplanned admissions to intensive care are considered a meaningful part of quality metrics due to the interplay between antecedent patient safety/quality issues, ICU admission, and worse outcome.40 It is hypothesized that the causes of the observed worse outcomes include the following: (1) a delay to recognition of the patient’s changing status; (2) decreased availability of equipment and personnel adapted to resuscitation; (3) decreased team experience with resuscitation on the floor; (4) possibly more severe disease trajectories with a falsely reassuring indolent initial course.41–47 Although patient condition, objective data, clinical experience, and hospital system factors may clearly dictate which patients should be admitted to the floor versus an ICU, there are some patients who do not neatly fit into a specific level of care.

    • Evaluation of the systemic inflammatory response syndrome criteria for the diagnosis of sepsis due to maternal bacteremia

      2016, International Journal of Gynecology and Obstetrics
      Citation Excerpt :

      Maternal bacteremia is a serious infection and a well-defined laboratory finding. We recognize that sepsis commonly occurs in the setting of nonbacteremic infections [14]. It is a limitation that our cohort did not include women with nonbacteremic infections.

    View all citing articles on Scopus

    Funding: The study was supported in part by National Institutes of Health, National Heart, Lung and Blood Institute Loan Repayment Program, Bethesda, MD.

    ☆☆

    Disclosures: For each of the above authors, no financial or other potential conflicts of interest exists related to the work. Presented as an abstract, in part, at the Society of Critical Care Medicine Congress in San Diego, CA, in 2011.

    View full text