Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals

• Type of Material: Article
• Authors: Chanu Rhee, Brigham and Women's Hospital; Travis M. Jones, Duke University School of Medicine; Yasir Hamad, Washington University School of Medicine in St. Louis; Anupam Pande, Washington University School of Medicine in St. Louis; Jack Varon, Brigham and Women's Hospital; Cara O'Brien, Duke University School of Medicine; Deverick J. Anderson, Duke University School of Medicine; David K. Warren, Washington University School of Medicine in St. Louis; Raymund Dantes, Emory University; Lauren Epstein, Centers for Disease Control and Prevention; Michael Klompas, Brigham and Women's Hospital
• Language: English
• Date: 2019-02-01
• Publisher: JAMA Network
• Publication Version: Final Published Version
• Copyright Statement: 2019 Rhee C et al. JAMA Network Open.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1001/jamanetworkopen.2018.7571
• Title of Journal or Parent Work: JAMA Network Open
• ISSN: 2574-3805
• Volume: 2
• Issue: 2
• Start Page: e187571
• End Page: e187571
• Grant/Funding Information: This work was funded by grant U54CK000484 from the Prevention Epicenters Program of the CDC.; Dr Rhee received support from grant K08HS025008 from the Agency for Healthcare Research and Quality.
• Keywords: prevention; acute care research; cause of death; hospital; comorbidity; sepsis mortality; medical records
• Research Categories: Health Sciences, Medicine and Surgery; Health Sciences, Public Health; Health Sciences, Health Care Management

Abstract

Importance: Sepsis is present in many hospitalizations that culminate in death. The contribution of sepsis to these deaths, and the extent to which they are preventable, is unknown. Objective: To estimate the prevalence, underlying causes, and preventability of sepsis-associated mortality in acute care hospitals. Design, Setting, and Participants: Cohort study in which a retrospective medical record review was conducted of 568 randomly selected adults admitted to 6 US academic and community hospitals from January 1, 2014, to December 31, 2015, who died in the hospital or were discharged to hospice and not readmitted. Medical records were reviewed from January 1, 2017, to March 31, 2018. Main Outcomes and Measures: Clinicians reviewed cases for sepsis during hospitalization using Sepsis-3 criteria, hospice-qualifying criteria on admission, immediate and underlying causes of death, and suboptimal sepsis-related care such as inappropriate or delayed antibiotics, inadequate source control, or other medical errors. The preventability of each sepsis-associated death was rated on a 6-point Likert scale. Results: The study cohort included 568 patients (289 [50.9%] men; mean [SD] age, 70.5 [16.1] years) who died in the hospital or were discharged to hospice. Sepsis was present in 300 hospitalizations (52.8%; 95% CI, 48.6%-57.0%) and was the immediate cause of death in 198 cases (34.9%; 95% CI, 30.9%-38.9%). The next most common immediate causes of death were progressive cancer (92 [16.2%]) and heart failure (39 [6.9%]). The most common underlying causes of death in patients with sepsis were solid cancer (63 of 300 [21.0%]), chronic heart disease (46 of 300 [15.3%]), hematologic cancer (31 of 300 [10.3%]), dementia (29 of 300 [9.7%]), and chronic lung disease (27 of 300 [9.0%]). Hospice-qualifying conditions were present on admission in 121 of 300 sepsis-associated deaths (40.3%; 95% CI 34.7%-46.1%), most commonly end-stage cancer. Suboptimal care, most commonly delays in antibiotics, was identified in 68 of 300 sepsis-associated deaths (22.7%). However, only 11 sepsis-associated deaths (3.7%) were judged definitely or moderately likely preventable; another 25 sepsis-associated deaths (8.3%) were considered possibly preventable. Conclusions and Relevance: In this cohort from 6 US hospitals, sepsis was the most common immediate cause of death. However, most underlying causes of death were related to severe chronic comorbidities and most sepsis-associated deaths were unlikely to be preventable through better hospital-based care. Further innovations in the prevention and care of underlying conditions may be necessary before a major reduction in sepsis-associated deaths can be achieved.