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'Stunning' Number of Sepsis Cases Among Patients Who Die in Hospitals

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   May 19, 2014

Researchers find that as many as one in every two patients who die while hospitalized have sepsis. Many, the report says, come to the hospital with mild or early-stage cases, which go under-recognized.

As many as one in two or one in three patients who die while hospitalized have sepsis, according to a report by researchers at Kaiser Permanente Northern California and others.

Most of those who died were septic at admission but not severely ill, so treatment may have been delayed.

The report looked at records from seven million non-obstetric patients hospitalized between 2010 and 2012, most of which were obtained from the Nationwide Inpatient Sample (NIS) of 1,051 hospitals, and the rest from 21 Kaiser Permanente hospitals in Northern California.

"That a substantial fraction of all patients who die in the hospital is as high as one in every two patients seems fairly substantial, and even a stunning number," says Vincent Liu, MD, a research scientist at Kaiser Permanente Northern California Division of Research and the principal author of the report.

He says the finding points to an under-recognition of patients who come to the hospital with less severe or early-stage cases of sepsis, and says the finding should make clinicians appreciate even more the importance of early recognition of sepsis.

Liu's study captured patients whose clinicians specifically coded their diagnosis as sepsis, and patients whose codes indicated both infection and acute organ failure thus qualifying as having sepsis, but who may not have been explicitly coded as having sepsis.

"When we use the broad category of sepsis, which include infections of all different kinds, whether pneumonia, urinary tract infections, skin infections, bowel infections—when we put them all under the umbrella of sepsis, which is a syndrome, it turns out there's a lot of unrecognized patients whose treatments could probably be improved, and those tend to be the patients (who initially enter the hospital) with less severe disease," Liu said.

The report, published as a research letter in the JAMA, was released on Sunday to coincide with Liu's presentation of it at the American Thoracic Society annual meeting in San Diego.

For hospital leadership, Liu says, the finding may raise awareness in the emergency department to look for sepsis and launching evidence-based protocols when appropriate.

Preventing hospital sepsis deaths might also affect 30-day mortality rates, which influences incentive payments under Medicare's value-based purchasing program. Higher rates of death among hospital patients within 30 days of discharge, whether they are back in the hospital or have been discharged to another setting, represent 20% of a hospital's value-based purchasing score.

A JAMA media release states that the impact on hospital death rates from sepsis has never been clearly measured before. In some studies of the sickest types of septic patients, those with septic shock, the death rate has been characterized at between 18% and 21%.

"It's likely that reductions in hospital mortality will also translate into reductions in 30-day mortality rates, in general," Liu says. In general, however, most of the patients who die from acute sepsis will die in the hospital, although some may have been discharged to other settings at the time of death. This study only measured in-hospital mortality as opposed to 30-day or 60-day mortality.

Liu says that the gravity of high mortality in sepsis should prompt both clinicians who treat patients as well as the public to pay more attention to patients when they begin to exhibit symptoms, such as fever and confusion, much like they would symptoms of heart attack or stroke.

"There's been a lot of attention and publicity surrounding other conditions like myocardial infarction, heart attacks, strokes, in which the public has been made aware of the need to get to the hospital quickly and to get the most appropriate care," Liu says.

In this study, the range of death rates from sepsis among the 21 Kaiser Permanente hospitals was slightly higher than those from the NIS sample, which Liu says is attributable to the more aggressive search at Kaiser for cases meeting the definition.

In the Kaiser sample of 14,206 inpatient deaths, between 36.9% (an explicit diagnosis of sepsis) and 55.9% (an implicit diagnosis of sepsis) died of sepsis. Of the 143,312 deaths culled from the NIS records, the range was 34.7% to 52%.

"Since 2008, Kaiser Permanente Northern California has been engaged in a large-scale performance improvement project to accelerate the early identification of these patients, and one of the ways that's been done, besides priming clinicians to always be on the alert, is through the use of serum lactate tests," Liu says.

"That's not just for the very sick, "but every time a blood culture is drawn for the remainder of the population, a lactate is also sent. We use those tests as a marker to increase our identification of these patients and risk stratify them."

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