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Study: Sepsis Patients Fare Better in Hospitals With Higher Case Volumes

Early diagnosis and treatment are keys to survival

Patients with sepsis — one of the most time-sensitive and hard-to-detect illnesses in medicine — are more likely to survive the life-threatening condition when treated at a hospital that sees a higher volume of sepsis cases.

New research at the University of Pennsylvania’s Perelman School of Medicine has shown a clear relationship between hospitals that treat the most cases of severe sepsis and lower rates of inpatient deaths among those patients.

The findings were published online in the American Journal of Respiratory and Critical Care Medicine.

“One of the main barriers to treatment of sepsis is recognizing its early stages, since the symptoms are nonspecific and often similar to those of a viral infection. However, early diagnoses and treatment are key to surviving sepsis, and it may be that physicians at hospitals that see a larger volume of patients with severe sepsis are more attuned to these nonspecific symptoms and have put protocols in place to aid in the detection of these critically ill patients,” said lead investigator David F. Gaieski, MD. “Our results provide preliminary support for the idea that severe sepsis patients may benefit from treatment at higher-volume specialty centers much the same as the reality that patients who’ve suffered severe injuries are brought to designated trauma centers and those who’ve had strokes typically come to certified stroke centers.”

A bacterial infection anywhere in the body may lead to sepsis, which can then cause the patient’s blood pressure to drop, and major organs and body systems to stop working properly because of poor blood flow. Not only is severe sepsis becoming more common, but the in-hospital mortality rate can be as high as 38% , and the illness has been estimated to cost the U.S. health care system approximately $24 billion annually. The Centers for Disease Control and Prevention (CDC) lists septicemia as the 11th leading cause of death in the U.S.

The new study looked at hospital admissions — examining the relationship between annual case volume, urban location, organ dysfunction, and survival — over a 7-year period (2004 to 2010) among 914,200 patients with severe sepsis, culled from the largest national database of publically available inpatient information.

The study found an inverse relationship between the severe sepsis case volume and inpatient mortality in both urban and rural hospitals. The overall in-hospital mortality rate was 28%, but the study found that patients treated at higher-volume hospitals (those that handled 500 or more cases per year) had a 36% increase in their odds of inpatient survival compared with patients treated at lower-volume hospitals (those that handled fewer than 50 cases per year). Typically, the highest-volume hospitals are academic medical centers, which tend to be located in urban areas.

The new study also examined the association between inpatient severe sepsis mortality and the type of organ dysfunction, finding that the most common organ-system dysfunctions were renal, respiratory, or cardiovascular. In addition, the study found that mortality from severe sepsis increased as the number of organ dysfunctions increased.

Severe sepsis treatment efforts in the emergency department of the Hospital of the University of Pennsylvania (HUP) have focused on the early measurement of serum lactate — which can help indicate whether enough oxygen is being delivered to tissues in the body — as a marker of impending shock. The results are then used to identify potentially critically ill patients more quickly and to deliver resuscitation during their first hours in the hospital. Since these new protocols were adopted in 2005, Gaieski says that deaths among severe sepsis patients admitted to HUP through the emergency department dropped from 24% in 2005 to 11% in 2009.

“The real question here is: can we take the critical next step of disseminating best practices from high-performing centers to the rest of the health care system?” asks senior author Brendan Carr, MD, MS. “We need large-scale strategies that ensure the best possible outcome for critically ill patients no matter where they are when they get sick. We’ve built good systems for a few conditions that require early aggressive diagnostics and intervention — like trauma and stroke — but our response to the unplanned critically ill patient requires us to cooperate across public health, public safety, and most importantly, competing health care systems.”

Source: Penn Medicine; September 3, 2014.

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