Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals
Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals
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DOI：
10.1001/jamanetworkopen.2018.7571
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发表时间：
2019-02-01
影响因子：
13.8
通讯作者：
Klompas, Michael
中科院分区：
文献类型：
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作者：
Rhee, Chanu;Jones, Travis M.;Klompas, Michael
脓毒症是目前在许多住院治疗，最终死亡。脓毒症对这些死亡的贡献，以及它们在多大程度上是可以预防的，是未知的。目的评估急性护理hospitals.DESIGN，SETTING，和参与者脓毒症相关死亡率的患病率，根本原因，和可预防性队列研究，其中回顾性病历审查，随机选择568名成年人从1月1日，2014年至2015年12月31日，在医院死亡或出院至临终关怀，未再次入院。回顾2017年1月1日至2018年3月31日的病历。主要结局和指标临床医生使用脓毒症-3标准、入院时的临终关怀资格标准、直接和潜在死亡原因以及次优脓毒症相关护理（如抗生素使用不当或延迟、源头控制不充分或其他医疗错误）审查住院期间的脓毒症病例。每一个败血症相关死亡的可预防性被评为6点Likert scale.Results研究队列包括568例患者（289 [50.9%]男性，平均[SD]年龄，70.5 [16.1]岁）谁死在医院或出院到临终关怀。300例住院病例中存在脓毒症（52.8%; 95% CI，48.6%-57.0%），198例病例中脓毒症是直接死亡原因（34.9%; 95% CI，30.9%-38.9%）。其次最常见的直接死亡原因是进行性癌症（92 [16.2%]）和心力衰竭（39 [6.9%]）。脓毒症患者最常见的潜在死亡原因是实体癌（63/300 [21.0%]）、慢性心脏病（46/300 [15.3%]）、血液癌（31/300 [10.3%]）、痴呆（29/300 [9.7%]）和慢性肺病（27/300 [9.0%]）。300例败血症相关死亡中有121例在入院时存在医院资格条件（40.3%; 95%CI 34.7%-46.1%），最常见的是终末期癌症。在300例脓毒症相关死亡中，有68例（22.7%）确定了次优护理，最常见的是抗生素延迟。然而，只有11脓毒症相关的死亡（3.7%）被判定肯定或中度可能预防;另外25脓毒症相关的死亡（8.3%）被认为是可能preventable.Conclusions和相关性在这个队列从6美国医院，脓毒症是最常见的直接死亡原因。然而，大多数死亡的根本原因与严重的慢性合并症有关，大多数脓毒症相关死亡不太可能通过更好的医院护理来预防。在实现败血症相关死亡的大幅减少之前，可能需要在预防和护理基础疾病方面进行进一步的创新。
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.