Sepsis Presenting in Hospitals versus Emergency Departments: Demographic, Resuscitation, and Outcome Patterns in a Multicenter Retrospective Cohort
Sepsis Presenting in Hospitals versus Emergency Departments: Demographic, Resuscitation, and Outcome Patterns in a Multicenter Retrospective Cohort
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DOI：
10.12788/jhm.3188
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发表时间：
2019-06-01
影响因子：
2.6
通讯作者：
Doerfler, Martin E.
中科院分区：
文献类型：
--
作者：
Leisman, Daniel E.;Angel, Catalina;Doerfler, Martin E.
背景技术背景：结果：我们的目的是（1）量化HPS与EDPS病例和结果的患病率;（2）比较HPS与EDPS的表现特征;（3）比较HPS与EDPS的过程和患者结果;设计：回顾性召唤样本队列，地点：2014年10月1日至2016年3月31日，9家医院。所有患有脓毒症或脓毒性休克的住院患者，根据同时（1）感染，（2）≥ 2个全身炎症反应综合征（SIRS）标准和（3）≥ 1个急性器官功能障碍标准定义。EDPS在急诊科（艾德）时符合入选标准。HPS符合标准后离开艾德。MEASUREMENTS：我们评估了整体HPS与EDPS的情况下患病率和结果的贡献，然后比较组间差异。过程结局包括3小时束流依从性和离散束流要素（例如，抗生素使用时间）。结果：在11，182例脓毒症住院患者中，2，509例（22.4%）为住院治疗。HPS导致785例（35%）败血症死亡。HPS组心力衰竭发生率（OR：1.31，CI：1.18-1.47），肾功能衰竭（OR：1.62，CI：1.38-1.91），胃肠道感染源（OR：1.84，CI：1.48-2.29）、体温正常（OR：1.45，CI：1.10-1.92）、低血压（OR：1.85，CI：1.65-2.08）或气体交换受损（OR：2.46，CI：1.43-4.24）。HPS较少从专业护理机构入院（OR：0.44，CI：0.32-0.60），患有慢性阻塞性肺疾病（OR：0.53，CI：0.36-0.78），呼吸急促（OR：0.76，CI：0.58-0.98）或急性肾损伤（OR：0.82，CI：0.68-0.97）。在倾向匹配队列（n = 3，844）中，HPS患者接受3小时集束治疗依从性治疗（17.0% vs 30.3%，OR：0.47，CI：0.40-0.57）或3小时内使用抗生素（66.2% vs 83.8%，OR：0.38，CI：0.32-0.44）的几率低于EDPS的一半。HPS与较高的死亡率相关（31.2% vs 19.3%，OR：1.90，CI：1.64-2.20）; 23.3%的相关性归因于初始复苏的差异（复苏调整OR：1.69，CI：1.43-2.00）。结论：HPS与EDPS在入院来源、合并症和临床表现方面不同。这些患者接受的初始复苏明显不及时;这种差异解释了中等比例的死亡率差异。(C)2019医院医学学会
BACKGROUND: Differences between hospital-presenting sepsis (HPS) and emergency department-presenting sepsis (EDPS) are not well described.OBJECTIVES: We aimed to (1) quantify the prevalence of HPS versus EDPS cases and outcomes; (2) compare HPS versus EDPS characteristics at presentation; (3) compare HPS versus EDPS in process and patient outcomes; and (4) estimate risk differences in patient outcomes attributable to initial resuscitation disparities.DESIGN: Retrospective consecutive-sample cohort.SETTING: Nine hospitals from October 1, 2014, to March 31, 2016.PATIENTS: All hospitalized patients with sepsis or septic shock, as defined by simultaneous (1) infection, (2) >= 2 Systemic Inflammatory Response Syndrome (SIRS) criteria, and (3) = 1 acute organ dysfunction criterion. EDPS met inclusion criteria while physically in the emergency department (ED). HPS met the criteria after leaving the ED.MEASUREMENTS: We assessed overall HPS versus EDPS contributions to case prevalence and outcomes, and then compared group differences. Process outcomes included 3-hour bundle compliance and discrete bundle elements (eg, time to antibiotics). The primary patient outcome was hospital mortality.RESULTS: Of 11,182 sepsis hospitalizations, 2,509 (22.4%) were hospital-presenting. HPS contributed 785 (35%) sepsis mortalities. HPS had more frequent heart failure (OR: 1.31, CI: 1.18-1.47), renal failure (OR: 1.62, CI: 1.38-1.91), gastrointestinal source of infection (OR: 1.84, CI: 1.48-2.29), euthermia (OR: 1.45, CI: 1.10-1.92), hypotension (OR: 1.85, CI: 1.65-2.08), or impaired gas exchange (OR: 2.46, CI: 1.43-4.24). HPS were admitted less often from skilled nursing facilities (OR: 0.44, CI: 0.32-0.60), had chronic obstructive pulmonary disease (OR: 0.53, CI: 0.36-0.78), tachypnea (OR: 0.76, CI: 0.58-0.98), or acute kidney injury (OR: 0.82, CI: 0.68-0.97). In a propensity-matched cohort (n = 3,844), HPS patients had less than half the odds of 3-hour bundle compliant care (17.0% vs 30.3%, OR: 0.47, CI: 0.40-0.57) or antibiotics within three hours (66.2% vs 83.8%, OR: 0.38, CI: 0.32-0.44) vs EDPS. HPS was associated with higher mortality (31.2% vs 19.3%, OR: 1.90, CI: 1.64-2.20); 23.3% of this association was attributable to differences in initial resuscitation (resuscitation-adjusted OR: 1.69, CI: 1.43-2.00).CONCLUSIONS: HPS differed from EDPS by admission source, comorbidities, and clinical presentation. These patients received markedly less timely initial resuscitation; this disparity explained a moderate proportion of mortality differences. (C) 2019 Society of Hospital Medicine