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

Rhee C1,2, Jones TM3, Hamad Y4, Pande A4, Varon J1, O'Brien C5, Anderson DJ3, Warren DK4, Dantes RB6,7, Epstein L7, Klompas M1,2; Centers for Disease Control and Prevention (CDC) Prevention Epicenters Program.

Author information

1: Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
2: Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts.
3: Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina.
4: Department of Medicine, Washington University School of Medicine at St Louis, St Louis, Missouri.
5: Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
6: Division of Hospital Medicine, Emory University School of Medicine, Atlanta, Georgia.
7: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

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.