Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA.
UCLA Division of General Internal Medicine, Los Angeles, CA, USA.
J Gen Intern Med. 2020 Apr;35(4):1153-1160. doi: 10.1007/s11606-020-05653-0. Epub 2020 Feb 10.
Sepsis is the leading cause of in-hospital death. The SEP-1 sepsis bundle is a protocol for early sepsis care that requires providers to diagnose and treat sepsis quickly. Limited evidence suggests that adherence to the sepsis bundle is lower in cases of hospital-onset sepsis.
To compare sepsis bundle adherence in hospital-onset vs. community-onset sepsis.
Retrospective cohort study using multivariable analysis of clinical data.
A total of 4658 inpatients age 18 or older were identified by diagnosis codes consistent with sepsis or disseminated infection.
Four university hospitals in California between 2014 and 2016.
The primary outcome was adherence to key components of the sepsis bundle defined by the Centers for Medicare and Medicaid Services in their core measure, SEP-1. Covariates included clinical characteristics related to the patient, infection, and pathogen.
Compared with community-onset, cases of hospital-onset sepsis were less likely to receive SEP-1 adherent care (relative risk 0.33, 95% confidence interval 0.29-0.38, p < 0.001). With the exception of vasopressors (RR 1.11, p = 0.002), each component of SEP-1 evaluated-blood cultures (RR 0.76, p < 0.001), serum lactate (RR 0.51, p < 0001), broad-spectrum antibiotics (RR 0.62, p < 0.001), intravenous fluids (0.47, p < 0.001), and follow-up lactate (RR 0.71, p < 0.001)-was less likely to be performed within the recommended time frame in hospital-onset sepsis. Within the hospital, cases of hospital-onset sepsis arising on the ward were less likely to receive SEP-1-adherent care than were cases arising in the intensive care unit (RR 0.68, p = 0.004).
Inpatients with hospital-onset sepsis receive different management than individuals with community-onset sepsis. It remains to be determined whether system-level factors, provider-level factors, or factors related to measurement explain the observed variation in care or whether variation in care affects outcomes.
脓毒症是院内死亡的主要原因。SEP-1 脓毒症护理包是一种早期脓毒症护理的方案，要求医护人员快速诊断和治疗脓毒症。有限的证据表明，在医院获得性脓毒症中，对脓毒症护理包的依从性较低。
比较医院获得性与社区获得性脓毒症护理包的依从性。
使用临床数据的多变量分析进行回顾性队列研究。
通过与脓毒症或播散性感染一致的诊断代码，共确定了 4658 名年龄在 18 岁或以上的住院患者。
加利福尼亚州的四家大学医院，时间为 2014 年至 2016 年。
主要结局是根据医疗保险和医疗补助服务中心在其核心指标 SEP-1 中定义的脓毒症护理包的关键组成部分的依从性。协变量包括与患者、感染和病原体相关的临床特征。
与社区获得性相比，医院获得性脓毒症患者接受 SEP-1 依从性护理的可能性较小（相对风险 0.33，95%置信区间 0.29-0.38，p<0.001）。除了血管加压素（RR 1.11，p=0.002）外，SEP-1 评估的每个组成部分——血培养（RR 0.76，p<0.001）、血清乳酸（RR 0.51，p<0.001）、广谱抗生素（RR 0.62，p<0.001）、静脉补液（0.47，p<0.001）和后续乳酸（RR 0.71，p<0.001）——在医院获得性脓毒症中，更不可能在推荐的时间范围内进行。在医院内，与 ICU 中发生的病例相比，病房中发生的医院获得性脓毒症病例接受 SEP-1 依从性护理的可能性较小（RR 0.68，p=0.004）。
与社区获得性脓毒症患者相比，医院获得性脓毒症患者接受的治疗不同。仍需确定是系统层面的因素、提供者层面的因素还是与测量相关的因素解释了护理方面的观察到的差异，还是护理方面的差异影响了结果。
