Severe Sepsis in Patients Admitted to the General Medical Ward: Organ Dysfunction and Functional Outcomes

1University of Michigan, Ann Arbor, MI
2Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI

Meeting: Hospital Medicine 2012, April 1-4, San Diego, Calif.

Abstract number: 97657

Background:

Severe sepsis, defined as infection causing new organ dysfunction, is the most common non–cardiac reason for ICU admission. Interventions to remedy the dismal outcomes related to severe sepsis have focused primarily in the ICU. However, more than half of patients with severe sepsis initially receive care outside of the ICU, and many never require ICU care. Moreover, severe sepsis is among the most common and costly causes of hospitalization in the US. We sought to describe organ dysfunction and functional outcomes of patients with severe sepsis admitted to the medical ward.

Methods:

We reviewed a random sample of patients initially admitted to the medical ward at a tertiary care center with discharge diagnoses of infection and new organ dysfunction. Three practicing hospitalists abstracted all charts and identified those with severe sepsis, defined as infection directly leading to new organ dysfunction. Patient demographics, co–morbidities, functional status, disposition location, and new organ dysfunction and its etiology were recorded.

Results:

Of 112 eligible patients, 64 (57%) were judged to have severe sepsis. Mean age was 63.2 [pm] 18 (range 21–104); 59% were female, 39% were immunocompromised, and 31% had diabetes. The most common confirmed sites of infection were urinary (50%), pulmonary (30%), and bloodstream (22%). The most common sepsis–induced organ dysfunctions were cardiovascular (66%), renal (64%), and neurologic (55%) (Table 1). Of severe sepsis cases, 47% were documented as such by the treating physician. Of the sample, 22% were transferred to an ICU during the hospitalization, and 27% had persistent organ dysfunction at discharge. While 82% of severe sepsis patients lived at home prior to admission, only 50% (32/64) were discharged home (Table 2). Among previously independent, surviving patients who never went to an ICU, new dependence was common, with 29% (10/25) discharged to a facility. In–hospital mortality was 17%. Reviewers had a kappa of 0.70 for the diagnosis of severe sepsis and 0.86 for discharge location, indicating excellent inter–rater agreement.

Conclusions:

Severe sepsis in hospitalized medical patients is under–recognized by treating physicians but is associated with a high burden of functional disability and persistent organ dysfunction. Patients are frequently discharged to a higher level of care than was required prior to admission regardless of whether they ever received care in an ICU. Novel interventions to improve recognition and management of severe sepsis outside the ICU are urgently needed. Such interventions should be targeted to hospitalists.

Table 1Prevalence of Organ Dysfunction

Organ Dysfunction Prevalence (%) Prevalence (#) Definition1
Cardiovascular 65.6% 42 Systolic BP <90, MAP <70, decrease in systolic BP >40, elevated lactate, requiring pressors >2 hours
Renal 64.0% 41 Creatinine increase >0.5 mg/dL, oliguria
Neurologic 54.7% 35 Acute mental status changes, such as delirium or change in level of consciousness
Pulmonary 29.7% 19 Intubation, BiPAP, supplemental oxygen >6 LPM or 40% face mask, PaO2/FiO2 <300
Hematologic 23.4% 15 INR >1.5 or PTT >60 not on anticoagulation, platelets <100 or 50% of baseline
Ileus 12.5% 8 Decreased bowel motility requiring a change in diet
Hepatic 7.8% 5 Bilirubin >4 mg/dl and >1.5x baseline
Adapted from the 2003 International Consensus Conference on the Definition of Sepsis.

Table 2Pre–Admission and Discharge Locations by Presence of Any ICU Care

Pre–Admission Location No ICU Any ICU Total
Home 82% (41) 86% (12) 83% (53)
Facility 18% (9) 14% (2) 17% (11)
Total 50 14 64
       
Discharge Location No ICU Any ICU Total
Home 52% (26) 43% (6) 50% (32)
Facility 36% (18) 21% (3) 33% (21)
Expired 12% (6) 36% (5) 17% (11)
Total 50 14 64

To cite this abstract:

Odden A, Bonham C, Rohde J, Kuhn L, Chen L, Malani P, Flanders S, Iwashyna T. Severe Sepsis in Patients Admitted to the General Medical Ward: Organ Dysfunction and Functional Outcomes. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97657. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/severe-sepsis-in-patients-admitted-to-the-general-medical-ward-organ-dysfunction-and-functional-outcomes/. Accessed November 13, 2019.

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