Original Investigation Critical Care Medicine

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

Chanu Rhee, Travis M. Jones, Yasir Hamad, et al

JAMA Netw Open. 2019;2(2):e187571. doi:10.1001/jamanetworkopen.2018.7571

Abstract

Importance 背景

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.

很多住院患者发生全身性感染并最终死亡。全身性感染对死亡的影响及其可预防程度尚未明确。

Objective  目的

To estimate the prevalence, underlying causes, and preventability of sepsis-associated mortality in acute care hospitals.

评价急性病医院中全身性感染相关病死率，基础病因及可预防性。

Design, Setting, and Participants  试验设计、场景及研究对象

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.

我们进行了一项回顾性队列研究，随机挑选了2014年1月1日至2015年12月31日期间6个美国学术及社区医院收治的成年患者，患者在住院期间死亡或转院至临终关怀医院且未再次入院。2017年1月1日至2018年3月31日完成病历检索。

Main Outcomes and Measures 主要预后指标

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.

临床医生回顾住院期间病历，根据sepsis-3标准诊断全身性感染，并确定入院时是否符合临终关怀医院收治标准，死亡的直接与基础病因，不恰当的全身性感染相关治疗（如不适当或延迟抗生素治疗，不充分的感染灶控制，或其他医疗差错）。针对每名全身性感染相关死亡患者，采用6分Likert评分评价其可预防性。

Results 结果

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.

研究队列纳入568名死亡或转至临终关怀医院的患者（289名 [50.9%] 男性；平均 [SD] 年龄，70.5 [16.1] 岁）。300名患者罹患全身性感染 (52.8%; 95% CI, 48.6%-57.0%)，且全身性感染是198名(34.9%; 95% CI, 30.9%-38.9%)患者的直接死因。其后最常见的直接死因依次为进展期肿瘤(92 [16.2%])和心功能衰竭(39 [6.9%])。全身性感染死亡患者最常见的基础病因为实体肿瘤(63/300 [21.0%])，慢性心脏病(46/300 [15.3%])，血液系统肿瘤(31/300 [10.3%])，痴呆(29/300 [9.7%])，及慢性肺病(27/300 [9.0%])。300名全身性感染相关死亡病例中，121名患者(40.3%; 95% CI 34.7%-46.1%)入院时即符合临终关怀医院收治标准，最常见的原因为终末期肿瘤。在300名全身性感染相关死亡患者中，68名患者(22.7%)接受了不适当治疗，以抗生素延迟最为常见。然而，仅有11例全身性感染相关死亡(3.7%)被判定为明确或中度可能得到预防；另有25例全身性感染相关死亡(8.3%)被判定为可能被预防。

Conclusions and Relevance 结论与意义

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.

在6所美国医院的队列研究中，全身性感染是最常见的直接死因。然而，多数死亡的基础病因与严重的慢性合并症相关，多数全身性感染相关死亡可能无法通过更好的医疗服务得以预防。需要在基础疾病的预防及治疗方面进一步创新，才能显著减少全身性感染的相关死亡。