{"id":17043,"date":"2019-04-29T05:07:03","date_gmt":"2019-04-28T21:07:03","guid":{"rendered":"http:\/\/csccm.org.cn\/?p=17043"},"modified":"2019-06-02T06:40:09","modified_gmt":"2019-06-01T22:40:09","slug":"medscape-%e5%85%a8%e8%ba%ab%e6%80%a7%e6%84%9f%e6%9f%93%e7%9b%b8%e5%85%b3%e6%ad%bb%e4%ba%a1%e6%98%af%e5%90%a6%e5%8f%af%e4%bb%a5%e9%a2%84%e9%98%b2%ef%bc%9f","status":"publish","type":"post","link":"https:\/\/csccm.org.cn\/?p=17043","title":{"rendered":"[MEDSCAPE]: \u5168\u8eab\u6027\u611f\u67d3\u76f8\u5173\u6b7b\u4ea1\u662f\u5426\u53ef\u4ee5\u9884\u9632\uff1f"},"content":{"rendered":"\n

Is Sepsis-Associated Mortality Often Preventable?<\/h1>\n\n\n\n

Authors:\u00a0News Author: Veronica Hackethal, MD<\/h3>\n\n\n\n

CME Author: Charles P. Vega, MD<\/h3>\n\n\n\n

Clinical Context<\/h2>\n\n\n\n

Approximately 1.7 million US adults are diagnosed annually with sepsis, and sepsis can contribute to more than a quarter of a million deaths among US residents per year. The authors of the current study acknowledged multiple programs to improve the care and outcomes of patients with sepsis; one of the best known of these programs is the Surviving Sepsis Campaign.<\/p>\n\n\n\n

Rhodes and colleagues performed an analysis of the International Multicenter Prevalence Study on Sepsis (IMPreSS) to determine whether adherence to the 3-hour and 6-hour bundle recommendations from the Surviving Sepsis Campaign had an effect on mortality outcomes on a global scale. Their results were published in the September 2015 issue of Intensive Care Medicine<\/em>.[1]<\/a><\/sup><\/p>\n\n\n\n

Overall adherence to the 3-hour bundle was poor: Just 19% of healthcare centers complied. In-hospital mortality rates for sepsis in centers with adherence vs no adherence to the 3-hour bundle were 20% and 31%, respectively. The respective mortality rates according to adherence to the 6-hour bundle were 22% and 32%. The adjusted odds ratios for mortality associated with adherence to the 3-hour and 6-hour bundles were 0.64 (95% CI: 0.47, 0.87) and 0.71 (95% CI: 0.56, 0.90).<\/p>\n\n\n\n

How many deaths because of sepsis are preventable with good care practices in the United States? The current study by Rhee and colleagues sought an answer to that question.<\/p>\n\n\n\n

Study Synopsis and Perspective<\/h2>\n\n\n\n

Sepsis remains one of the leading causes of hospital deaths in the United States, but there may not be much clinicians can do to prevent them, a study has found.<\/p>\n\n\n\n

The findings were published February 1, 2019, in JAMA Network Open<\/em>.[2]<\/a><\/sup><\/p>\n\n\n\n

The study found that 88% of sepsis deaths were not preventable.<\/p>\n\n\n\n

\"Although the burden of sepsis-associated mortality is high, our study indicates that most of these deaths may not be preventable through better hospital-based care,\" Chanu Rhee, MD, MPH, of Harvard Medical School, Boston, Massachusetts, and colleagues wrote.<\/p>\n\n\n\n

That is because many of the patients who died from sepsis had other serious medical problems, such as cancer or dementia, that may have contributed to their deaths.<\/p>\n\n\n\n

\"Our findings do not diminish the importance of trying to prevent as many sepsis-associated deaths as possible, but rather underscore that most fatalities occur in medically complex patients with severe comorbid conditions,\" the researchers continued.<\/p>\n\n\n\n

More progress is needed in treating the underlying cause of death before further gains can be made in reducing sepsis-related deaths, they added.<\/p>\n\n\n\n

Approximately 1.7 million people in the United States develop sepsis each year, and the problem contributes to more than 250,000 deaths, the authors explained. To improve the situation, sepsis care quality improvement initiatives have sprung up around the country, some of which have reported a decrease in sepsis deaths after mandating a sepsis protocol or a sepsis care bundle.<\/p>\n\n\n\n

Yet frail individuals such as the elderly and persons with serious underlying conditions are among the most vulnerable to sepsis and may be at risk for death even if they receive the best care. This raises the question: How preventable is sepsis?<\/p>\n\n\n\n

The researchers conducted a medical record review of 568 randomly selected adults who died during hospitalization at one of 6 academic and community hospitals in the United States or were discharged to hospice care. Of these, 50.9% were men with a mean age of 70.5\u00b116.1 years.<\/p>\n\n\n\n

Two trained reviewers judged cases for overall preventability of sepsis death and suboptimal sepsis care, such as delays in starting antibiotics and other medical errors.<\/p>\n\n\n\n

More than half (52.8% [95% CI: 48.6%, 57%]) of hospital deaths in this study involved sepsis, and sepsis represented the most common immediate cause of death, accounting for 198 (34.9% [95% CI: 30.9%, 38.9%]) of cases.<\/p>\n\n\n\n

Severe illness accounted for most underlying causes of death. The most common of these included cancer, chronic heart disease, dementia, and lung disease.<\/p>\n\n\n\n

On admission, 300 (40.3% [95% CI: 34.7%, 46.1%]) individuals had hospice-qualifying conditions, most commonly terminal cancer.<\/p>\n\n\n\n

Overall, reviewers judged 264 of 300 deaths from sepsis (88% [95% CI: 83.8%, 91.5%]) as unpreventable. They deemed only 8.3% (n=25) as possibly preventable and just 1.3% as definitely preventable.<\/p>\n\n\n\n

Furthermore, only 22.7% (n=68) of sepsis deaths involved suboptimal care, usually delays in antibiotics.<\/p>\n\n\n\n

In a linked editorial,[3]<\/a><\/sup> Laura Evans, MD, MSc, New York University School of Medicine, New York, New York, wrote that the results should be interpreted with caution.<\/p>\n\n\n\n

According to Dr Evans, the reviewers reached only limited agreement in their judgments, and the rate of suboptimal sepsis care in this study was much lower than in other studies. That suggests better sepsis care in the hospitals in this study than other hospitals in the country; therefore, there may not have been much more room for improvement. If so, the results may underestimate the number of preventable sepsis deaths through improved care.<\/p>\n\n\n\n

Nevertheless, Dr Evans continues, \"this study does reflect the reality that, with currently available tools for recognition and management of sepsis, some sepsis-associated deaths are not preventable.\"<\/p>\n\n\n\n

The findings should serve as a \"call to action,\" for sepsis research to help improve early recognition and management of sepsis, she added.<\/p>\n\n\n\n

\"The need for improved rapid diagnostics that can be used to trigger time-sensitive interventions that can be applied across different resource settings is urgent to reduce sepsis-associated deaths to their lowest possible levels,\" Dr Evans concluded.<\/p>\n\n\n\n

The study was funded by the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ). One or more authors reported royalties, personal fees, grants, and\/or other funding from one or more of the following: Carefusion\/BD; PDI Inc.; and Pursuit Vascular Inc.. A complete list is available on the journal's website. Dr Evans reported serving on the steering committee of the Surviving Sepsis Campaign and as co-chair of the Surviving Sepsis Campaign Guidelines<\/em>.<\/p>\n\n\n\n

Study Highlights<\/h2>\n\n\n\n
  • Study patients were admitted between 2014 and 2015 at one of 3 prominent US academic health centers plus 3 of these centers\u2019 regional partner hospitals. Patients enrolled in hospice before hospital admission were excluded from analysis.<\/li>
  • 100 patients at each site who died in the hospital or emergency department were randomly selected for a full chart review. Researchers were interested in the immediate and underlying causes of death, with a focus on sepsis as defined by an infection with an increase in the Sequential Organ Failure Assessment Score by \u22652 points from baseline.<\/li>
  • Researchers were trained to identify suboptimal practices in the care of sepsis; 2 reviewers then judged how preventable death related to sepsis was by using a 6-point Likert scale. Each sepsis case was judged by 2 reviewers, and interrater reliability was measured.<\/li>
  • A total of 568 patients were ultimately included in the study analysis. The mean age of patients at the time of death was 70.5\u00b116.1 years, and almost half were female; 69.5% of patients died in the hospital, and 30.5% were discharged to hospice.<\/li>
  • Sepsis was present in 52.8% of cases overall, and most cases of sepsis were diagnosed on admission vs hospital-acquired. There was no predilection for sepsis according to age, sex, race\/ethnicity, type of admission, and most types of chronic illness; however, solid cancers were less common in cases of sepsis.<\/li>
  • Sepsis was the immediate cause of death in 34.9% of cases, and it contributed to death in another 43.1% of cases. <\/li>
  • The most common source of sepsis was pneumonia, accounting for >50% of cases.<\/li>
  • 88% of deaths because of sepsis were considered unpreventable. Only 3.7% of sepsis deaths were considered definitely or moderately likely preventable; 8.3% of deaths were classified as possibly preventable. <\/li>
  • 22.7% of cases of sepsis had evidence of suboptimal care. The most common types of suboptimal care were a delay in antibiotics (48.5% of all suboptimal care); delay in source control (27.9%); and inappropriate choice for initial antibiotics (23.5%).<\/li>
  • The first set of preventability ratings had poor interrater concordance, but retraining and reevaluation of the data helped improve this statistic.<\/li>
  • Preventability ratings were generally similar in comparing academic and community hospitals.<\/li><\/ul>\n\n\n\n

    Clinical Implications<\/h2>\n\n\n\n
    • A previous study by Rhodes et al found significant mortality benefits associated with adherence to the 3-hour and 6-hour recommendation bundles from the Surviving Sepsis Campaign.<\/li>
    • In the current study of cases ending in death or referral to hospice, sepsis was present in more than half of the patient cohort. Pneumonia was the most common source of sepsis. Less than 5% of cases of death because of sepsis were considered definitely or probably preventable.<\/li>
    • Implications for the Healthcare Team: The healthcare team should adhere to best practices in the care of patients with sepsis, but they should also be invested in the prevention or mitigation of severe chronic illnesses that make sepsis highly deadly.<\/li><\/ul>\n","protected":false},"excerpt":{"rendered":"

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