Sepsis Surveillance at a Rural Critical Access Hospital

Transcription

1 Sepsis Surveillance at a Rural Critical Access Hospital Pacific Northwest Sepsis Conference University of Washington, 3/21/2017 Jonathan Hibbs MD Kittitas Valley Hospital jhibbs@kvhealthcare.org Background >1 million patients a year in the US with sepsis 1 28% US hospital mortality from severe sepsis in Single most expensive hospital diagnosis 3 Surviving sepsis guidelines since Mortality from severe sepsis tends to be lower at hospitals with high guideline compliance 5 Significant refinements to definitions 6 & management guidelines 7 in ) De Backer & Dorman JAMA : ) Angus et al Crit Care Med : ) Pfuntner et al, HCUP Statistical Brief #168, 12/2013 4) Dellinger et al Intensive Care Med 2004; 30: ) Levy et al Intensive Care Med 2014; 40: ) Singer et al JAMA 2016; 315: ) Evans et al Crit Care Med 2017: 45: Sepsis at a Rural Hospital Most data for sepsis publications are derived from academic, tertiary and larger community hospitals Rural patients going directly to larger centers may have higher mortality compared to those who initiate care at a rural hospital 8 Data specific to clinical effectiveness of sepsis management in rural hospitals are hard to to find 9 What is the incidence, severity and outcome of sepsis at our rural hospital? 8) Mohr et al Crit Care Med 2017; 45: ) Canadian Agency for Drugs and Techology, 8/11/2016 Rapid Response Report. 1

2 1,332 Critical Access Hospitals Created in 1997 Balanced Budget Act, in response to 2 decades of rural hospital closures Center for Medicare/Medicaid Services designation Must have 25 or fewer acute care beds > 35 miles from another hospital Average length of stay < 96 hours 24hr, 7-day emergency services Kittitas County 43,000 people (2015 estimate) 2,333 square miles 19 people/square mile (vs 983 for King County) 19% of people living in poverty (vs 13% for WA) 15% 65 years old or older (vs 14% for WA) Kittitas Valley Hospital in Ellensburg (only one) Kittitas Valley Hospital (KVH) 575 employees (approximate) 6 bed Coronary Care unit 13 bed Medical Surgical unit 6 bed Family Birthing Center 24/7 Emergency Department 3 Operating Rooms 2,719 admissions 2

3 Study Inclusion Criteria Physician dx (admit dx, discharge dx, primary or secondary diagnoses) for any sepsis diagnosis 10 Admitted (inpatient or observation) to KVH from 10/1/2015 through 9/30/ ) Appendix A, table 4.01 KVH Admit Status, 10/1/15-9/30/16 2,719 admissions (inpatient & observation) 116 (4.3% of total) had sepsis diagnoses Primary or secondary Using the joint commission diagnostic code list 2,603 patients had no sepsis diagnoses Compared to other admissions, sepsis case-patients were more likely to be Inpatients 90% vs 59%, Risk ratio (RR) = % Confidence Interval (CI) 1.4 to or more years old 44% vs 26% RR=1.7, CI=1.4 to 2.1 Median ages 70 vs 57 11) 3

4 Higher risk of poor outcomes among sepsis case-patients than others Skilled Nursing Facility (SNF) discharge 9.8% vs 5.1% RR=1.9, CI=1.1 to 3.5 Excludes 4 sepsis patients admitted from SNF Transfer to higher level hospitals 13.0% vs 4.6% Risk ratio (RR) = 2.8, CI = 1.7 to 4.6 In hospital longer than 96 hours 19.8% vs 2.9% RR=6.9, CI=4.5 to 10 Hospital deaths 5.17% vs 0.53% RR=9.6, CI=3.8 to 24.6 Age>74 was associated with death, but sepsis & death were associated even within this age group Among 116 sepsis patients: 6 (11.8%) of 51 patients 75 years & older died None of 65 patients younger than 75 died RR indeterminate, Fisher s 2-tailed p 11 =0.006 Among 2,603 other patients: 9 (1.33%) of 675 patients 75 years & older died 5 (0.26%) of 1,928 patients younger than 75 died Risk ratio (RR) = 5.1, CI = 1.7 to 15.3 Among patients 75 years & older, hospital mortality was higher among sepsis patients 11.8% among sepsis patients 1.33% among other patients RR=8.8, CI=3.3 to ) Quick Sequential Organ Failure Assessment (qsofa) Scores SOFA Uses 2 clinical & 4 lab factors (Glascow Coma Scale, Mean Pressure + use of pressors, PaO2/FiO2, bilirubin, platelets & creatinine) Applied to critical care patients over time qsofa Uses 3 clinical factors (respiratory rate>21, systolic blood pressure<100; altered mentation from baseline) Can be applied to Emergency Department or clinic patients Per Sepsis-3 5, QSOFA >2, or SOFA >2, are Clinical operational definitions of sepsis Associated with hospital mortality > 10% 6) M Singer et al JAMA 2016; 315:

5 Only 22 (19.0%) of Physician Diagnosed Sepsis Cases had a QSOFA score of 2 or higher 60 Cases QSOFA score QSOFA>2 was strongly associated with hospital mortality among patients with sepsis diagnoses QSOFA Died Survived Total 2 or 3 4 (15.4%) or 1 2 (2.2%) All 6 (5.2%) RR = 6.9, CI = 1.34 to 35.7 Fisher s 2-tailed p =.022 Among sepsis patients, qsofa>2 was associated with hospital deaths even if only patients older than 74 are analyzed QSOFA Died Survived Total 2 or 3 4 (28.5%) or 1 2 (5.4%) All 6 (11.8%) RR = 5.3, CI = 1.1 to 25.7 Fisher s 2-tailed p =.04 5

6 QSOFA validation in Emergency Department (ED) Settings Elsewhere 12 Multicenter study of 879 patients in EDs 3% hospital mortality for patients with qsofa<2 24% hospital mortality for patients with qsofa>2 Cox proportional hazards model (multivariate) Hazard ratio of ) Freund et al JAMA 2017; 317:301-8 Physician diagnoses of sepsis at a rural hospital 1 in 25 admissions Older & more inpatients compared with other admissions Poor outcomes likelier compared with other admissions Nursing home discharge Transfer Long stays Death QSOFA >2 strongly associated with hospital mortality No higher mortality in our series compared with other sites Association of qsofa with mortality similar to other sites Limitations Small sample size Single chart reviewer Death rate among 16 transfers unknown 3 month mortality unknown Physician diagnosis as a surveillance criterion likely to be problematic 6

7 Acknowledgments Emergency Department staff Medical/Surgical and Critical Care staff Claudia Eattock, RN, QA Specialist Jackie Robinson, Electronic Records Analyst Lori St. Mary, Medical Technologist 7