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

Abstract

Importance: 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.

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

Design, setting, and participants: 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.

Main outcomes and measures: 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.

Results: 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.

Conclusions and relevance: 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.

Figure 1.. Distribution of Causes of Death

A, Immediate cause of death among all patients (with and without sepsis). B, Underlying cause of death in patients with sepsis. The cohort included 568 patients who died in the hospital or were discharged to hospice, of whom 300 had sepsis at some point during hospitalization. Per Centers for Disease Control and Prevention guidelines, the immediate cause of death was defined as the final disease, injury, or complication causing death, while the underlying cause of death was defined as the disease or injury that initiated the chain of events that led directly or inevitably to death. For patients discharged to hospice, the immediate cause of death was considered to be the disease or injury that triggered the decompensation leading to a shift in goals of care and transition to hospice. Among the patients with sepsis as the immediate cause of death, 100 of 198 deaths (50.5%) were from pneumonia, 38 of 198 (19.2%) from intra-abdominal infections, 25 of 198 (12.6%) from endovascular infections, 19 of 198 (9.6%) from urinary infections, and 11 of 198 (5.6%) from unknown infectious source.

Figure 2.. Distribution of Preventability Ratings for Patients With Sepsis Who Died

The cohort included 300 patients with sepsis at some point during hospitalization who died or were discharged to hospice and not readmitted. Preventability assessments focused only on care received in the hospital and took into account patients’ comorbidities and functional status, severity of illness at sepsis onset, concurrent acute illnesses, goals of care, and quality of care (including any delays or errors in sepsis management). Preventability ratings: 1 indicates definitely preventable; 2, moderately likely to be preventable; 3, potentially preventable under the best circumstances and optimal clinical care; 4, unlikely to be preventable even though some circumstances and clinical care may not have been optimal; 5, moderately likely not to be preventable; and 6, definitely not preventable owing to rapidly fatal illness present on admission and/or goals of care on admission that precluded aggressive care.