Discrepency in sepsis care identified between the United States and Europe

^{ICU patients with sepsis and septic shock in Europe were more severely ill and had a higher unadjusted mortality rate than patients in the US.}[tabs tab1=”2MM Rundown” tab2=”Full 2MM Report” tab3=”About the Authors”]

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Image: PD

1.  ICU patients with sepsis and septic shock in Europe were more severely ill and had a higher unadjusted mortality rate than patients in the US.

2.  The significant difference in mortality outcomes disappeared when the data were adjusted for disease severity.

This is the first study to directly compare outcomes between the US and Europe for septic patients.  The results suggest that patients admitted to the ICU in Europe are sicker initially than patients admitted to ICU’s in the US, which likely accounts for the higher unadjusted mortality rate of patients in Europe.  The difference may be due in part to the fact that patients in the US were more often admitted directly to the ICU upon presenting to the ED, while in Europe patients are more readily admitted to the wards first.  This study was not randomized, nor did it track patients who were not admitted to the ICU’s and may have had sepsis.  These are both factors that may have skewed the results.  Ultimately, this study has provided insight on the differences of care and outcomes in the US and Europe – further studies will be required to elucidate what changes can be made to optimize all care of this complex disease.

Click to read the study in The Lancet Infectious Diseases

Click to read an accompanying editorial in The Lancet Infectious Diseases

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1.  ICU patients with sepsis and septic shock in Europe were more severely ill and had a higher unadjusted mortality rate than patients in the US.

2.  The significant difference in mortality outcomes disappeared when the data were adjusted for disease severity.

Primer: Sepsis is a systemic condition resulting from infection that is a significant cause of mortality worldwide.  When a patient has 2 systemic inflammatory response syndrome (SIRS) criteria (heart rate above 90, respiratory rate above 20, white blood cell count above 12 or below 4, or temperature above 100.5) and a confirmed or suspected infection of any kind, sepsis is diagnosed.  Treatment of sepsis requires broad spectrum antibiotic therapy, extensive fluid resuscitation to maintain systemic perfusion, and often mechanical ventilation. Patients can progress from sepsis to severe sepsis and septic shock.  These conditions are even more serious and involve multi-organ failure and often death.  The Surviving Sepsis Campaign (SSC) is a global initiative that was launched to optimize management of sepsis around the world.  They have established guidelines on managing sepsis as well as a global database to compare outcomes of compliance, mortality and other factors involved in treating sepsis.  This study examined data from the SSC database and compared compliance and outcomes of sepsis for patients in the US and Europe.

Background reading:

1. Chapter 271. Severe Sepsis and Septic Shock. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012.

2. Comparison of medical admissions to intensive care units in the United States and United Kingdom.

This [prospective cohort] study: analyzed data from 25,375 patients enrolled in the SSC database. Patients included in the study were admitted to the ICU with severe sepsis or septic shock between 2005 and 2010 at participating hospital sites throughout the US and Europe.  Outcomes of interest included hospital mortality, length of stay, and ICU length of stay.  Unadjusted hospital mortality in the US was 28.3%; in Europe it was 41.1% (p < 0.0001), however the difference disappeared once the data was adjusted for disease severity.  In the US, most patients were admitted to the ICU from the emergency department (ED) (65.1%) while in Europe most were admitted to the ICU from the wards (51.5%). Length of stay in the hospital and ICU were longer in Europe.  A higher percentage of patients had multiorgan dysfunction and required mechanical ventilation in Europe than in the US when admitted to the ICU.

In sum: This is the first study to directly compare outcomes between the US and Europe for septic patients.  The results suggest that patients admitted to the ICU in Europe are sicker initially than patients admitted to ICU’s in the US, which likely accounts for the higher unadjusted mortality rate of patients in Europe.  The difference may be due in part to the fact that patients in the US were more often admitted directly to the ICU upon presenting to the ED, while in Europe patients are more readily admitted to the wards first.  This study was not randomized, nor did it track patients who were not admitted to the ICU’s and may have had sepsis.  These are both factors that may have skewed the results.  Ultimately, this study has provided insight on the differences of care and outcomes in the US and Europe – further studies will be required to elucidate what changes can be made to optimize all care of this complex disease.

Click to read the study in The Lancet Infectious Diseases

Click to read an accompanying editorial in The Lancet Infectious Diseases

By [AS] and [MS]

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Akira Shishido: Aki is a 4th year M.D. candidate at Harvard Medical School, and is currently working on small molecule inhibitors of Lassa and Ebola viruses. He is planning on specializing in infectious disease, but also dabbles in general medicine, emergency, trauma and critical care. Outside of medicine, Aki frequents Irish Sessions, enjoys a good pint, and is frequently tapped by Kimuras but can throw a good triangle.

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