Rural Patients With Severe Sepsis or Septic Shock Who Bypass Rural Hospitals Have Increased Mortality: An Instrumental Variables Approach*

Mohr, Nicholas M.; Harland, Karisa K.; Shane, Dan M.; Ahmed, Azeemuddin; Fuller, Brian M.; Ward, Marcia M.; Torner, James C.

doi:10.1097/ccm.0000000000002026

Cited by 44 publications

(40 citation statements)

References 41 publications

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“…The quality of early sepsis management in rural EDs is critical, as over 40% of all US EDs are in rural counties 8 and delays in early care are associated with worse outcomes. 20,21 Rural hospital bypass and interfacility transfer both are associated with increased sepsis mortality, 22 and transfer is associated with low adherence with national sepsis resuscitation guidelines. 10,22 This study expands the field of rural sepsis care research by being the first to examine compliance with national sepsis guidelines between rural and urban EDs/ hospitals.…”

Section: Discussionmentioning

confidence: 99%

“…20,21 Rural hospital bypass and interfacility transfer both are associated with increased sepsis mortality, 22 and transfer is associated with low adherence with national sepsis resuscitation guidelines. 10,22 This study expands the field of rural sepsis care research by being the first to examine compliance with national sepsis guidelines between rural and urban EDs/ hospitals. Literature on rural health care quality is scarce as rural hospitals are traditionally exempted or excluded from quality reporting.…”

Section: Discussionmentioning

confidence: 99%

“…Low‐volume EDs are often located in rural communities . Patients who experience rural hospital bypass and interfacility transfer have observed worse outcomes . Thus, rural EDs play an important role in sepsis survival.…”

mentioning

confidence: 99%

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Urban and Rural Emergency Department Performance on National Quality Metrics for Sepsis Care in the United States

Greenwood-Ericksen

Rothenberg

Mohr

et al. 2018

The Journal of Rural Health

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Purpose The Centers for Medicare and Medicaid Services (CMS) and the American College of Emergency Physicians (ACEP) developed national quality measures for emergency department (ED) sepsis care. Like care for many conditions, meeting sepsis quality metrics can vary between settings. We sought to examine and compare sepsis care quality in rural vs urban hospital‐based EDs. Methods We analyzed data from EDs participating in the national Emergency Quality Network (E‐QUAL). We collected preliminary performance data on both the CMS measure (SEP‐1) and the ACEP measures via manual chart review. We analyzed SEP‐1 data at the hospital level based on existing CMS definitions and analyzed ACEP measure data at the patient level. We report descriptive statistics of performance variation in rural and urban EDs. Findings Rural EDs comprised 58 of the EDs reporting SEP‐1 results and 405 rural patient charts in the manual review. Of sites reporting SEP‐1 results, 44% were rural and demonstrated better aggregate SEP‐1 bundle adherence than urban EDs (79% vs 71%; P = .049). Both urban and rural hospitals reported high levels of compliance with the ACEP recommended initial actions of obtaining lactate and blood cultures, with urban EDs outperforming rural EDs on metrics of IV fluid administration and antibiotics (74% urban vs 60% rural; P ≤ .001; 91% urban vs 84% rural; P ≤ .001, respectively). Conclusions Sepsis care at both rural and urban EDs often achieves success with national metrics. However, performance on individual components of ED sepsis care demonstrates opportunities for improved processes of care at rural EDs.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Urban and Rural Emergency Department Performance on National Quality Metrics for Sepsis Care in the United States

Greenwood-Ericksen

Rothenberg

Mohr

et al. 2018

The Journal of Rural Health

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“…Previous work has shown that the increasing trend toward rural hospital bypass may be putting patients with timesensitive conditions at greater risk of hospital death due to delays in care related to transportation. 32 Alternatively, this could suggest lower quality of care at urban hospitals. Future work is needed to fully evaluate these hypotheses.…”

Section: Discussionmentioning

confidence: 99%

Worsening Rural-Urban Gap in Hospital Mortality

2017

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Background: One out of every 5 Americans live in rural communities. Rural Americans have higher rates of early and preventable deaths outside of the hospital than their urban counterparts. How rurality relates to hospital mortality is unknown. We sought to determine the association between rural versus urban residence and hospital mortality.Methods: This is a retrospective observational study of 4,412,942 nonmaternal, nonneonatal hospitalizations in 2008, and 3899,464 nonmaternal, nonneonatal hospitalizations in 2013 using all-payer, all-age data from the National Inpatient Sample of the Health care Cost and Utilization Project. Using multivariable logistic regression, we report the association between rural versus urban location of residence and hospital mortality, adjusting for chronic disease burden, age, income, and insurance status.Results: The unadjusted probability of hospital mortality for urban patients decreased from 2.51% (95% CI ,

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“…1,2 Furthermore, when patients bypass local hospitals and directly present to tertiary care, mortality for time-sensitive illnesses, such as sepsis, increases. 3 Unfortunately, although critical access hospitals (CAHs) had an equivalent risk-adjusted mortality in 2002, they have failed to improve their performance at the same rate as that of larger hospitals and lag in quality metrics. 4,5 One potential contributor to the lagging performance may be the low uptake of the hospitalist model at these facilities.…”

mentioning

confidence: 99%

The Virtual Hospitalist: A Single‐Site Implementation Bringing Hospitalist Coverage to Critical Access Hospitals

Kuperman

Linson

Klefstad

et al. 2018

Journal of Hospital Medicine

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BACKGROUND On‐site hospitalist care can improve patient care, but it is economically infeasible for small critical access hospitals (CAHs). A telemedicine “virtual hospitalist” may expand CAH capabilities at a fractional cost of an on‐site provider. OBJECTIVE To evaluate the impact of a virtual hospitalist on transfers from a CAH to outside hospitals. DESIGN, SETTING, AND PARTICIPANTS A six‐month pilot program providing “virtual hospitalist” coverage to patients at a CAH in rural Iowa. MEASUREMENTS The primary outcome was the rate of outside transfers from the CAH Emergency Department (ED). The secondary outcomes included transfer from either the ED or the inpatient wards, daily census, length of stay, transfers after admission, virtual hospitalist time commitment, and patient and staff satisfaction. The preceding 24‐week baseline was compared with 24 weeks after implementation, excluding a two‐week transition period. RESULTS At baseline, there were 947 ED visits and 176 combined inpatient and observation encounters, compared to 930 and 176 after implementation, respectively. Outside transfers from the ED decreased from 16.6% to 10.5% (157/947 to 98/930, P < .001), and transfers at any time decreased from 17.3% to 11.9% (164/947 to 111/930, P < .001). Daily census, length of stay, and transfers after admission were unchanged. Time commitment for a virtual hospitalist was 35 minutes per patient per day. The intervention was well received by the CAH staff and patients. CONCLUSIONS The virtual hospitalist model increased the percentage of ED patients who could safely receive their care locally. A single virtual hospitalist may be able to cover multiple CAHs simultaneously.

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Rural Patients With Severe Sepsis or Septic Shock Who Bypass Rural Hospitals Have Increased Mortality: An Instrumental Variables Approach*

Cited by 44 publications

References 41 publications

Urban and Rural Emergency Department Performance on National Quality Metrics for Sepsis Care in the United States

Urban and Rural Emergency Department Performance on National Quality Metrics for Sepsis Care in the United States

Worsening Rural-Urban Gap in Hospital Mortality

The Virtual Hospitalist: A Single‐Site Implementation Bringing Hospitalist Coverage to Critical Access Hospitals

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