Trends, Cost, and Mortality From Sepsis After Trauma in the United States: An Evaluation of the National Inpatient Sample of Hospitalizations, 2012–2016

Abstract

Objectives: Identification and outcomes in patients with sepsis have improved over the years, but little data are available in patients with trauma who develop sepsis. We aimed to examine the cost and epidemiology of sepsis in patients hospitalized after trauma. Design: Retrospective cohort study. Patients: National Inpatient Sample. Interventions: Sepsis was identified between 2012 and 2016 using implicit and explicit International Classification of Diseases, Ninth and Tenth Revision codes. Analyses were stratified by injury severity score greater than or equal to 15. Annual trends were modeled using generalized linear models. Survey-adjusted logistic regression was used to compare the odds for in-hospital mortality, and the average marginal effects were calculated to compare the cost of hospitalization with and without sepsis. Measurements and Main Results: There were 320,450 (se = 3,642) traumatic injury discharges from U.S. hospitals with sepsis between 2012 and 2016, representing 6.0% (95% CI, 5.9–6.0%) of the total trauma population (n = 5,329,714; se = 47,447). In-hospital mortality associated with sepsis after trauma did not change over the study period (p > 0.40). In adjusted analysis, severe (injury severity score ≥ 15) and nonsevere injured septic patients had an odds ratio of 1.39 (95% CI, 1.31–1.47) and 4.32 (95% CI, 4.06–4.59) for in-hospital mortality, respectively. The adjusted marginal cost for sepsis compared with nonsepsis was $16,646 (95% CI, $16,294–$16,997), and it was greater than the marginal cost for severe injury compared with nonsevere injury $8,851 (95% CI, $8,366–$8,796). Conclusions: While national trends for sepsis mortality have improved over the years, our analysis of National Inpatient Sample did not support this trend in the trauma population. The odds risk for death after sepsis and the cost of care remained high regardless of severity of injury. More rigor is needed in tracking sepsis after trauma and evaluating the effectiveness of hospital mandates and policies to improve sepsis care in patients after trauma.

The impact of infection complications after trauma differs according to trauma severity

“…Among patients with mild or moderate trauma, infection complications were associated with increased in-hospital mortality. Our results were consistent with previous studies using a national database 1 and a statewide database 16 in the United States. Although other studies 10 , 14 , 19 did not show the association between infection and in-hospital mortality among trauma, their results have limited generalizability because they were small and single-center studies.…”

“…This definition is similar to the definition of severe sepsis in the Sepsis-2 criteria 15 . We divided trauma severity into three groups based on the ISS to reflect the clinically relevant categories, similar to previous reports 1 , 16 : ISS < 15 (mild), ISS 15–29 (moderate), and ISS ≥ 30 (severe). Types of infections included pneumonia, urinary tract infection, surgical site infection, myelitis, meningitis, abdominal abscess, cholecystitis, enterocolitis, empyema, and bacteremia.…”

“…We performed a multivariable logistic regression analysis to investigate the influence of infection on in-hospital mortality for trauma patients. The adjusted variables included age, sex, number of comorbidities, transfusion, emergency procedures, admission disposition, any operations, and concomitant complications; these variables were chosen based on previous reports and clinical relevance 1 , 16 – 18 . We assessed the multicollinearity of variables using the variance inflation factor, and the tolerance value was set at less than 2.…”

“…Infection after trauma, including sepsis, is the most common complication affecting trauma patients; unfortunately, it has a poor prognosis. However, some infections may be preventable or recognized early because infections are typically acquired during hospitalization after the onset of trauma 1 . Therefore, complication rates and the failure to rescue including infection are considered indicators of the quality of trauma care 2 .…”

“…Additionally, many studies have shown the improvement in outcomes for patients with sepsis following the development subsequent revision of definitions, guidelines, and bundles 5 – 8 . Conversely, only limited information is available on the development of infection and sepsis in patients with trauma 1 , likely because the definition of sepsis continues to change 9 . Patients with trauma often arrive with organ dysfunction, which adds complexity and inaccuracy to applying the definition of sepsis using organ failure scores such as sequential organ failure assessment scores 10 .…”