Volume-Mortality Relationships during Hospitalization with Severe Sepsis Exist Only at Low Case Volumes

Goodwin, Andrew; Simpson, Kit N.; Ford, Dee W.

doi:10.1513/annalsats.201406-287oc

Cited by 7 publications

(5 citation statements)

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“…B, Severe sepsis inhospital mortality rates are similarly higher in patients who reside in medically underserved areas (P < .01), with peak rate ratios in the 40-to 65-year old age group. 14,15 Interestingly, this association exists despite similar Charlson comorbidity index scores and severity of illness levels between patients who do and do not reside in MUAs. Finally, historical ZIP code-based methods of adjustment for access-to-care demonstrated minimal to no association with sepsis outcomes in this cohort.…”

Section: Discussionmentioning

confidence: 99%

“…This limitation likely explains the observation that care in rural hospitals was associated with reduced odds of mortality despite evidence that small-volume hospitals are associated with higher severe sepsis mortality rates. 14,15 An additional limitation of this study is the cumbersome approach required to assign MUA status to a particular ZIP code. The DHHS Health Resources and Services Administration 29 currently allows users to search for MUA status by street address, but it does not allow for users to easily identify if an individual ZIP code contains MUAs.…”

Section: Discussionmentioning

confidence: 99%

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McElligott

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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McElligott

et al. 2016

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“…Previous analyses have found higher mortality for inpatient care at rural hospitals and CAHs compared with urban hospitals, but these analyses did not include the ED setting, and little is known about patient outcomes tied to ED visits. Low case volumes are implicated in driving higher mortality in rural inpatient care, but this issue may not be relevant to emergency care, with many rural and critical access EDs experiencing relatively high patient volumes . However, there are specific features that may adversely affect emergency care at rural facilities, including limited and declining inpatient capacity and ED clinicians with varying expertise in emergency care .…”

Section: Introductionmentioning

confidence: 99%

Association of Rural and Critical Access Hospital Status With Patient Outcomes After Emergency Department Visits Among Medicare Beneficiaries

et al. 2021

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IMPORTANCERural US residents disproportionately rely on emergency departments (ED), yet little is known about patient outcomes after ED visits to rural hospitals or critical access hospitals (CAHs).OBJECTIVE To compare 30-day outcomes after rural vs urban ED visits and in CAHs, a subset of rural hospitals. DESIGN, SETTING, AND PARTICIPANTSThis propensity-matched, retrospective cohort study used a 20% sample of national Medicare fee-for-service beneficiaries from January 1, 2011, to October 31, 2015. Rural and urban ED visits were matched on demographics, patient prior use of EDs, comorbidities, and diagnoses. Thirty-day outcomes overall and stratified by 25 common ED diagnoses were evaluated, with similar analysis of CAHs vs non-CAHs. Data were analyzed from February 15, 2020, to May 17, 2021. MAIN OUTCOMES AND MEASURESThe primary outcome was 30-day all-cause mortality.Secondary outcomes were ED revisits with and without hospitalization. RESULTSThe matched cohort included 473 152 rural and urban Medicare beneficiaries with a mean (SD) age of 75.1 (7.9) years (59.1% and 59.3% women, respectively; 86.9% and 87.1% White, respectively). Medicare beneficiaries at rural vs urban EDs experienced similar all-cause 30-day mortality (3.9% vs 4.1%; effect size, 0.01), ED revisits (18.1% vs 17.8%; effect size, 0.00), and ED revisits with hospitalization (6.0% vs 8.1%; effect size, 0.00). Rural ED visits were associated with more transfer (6.2% vs 2.0%; effect size, 0.22) and fewer hospitalizations (24.7% vs 39.2; effect size, 0.31). Stratified by diagnosis, patients in rural EDs with life-threatening illnesses experienced more transfer with 30-day mortality similar to that of patients in urban EDs. In contrast, mortality differed for patients in rural EDs with symptom-based diagnoses, including chest pain (odds ratio [OR], 1.54 [95% CI, 1.25-1.89]), nausea and vomiting (OR, 1.68 [95% CI,, and abdominal pain (OR, 1.73 [95% CI,). All findings were similar for CAHs. CONCLUSIONS AND RELEVANCEThe findings of this cohort study of rural ED care suggest that patient mortality for potentially life-threatening conditions is comparable to that in urban settings.Further research is needed to understand the sources of greater rural ED mortality for symptombased conditions. These findings underscore the importance of ensuring access to treatment of lifethreatening conditions at local EDs in rural communities, which are increasingly endangered by hospital closures.

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“…2 Hospitals that have implemented protocol-based care for sepsis patients have improved treatment guideline adherence and improved survival. 3,4 Accurate recognition and resuscitation in the emergency department (ED) are critical for improving sepsis outcomes.…”

Section: Introductionmentioning

confidence: 99%

Provider-to-provider telemedicine improves adherence to sepsis bundle care in community emergency departments

et al. 2020

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Introduction Sepsis is a life-threatening emergency. Together, early recognition and intervention decreases mortality. Protocol-based resuscitation in the emergency department (ED) has improved survival in sepsis patients, but guideline-adherent care is less common in low-volume EDs. This study examined the association between provider-to-provider telemedicine and adherence with sepsis bundle components in rural community hospitals. Methods This is a prospective cohort study of adults presenting with sepsis or septic shock in community EDs participating in rural telemedicine networks. The primary outcome was adherence to four sepsis bundle requirements: lactate measurement within 3 hours, blood culture before antibiotics, broad-spectrum antibiotics, and adequate fluid resuscitation. Multivariable generalized estimating equations estimated the association between telemedicine and adherence. Results In this cohort ( n = 655), 5.6% of subjects received ED telemedicine consults. The telemedicine group was more likely to be male and have a higher severity of illness. After adjusting for severity and chief complaint, total sepsis bundle adherence was higher in the telemedicine group compared with the non-telemedicine group (aOR 17.27 [95%CI 6.64–44.90], p < 0.001). Telemedicine consultation was associated with higher adherence with three of the individual bundle components: lactate, antibiotics, and fluid resuscitation. Discussion Telemedicine patients were more likely to receive initial blood lactate measurement, timely broad-spectrum antibiotics, and adequate fluid resuscitation. In rural, community EDs, telemedicine may improve sepsis care and potentially reduce disparities in sepsis outcomes at low-volume facilities. Future work should identify specific components of telemedicine-augmented care that improve performance with sepsis quality indicators.

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Volume-Mortality Relationships during Hospitalization with Severe Sepsis Exist Only at Low Case Volumes

Cited by 7 publications

References 50 publications

Where You Live Matters

Where You Live Matters

Association of Rural and Critical Access Hospital Status With Patient Outcomes After Emergency Department Visits Among Medicare Beneficiaries

Provider-to-provider telemedicine improves adherence to sepsis bundle care in community emergency departments

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