Hospital inpatients who develop sepsis after admission have worse outcomes than patients who present with community-acquired sepsis, even after controlling for comorbidities. The purpose of this study was to investigate whether this difference persists in different at-risk patient populations, including patients undergoing major surgery, residents of long-term care facilities, transplant patients, and the elderly.
Retrospective cohort study analyzing publicly available de-identified discharge data from the California Office of Statewide Health Planning and Development. Adults admitted to a nonfederal hospital for acute care in California in 2010 were considered eligible. Patients with severe sepsis were identified using a validated approach based on ICD-9-CM codes. Multivariate logistic regression with adjustment for patient and hospital characteristics was performed to evaluate risk factors for an association with mortality. Interaction terms were created to evaluate potential moderators of the impact of hospital-onset of sepsis. Multiple imputation was used to address missing values for race, ethnicity, gender and age.
799,110 admissions with diagnosis codes for severe sepsis met the inclusion criteria. 171,390 (21.45%) patients died. Hospital-onset of sepsis was a significant risk factor for mortality, both on bivariate analysis (OR 1.183) and when adjusting for patient and hospital characteristics (adjusted OR 1.346). Major surgery during admission, admission from long term care facility, and status-post transplant all showed significant interactions with hospital-onset of sepsis, such that the impact of developing sepsis in the hospital was magnified in surgical and transplant patients and lessened in patients admitted from long-term care facilities. Though age itself was a significant predictor of mortality, age ≥ 65 did not moderate the effect of hospital-onset of sepsis.
Our findings suggest a one size fits all approach may not be appropriate for the diverse patient populations who develop sepsis. In post-surgical and post-transplant patients, a more aggressive scheme for recognition and management of sepsis may be called for.