Elsevier

Journal of Critical Care

Volume 39, June 2017, Pages 220-224
Journal of Critical Care

Sepsis/Infection
Filtering authentic sepsis arising in the ICU using administrative codes coupled to a SIRS screening protocol

https://doi.org/10.1016/j.jcrc.2017.01.012Get rights and content

Highlights

  • Approximately 1/3 of patients identified by our protocol developed sepsis in the ICU.

  • Overall mortality for all patients identified was 19%.

  • Mortality rate appeared to be unaffected by location of sepsis onset.

Abstract

Purpose

Using administrative codes and minimal physiologic and laboratory data, we sought a high-specificity identification strategy for patients whose sepsis initially appeared during their ICU stay.

Materials and methods

We studied all patients discharged from an academic hospital between September 1, 2013 and October 31, 2014. Administrative codes and minimal physiologic and laboratory criteria were used to identify patients at high risk of developing the onset of sepsis in the ICU. Two clinicians then independently reviewed the patient record to verify that the screened-in patients appeared to become septic during their ICU admission.

Results

Clinical chart review verified sepsis in 437/466 ICU stays (93.8%). Of these 437 encounters, only 151 (34.6%) were admitted to the ICU with neither SIRS nor evidence of infection and therefore appeared to become septic during their ICU stay.

Conclusions

Selected administrative codes coupled to SIRS criteria and applied to patients admitted to ICU can yield up to 94% authentic sepsis patients. However, only 1/3 of patients thus identified appeared to become septic during their ICU stay. Studies that depend on high-intensity monitoring for description of the time course of sepsis require clinician review and verification that sepsis initially appeared during the monitoring period.

Section snippets

Background

Sepsis is the life-threatening inflammatory response to infection [1]. In 2011, septicemia ranked as the most expensive condition for all United States hospitalizations accounting for 20.3 billion dollars [2]. Sepsis frequently causes inpatient death [3]. Survivors fare poorly: 26% require readmission within 30 days and 48% within 180 days [4], [5]. Almost half of all patients who survive severe sepsis (sepsis accompanied by organ failure) to hospital discharge die within the following year [6].

Ethical approval, study design, search strategy

This study was conducted under the approval of the Emory University Institutional Review Board. In this work, we retrospectively studied 6 ICUs (1 27-bed neurosurgical, 1 20-bed general surgical, 2 7-bed medical, and 2 9-bed cardiothoracic) at Emory University Hospital, a 605-bed acute care teaching facility, between September 1, 2013 and October 31, 2014. The search strategy began with all 24,323 hospital discharges that occurred during this timeframe. The screening protocol was applied to

Results

A total of 24,323 encounters were discharged from the 605 hospital beds between September 1, 2013 and October 31, 2014 (Fig. 3). The initial physiologic exclusion criteria resulted in 466 encounters that (1) received an administrative code and (2) met 2 of 4 SIRS criteria initially in the ICU, and thus these 466 encounters constituted the initial study population. Of the 466 encounters with administratively coded sepsis and valid SIRS physiology, clinical chart review identified sepsis in 437

Discussion

The purpose of this effort was to evaluate a protocol that could rapidly and reliably identify a small cohort of patients whose sepsis initially appeared during their ICU stay. These patients represent a first cohort for precision medicine: early identification and rapid, tailored response to this life-threatening condition. We found that we could reliably identify a patient population with sepsis by coupling a refined code set with SIRS criteria. Manual review revealed a 6% error rate. The

Conclusions

Coupling a refined administrative code set with SIRS criteria screens for authentic sepsis yielded a 93.8% positive predictive value. Errors arose from shock states subsequently attributed to non-septic etiologies. Approximately 1/3 of patients screened manifested sepsis for the first time during (not prior to) the ICU admission. This subpopulation is of significant importance to studies using high-intensity monitoring for early detection and targeted treatment of sepsis.

Conflicts of interest

None.

Funding

This work was supported by the Emory University Center for Critical Care; and the Surgical and Critical Care Initiative. The funding sources had no role in study design, data collection, data analysis, data interpretation, in writing the report, nor in the decision to submit the article for publication.

Acknowledgements

The authors acknowledge the assistance of Qiao Li, PhD, Gari Clifford, PhD, Monica Crubezy, PhD, Terry Willey, and Sara Gregg, MHA.

References (18)

  • R.C. Bone et al.

    Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis

    Chest

    (1992)
  • C.M. Torio et al.

    National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2011: Statistical Brief #160

    (2013)
  • V. Liu et al.

    Hospital deaths in patients with sepsis from 2 independent cohorts

    JAMA

    (2014)
  • A.J. Goodwin et al.

    Frequency, Cost, and Risk Factors of Readmissions Among Severe Sepsis Survivors

    Crit Care Med

    (2015)
  • A. Elixhauser et al.

    Readmissions to U.S. Hospitals by Diagnosis, 2010

    (2013)
  • H.C. Prescott et al.

    Increased 1-year healthcare use in survivors of severe sepsis

    Am J Respir Crit Care Med

    (2014)
  • D.C. Angus et al.

    Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care

    Crit Care Med

    (2001)
  • G.S. Martin et al.

    The epidemiology of sepsis in the United States from 1979 through 2000

    N Engl J Med

    (2003)
  • V.Y. Dombrovskiy et al.

    Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: a trend analysis from 1993 to 2003

    Crit Care Med

    (2007)
There are more references available in the full text version of this article.
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