Skip to main content

Delayed ICU admission with community-acquired severe sepsis greatly increases mortality and resource use

Introduction

While many severe sepsis (SS) patients go to the ICU on hospital admission, others with community-acquired infection (CAI) either progress to SS later in the hospitalization or are not considered severely ill on admission. The proportion of SS cases falling into these two groups is not known, and their outcomes are not well described.

Methods

We identified all adult hospitalizations in the 2008 Premier database that had an ICD-9-CM code for SS (995.92, 785.52), a CAI, and who entered the hospital through the ED (for example, not transferred from another hospital). Patients were characterized by the sequence of ICU and floor care, the number of antibiotic classes (AbxC) on day 1, and the duration of floor stay before ICU admission. We assessed resource use via length of stay (LOS) and total cost. We also examined hospital mortality.

Results

The cohort included 33,059 discharges (49.1% male, mean age 69.0 years), of whom 17,690 (53.5%) were admitted to the ICU at hospital presentation. Mortality in direct to ICU subjects equaled 31.2%, and these patients had an average LOS of 12.0 days with a mean cost of $30,174, with only 22.8% given a single AbxC. Those admitted to the floor initially (46.5%) had a similar LOS (11.7 days) and mortality (31.1%) but had lower mean costs ($22,728) and nearly half (49.3%) had a single AbxC. Of these initial floor patients, those that were never admitted to the ICU (28.0% of all cases) had the shortest stay (7.6 days), lowest cost ($11,753), and lowest mortality (24.2%) with 44.3% receiving a single AbxC on day 1. Those starting on the floor and later transferred to the ICU (18.4% of all cases) had the longest stay (17.7 days), highest cost ($39,332) and highest mortality (41.5%), and were most likely to have a single AbxC on day 1 (56.8%). Even those admitted to the ICU after 1 day on the floor (3,179, 52.1% of delayed ICU cases) had higher mortality (36.0%) than those starting in the ICU (P < 0.0001). Mortality increased with longer delays before ICU admission (40.7%, for a 2-day delay (14.1% of delayed cases) and 50.3% for those with a 3-day or more delay (33.8% of delay cases)).

Conclusions

SS patients with CAI admitted to the floor and later transferred to the ICU are a major fraction of all SS cases and have the worst outcomes. While many may have developed organ dysfunctions later in the hospitalization, nearly two-thirds were admitted to the ICU after just 1 or 2 days on the ward, indicating that they may have been mis-triaged. Interventions to better identify and aggressively treat these cases may improve outcomes.

Author information

Affiliations

Authors

Corresponding author

Correspondence to A Shorr.

Rights and permissions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Cite this article

Shorr, A., Choe, Y. & Linde-Zwirble, W. Delayed ICU admission with community-acquired severe sepsis greatly increases mortality and resource use. Crit Care 15, P211 (2011). https://doi.org/10.1186/cc9631

Download citation

Keywords

  • Severe Sepsis
  • Hospital Mortality
  • Short Stay
  • Longe Stay
  • Antibiotic Classis