Sepsis Death Common, Often Unpreventable

Veronica Hackethal, MD

February 15, 2019

Sepsis remains one of the leading causes of hospital death in the United States, but there may not be much doctors can do to prevent them, a study has found.

The findings were published online February 15, 2019, in JAMA Network Open.

The study found that 88% of sepsis deaths were not preventable.

"Although the burden of sepsis-associated mortality is high, our study indicates that most of these deaths may not be preventable through better hospital-based care," Chanu Rhee, MD, MPH, of Harvard Medical School, Boston, Massachusetts, and colleagues write.

That is because many of the patients who died from sepsis had other serious medical problems, such as cancer or dementia, that may have contributed to their deaths.

"Our findings do not diminish the importance of trying to prevent as many sepsis-associated deaths as possible, but rather underscore that most fatalities occur in medically complex patients with severe comorbid conditions," the researchers continue.

More progress is needed in treating the underlying cause of death before further gains can be made in reducing sepsis-related deaths, they add.

Approximately 1.7 million people in the United States develop sepsis each year, and the problem contributes to about 250,000 deaths, the authors explain. To improve the situation, sepsis care quality improvement initiatives have sprung up around the country, some of which have reported a decrease in sepsis deaths after mandating a sepsis protocol or a sepsis care bundle.

Yet frail individuals such as the elderly and those with serious underlying conditions are among the most vulnerable to sepsis and may be at risk for death even if they receive the best care. This raises the question: How preventable is sepsis?

The researchers conducted a medical record review of 568 randomly selected adults who died during hospitalization at one of six academic and community hospitals in the United States or were discharged to hospice care. Of these, 50.9% were men with a mean age of 70.5 years.

Two trained reviewers judged cases for overall preventability of sepsis death and suboptimal sepsis care, such as delays in starting antibiotics and other medical errors.

More than half (52.8%; n = 300) of hospital deaths in this study involved sepsis and sepsis represented the most common immediate cause of death (95% confidence interval [CI], 48.6% - 57.0%), accounting for 34.9% (n = 198) of cases (95% CI, 30.9% - 38.9%).

Severe illness accounted for most underlying causes of death. The most common of these included cancer, chronic heart disease, dementia, and lung disease.

On admission, 40.3% (n = 300) of individuals (95% CI, 34.7% - 46.1%) had hospice-qualifying conditions, most commonly terminal cancer.

Overall, reviewers judged most deaths from sepsis (88%; n = 264) as unpreventable (95% CI, 83.8% - 91.5%). They deemed only 8.3% (n = 25) as possibly preventable, and just 1.3% as definitely preventable.

Furthermore, only 22.7% (n = 300) of sepsis deaths involved suboptimal care, usually delays in antibiotics.

In a linked editorial, Laura Evans, MD, MSc, New York University School of Medicine, writes that the results should be interpreted with caution.

According to Evans, the reviewers reached only limited agreement in their judgments, and the rate of suboptimal sepsis care in this study was much lower than in other studies. That suggests better sepsis care in the hospitals in this study than other hospitals in the country; therefore, there may not have been much more room for improvement. If so, the results may underestimate the number of preventable sepsis deaths through improved care.

Nevertheless, Evans continues, "this study does reflect the reality that, with currently available tools for recognition and management of sepsis, some sepsis-associated deaths are not preventable."

The findings should serve as a "call to action," for sepsis research to help improve early recognition and management of sepsis, she adds.

"The need for improved rapid diagnostics that can be used to trigger time-sensitive interventions that can be applied across different resource settings is urgent to reduce sepsis-associated deaths to their lowest possible levels," Evans concludes.

The study was funded by the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ). One or more authors report royalties, personal fees, grants, and/or other funding from one or more of the following: UpToDate, CDC, AHRQ, Carefusion/BD, Pursuit Vascular Inc, and PDI Inc. A complete list is available on the journal's website. Evans reports serving on the steering committee of the Surviving Sepsis Campaign and being co-chair of the Surviving Sepsis Campaign Guidelines.

JAMA Network Open. Published online February 15, 2019. Full text, Editorial

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