Severe Sepsis in Do-not-resuscitate Patients: Intervention and Mortality Rates

Powell, Emilie S.; Sauser, Kori; Cheema, Navneet; Pirotte, Matthew; Quattromani, Erin; Avula, Uma Mahesh R.; Khare, Rahul K.; Courtney, D. Mark

doi:10.1016/j.jemermed.2012.09.034

Cited by 15 publications

(14 citation statements)

References 26 publications

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“…In our large, representative cohort, we confirmed prior work that an early DNAR order is indeed a strong, independent predictor of in-hospital mortality [8,13]. However, in contrast to a prior single-center study [12], we found that an early DNAR order was associated with less aggressive utilization of critical procedures, including central venous line placement, hemodialysis, mechanical ventilation, and operating room procedures. A number of differences in demographic and clinical characteristics for early DNAR orders, associated procedures, and in-hospital mortality indicate disparities, perhaps intended or unintended.…”

Section: Discussionsupporting

confidence: 86%

“…Little is known regarding how treatment is affected in septic patients with an early DNAR order. A prior single-center study found that DNAR orders in severe sepsis were associated with higher mortality but similarly aggressive therapy [12]. However, whether a DNAR order influences critical interventions in patients with severe sepsis is unknown, as well as what patient-level characteristics among those with DNAR are associated with outcomes.…”

Section: Introductionmentioning

confidence: 99%

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Impact of early do-not-attempt-resuscitation orders on procedures and outcomes of severe sepsis

Sarkari

Perman

Ginde

2016

Journal of Critical Care

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Purpose Do-not-attempt-resuscitation (DNAR) orders are common in severe sepsis, but the impact on clinical care is not known. Our primary objective was to determine the impact of early DNAR orders on in-hospital mortality and performance of key interventional procedures among severe sepsis hospitalizations. Our secondary objective was to further investigate what patient characteristics within the sepsis DNAR population affected outcomes. Methods Using the 2010–2011 California State Inpatient Dataset, we analyzed hospitalizations for adults admitted through the emergency department with severe sepsis. Our primary predictor was a DNAR order, and our outcomes were in-hospital mortality and performance of interventional procedures. Results Visits with early DNAR orders accounted for 20.3% of severe sepsis hospitalizations. An early DNAR order was a strong, independent predictor of higher in-hospital mortality (odds ratio [OR], 4.03; 95% confidence interval, 3.88–4.19) and lower performance of critical procedures: central venous line (OR, 0.70), mechanical ventilation (OR, 0.80), hemodialysis (OR, 0.61), and major operative procedure (OR, 0.46). Among those with early DNAR orders, older age and rural location were the strongest predictors for a lack of interventional procedures. Conclusion Although DNAR orders are not synonymous with “do not treat,” they may unintentionally limit aggressive treatment for severe sepsis patients, especially in older adults.

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Section: Discussionsupporting

confidence: 86%

Section: Introductionmentioning

confidence: 99%

Impact of early do-not-attempt-resuscitation orders on procedures and outcomes of severe sepsis

Sarkari

Perman

Ginde

2016

Journal of Critical Care

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“…A previous study showed that about half of septic patients with DNR/DNI status survived to hospital discharge [31]. DNR patients also received invasive measures at a rate similar to that of patients without DNR status [31]. Our subgroup analysis showed that compliance with 3-hour protocol, vasopressor use, and achievement of optimal resuscitation in each respective code status were not affected by the timing of ED to ICU transfer.…”

Section: Discussionmentioning

confidence: 55%

Section: Discussionmentioning

confidence: 99%

Impact of Delayed Admission to the Intensive Care Unit from the Emergency Department upon Sepsis Outcomes and Sepsis Protocol Compliance

Agustin

Price

Andoh-Duku

et al. 2017

Critical Care Research and Practice

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Rationale. The impact of emergency department length of stay (EDLOS) upon sepsis outcomes needs clarification. We sought to better understand the relationship between EDLOS and both outcomes and protocol compliance in sepsis. Methods. We performed a retrospective observational study of septic patients admitted to the ICU from the ED between January 2012 and December 2015 in a single tertiary care teaching hospital. 287 patients with severe sepsis and septic shock were included. Study population was divided into patients with EDLOS < 6 hrs (early admission) versus ≥6 hours (delayed admission). We assessed the impact of EDLOS on hospital mortality, compliance with sepsis protocol, and resuscitation. Statistical significance was determined by chi-square test. Results. Of the 287 septic ED patients, 137 (47%) were admitted to the ICU in <6 hours. There was no significant in-hospital mortality difference between early and delayed admissions (p = 0.68). Both groups have similar compliance with the 3-hour protocol (p = 0.77). There was no significant difference in achieving optimal resuscitation within 12 hours (p = 0.35). Conclusion. We found that clinical outcomes were not significantly different between early and delayed ICU admissions. Additionally, EDLOS did not impact compliance with the sepsis protocol with the exception of repeat lactate draw.

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“…To our knowledge, only one previous study has examined the prevalence of DNR orders in sepsis. 18 In that study, patients were retrospectively identified using a clinical definition of sepsis at a single academic institution. Within the cohort, 13 % of patients had DNR orders during their hospitalization.…”

Section: Discussionmentioning

confidence: 99%

Patient and Hospital-Level Characteristics Associated with the Use of Do-Not-Resuscitate Orders in Patients Hospitalized for Sepsis

Chang

Brass

2014

J GEN INTERN MED

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BACKGROUND: Identifying factors associated with donot-resuscitate (DNR) orders is an informative step in developing strategies to improve their use. As such, a descriptive analysis of the factors associated with the use of DNR orders in the early and late phases of hospitalizations for sepsis was performed. METHODS: A retrospective cohort of adult patients hospitalized for sepsis was identified using a statewide administrative database. DNR orders placed within 24 h of hospitalization (early DNR) and after 24 h of hospitalization (late DNR) were the primary outcome variables. Multivariable logistic regression analysis was used to identify patient, hospital, and healthcare system-related factors associated with the use of early and late DNR orders. RESULTS: Among 77,329 patients hospitalized for sepsis, 27.5 % had a DNR order during their hospitalization. Among the cases with a DNR order, 75.5 % had the order within 24 h of hospitalization. Smaller hospital size and the absence of a teaching program increased the likelihood of an early DNR order being written. Additionally, greater patient age, female gender, White race, more medical comorbidities, Medicare payer status and admission from a skilled nursing facility were all significantly associated with the likelihood of having an early DNR. The strength of association between these factors and the use of late DNR orders was weaker. In contrast, the greater the burden of medical comorbidities, the more likely a patient was to receive a late DNR order. CONCLUSION: Multiple patient, hospital, and healthcare system-related factors are associated with the use of DNR orders in sepsis, many of which appear to be independent of a patient's clinical status. Over the course of the hospitalization, the burden of medical illness shows a stronger association relative to other variables. The influence of these multi-level factors needs to be recognized in strategies to improve the use of DNR orders. .KEY WORDS: end-of-life care; healthcare delivery; epidemiology.

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Severe Sepsis in Do-not-resuscitate Patients: Intervention and Mortality Rates

Cited by 15 publications

References 26 publications

Impact of early do-not-attempt-resuscitation orders on procedures and outcomes of severe sepsis

Impact of early do-not-attempt-resuscitation orders on procedures and outcomes of severe sepsis

Impact of Delayed Admission to the Intensive Care Unit from the Emergency Department upon Sepsis Outcomes and Sepsis Protocol Compliance

Patient and Hospital-Level Characteristics Associated with the Use of Do-Not-Resuscitate Orders in Patients Hospitalized for Sepsis

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