Unexpected intensive care transfer of admitted patients with severe sepsis

Abstract

BackgroundPatients with severe sepsis generally respond well to initial therapy administered in the emergency department (ED), but a subset later decompensate and require unexpected transfer to the intensive care unit (ICU). This study aimed to identify clinical factors that can predict patients at increased risk for delayed transfer to the ICU and the association of delayed ICU transfer with mortality.MethodsThis is a nested case-control study in a prospectively collected registry of patients with severe sepsis and septic shock at two EDs. Cases had severe sepsis and unexpected ICU transfer within 48 h of admission from the ED; controls had severe sepsis but remained in a non-ICU level of care. Univariate and multivariate regression analyses were used to identify predictors of unexpected transfer to the ICU, which was the primary outcome. Differences in mortality between these two groups as well as a cohort of patients directly admitted to the ICU were also calculated.ResultsOf the 914 patients in our registry, 358 patients with severe sepsis were admitted from the ED to non-ICU level of care; 84 (23.5%) had unexpected ICU transfer within 48 h. Demographics and baseline co-morbidity burden were similar for patients requiring versus not requiring delayed ICU transfer. In unadjusted analysis, lactate ≥4 mmol/L and infection site were significantly associated with unexpected ICU upgrade. In forward selection multivariate logistic regression analysis, lactate ≥4 mmol/L (OR 2.0, 95% CI 1.03, 3.73; p = 0.041) and night (5 PM to 7 AM) admission (OR 1.9, 95% CI 1.07, 3.33; p = 0.029) were independent predictors of unexpected ICU transfer. Mortality of patients who were not upgraded to the ICU was 8.0%. Patients with unexpected ICU upgrade had similar mortality (25.0%) to those patients with severe sepsis/septic shock (24.6%) who were initially admitted to the ICU, despite less severe indices of illness at presentation.ConclusionsSerum lactate ≥4 mmol/L and nighttime admissions are associated with unexpected ICU transfer in patients with severe sepsis. Mortality among patients with delayed ICU upgrade was similar to that for patients initially admitted directly to the ICU.

The Levels of Lactate, Troponin, and N-Terminal Pro-B-Type Natriuretic Peptide Are Predictors of Mortality in Patients with Sepsis and Septic Shock: A Retrospective Cohort Study

“…Elevated levels of serum lactate have been associated with an increased chance of admission to the ICU in patients with sepsis and septic shock [ 26 , 27 ]. Similarly, elevated troponin levels are frequently seen in critically ill patients admitted to the ICU [ 28 , 29 ].…”

Quantitative and Qualitative Assessments of Cholesterol Association With Bacterial Infection Type in Sepsis and Septic Shock

“…Prompt recognition of patients at risk for rapid illness progression is critical because patients who are admitted to the floor and subsequently upgraded to the intensive care have worse outcomes. [34][35][36][37] Thus an early indication of increased likelihood of culture-positive sepsis could be valuable to the provider. Our evidence suggests that cholesterol levels, combined with standard clinical and microbiology data, may provide additional information of increased likelihood of certain types of infection prior to culture results, though these data remain hypothesis generating.…”

Concept review of regionalized systems of acute care: Is regionalization the next frontier in sepsis care?

“…Unfortunately, those triage networks have not yet been optimized, and overtriage and undertriage still plague sepsis network development. 141 , 142 , 143 , 144 , 145 , 146 These networks could be built on a hierarchical structure of patient‐focused and facility‐focused criteria that can better distribute patients among inpatient resources. In an era of resource constraints, increased regionalization, and overcrowding in tertiary care centers, formalizing risk stratification 147 , 148 , 149 , 150 to match patient needs seems a viable approach to sepsis process improvement efforts.…”