29: Inpatient Mortality for Sepsis Patients From the Emergency Department Versus Direct Admission: A Nationwide Cross-Sectional Study

Abstract

Early aggressive resuscitation in patients with sepsis decreases mortality. Evidenced-based guidelines exist for both resuscitation in the emergency department (ED) and for care-environments outside of the ED, typically the intensive care unit. It has not been demonstrated on a national level if one venue for initial resuscitation is superior. We hypothesized that patients with a principal diagnosis of sepsis admitted via the ED would have lower inpatient mortality than patients admitted directly to the hospital. We performed a cross-sectional analysis of 91,828 admissions categorized as either admitted via the ED or directly to the inpatient hospital with a principal diagnosis of sepsis from 351 hospitals in the 2007 Nationwide Inpatient Sample. Admissions were excluded if admitted to a hospital with less than 25 ED or 25 direct sepsis admissions in 2007, or if the patient was transferred into or out of the hospital from/to another hospital. Univariate association of patient and hospital factors with mortality by admission route was evaluated by chi-square test or ANOVA. A population-averaged logistic regression model was used to estimate the effects of age, sex, co-morbid conditions, payer-status, median zip code income, hospital bed-size, teaching-status, hospital-wide sepsis case volume, and route of admission on the likelihood of either early (two-day post-admission) or overall inpatient mortality. The analysis compared mortality after 65,903 ED sepsis admissions and 25,925 sepsis admissions admitted directly to the hospital. Overall sepsis mortality for the sample was 18.0%: 17.8% for patients admitted via the ED and 18.7% for those admitted directly to the hospital (p<0.05). Patients admitted via the ED were older (69.5 versus 68.7, p<0.001) and had more co-morbid conditions coded (3.5 versus 3.1, p<0.001). Direct-to-hospital admissions had a greater proportion with a cancer diagnosis (13.6% versus 10.8%, p<0.001). Alcohol abuse, chronic heart failure, chronic pulmonary disease, coagulopathy, fluid and electrolyte disorder, renal failure, and liver failure were coded more frequently among patients admitted through the ED (p<0.001). ED admissions were more likely to be covered by Medicaid or be without insurance (11.8% versus 10.0%, p<0.001). Hospital length of stay was similar by admission route (direct admissions mean of 9.2 days versus 9.1 for ED admissions, p=0.17). ED admissions were more likely to be to large bed-size or teaching hospitals (p<0.001). The risk-adjusted odds of inpatient death was 0.89 (95% CI 0.85-0.92) for ED admissions as compared to direct-to-hospital admissions. A similar result was found for the odds of early death with the ED admission route equally as protective (OR=0.90 95% CI 0.85-0.96). After adjustment for co-morbid conditions and other significant patient and hospital factors, mortality outcomes for patients admitted to the hospital with a principal diagnosis of sepsis differed between directly admitted patients and patients admitted through the ED. Being admitted via the ED was associated with an 11% lower odds of inpatient mortality in this large, heterogeneous sample. This evidence supports the valuable role that the ED may provide in the early aggressive resuscitation of patients with sepsis.