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Swanson Dissertation Final rev3.35 MB
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Dissertation
Access to and delivery of emergency sepsis care for high-risk age groups
University of Iowa
Doctor of Philosophy (PhD), University of Iowa
Spring 2023
DOI: 10.25820/etd.007109
Abstract
Sepsis affects over 50,000 U.S. children and 1.7 million U.S. adults each year, resulting in long-term functional disability and a high risk of mortality. Early recognition and resuscitation of sepsis can reduce mortality and improve outcomes. However, current adherence to early resuscitation guidelines remains low among pediatric and adult sepsis and septic shock patients. This dissertation investigates early sepsis care in two populations: pediatrics (0-18 years) and older adults (65 years and older).
Adherence to pediatric sepsis care guidelines is lower than in the adult sepsis population, especially in low-volume facilities. Compared to adults, pediatric sepsis patients may be at higher risk of disparate incidence and outcomes given sparser access to definitive pediatric hospital care. The first two aims of this dissertation use multi-state all-payer administrative claims data and a national readiness survey of emergency departments (EDs) to: (1) identify facility-level characteristics associated with effective pediatric sepsis care and (2) determine the role of distance to care in pediatric sepsis outcomes. In Aim 1, there was no association between ED pediatric readiness and hospital-free days (a composite measure of death, length-of-stay, and readmission) among pediatric sepsis patients. Lower pediatric readiness is, however, associated with increased odds of transfer. In Aim 2, there was also no association between geographic proximity to care (i.e., distance) and hospital-free days in pediatric sepsis patients. Taken together, these findings suggest the current sepsis care system may deliver adequate early sepsis care and utilize transfer to triage patients to the appropriate level of definitive care decreasing the barriers of greater distance and lower pediatric readiness. This is unique from other pediatric emergency conditions, such as trauma, where shorter distance to care and higher pediatric readiness are associated with improved outcomes.
In the final aim, national Medicare claims data is leveraged to investigate the sepsis transfer networks of older adults with severe sepsis and septic shock. Currently, there are not universal transfer protocols or guidelines, and there are not national sepsis regionalization networks. Therefore, understanding the actual and potential transfer patterns of sepsis patients can help both elucidate current practice and identify potential next steps for creating a more universal system. In Aim 3, a high degree of exclusivity is noted, as the majority of sepsis hospitals were transferring patients to one to two receiving hospitals. Predictors of sepsis receiving hospitals, including increased ICU capabilities and lower distance, are identified. Further, a paradoxical relationship of worse sepsis care metrics (i.e., lower SEP-1 score and higher hospital adjusted mortality) are associated with greater odds of being a sepsis receiving hospital. These findings illustrate that the sepsis care networks have potential for optimization to improve sepsis outcomes in transferred patients by creating standardized systems to determine sepsis care.
Overall, this dissertation uses three studies to better understand the current sepsis regionalized systems of care for children and older adults. It highlights the importance of transfer as an intervention to bring sepsis patients to definitive care and suggests that, in pediatrics, the majority of initial hospital destinations may be able to provide adequate early sepsis care. Further, it highlights an opportunity for future study to develop sepsis transfer systems that may further improve patient outcomes.
Details
- Title: Subtitle
- Access to and delivery of emergency sepsis care for high-risk age groups
- Creators
- Morgan B Swanson
- Contributors
- James C Torner (Advisor)Nicholas M Mohr (Advisor)Ryan M Carnahan (Committee Member)Knute D Carter (Committee Member)Kang Zhao (Committee Member)
- Resource Type
- Dissertation
- Degree Awarded
- Doctor of Philosophy (PhD), University of Iowa
- Degree in
- Epidemiology
- Date degree season
- Spring 2023
- Publisher
- University of Iowa
- DOI
- 10.25820/etd.007109
- Number of pages
- xii, 159 pages
- Copyright
- Copyright 2022 Morgan B Swanson
- Language
- English
- Date submitted
- 07/25/2022
- Date approved
- 06/30/2023
- Description illustrations
- illustrations, tables, graphs
- Description bibliographic
- Includes bibliographical references (pages 105-132).
- Public Abstract (ETD)
- Sepsis has a large morbidity and mortality burden among people at both extremes of age: young children and older adults. Variation in recognition and initial sepsis care may represent an opportunity to improve sepsis outcomes, especially for sepsis patients that live farther from and initially present to hospitals where they may require subsequent transfer. This dissertation evaluates: (1) if an existing pediatric quality improvement program (“pediatric readiness”) improves sepsis outcomes for children, (2) if how far a child lives from a hospital affects how long they stay in the hospital with sepsis, and (3) the qualities of hospitals that accept older adult sepsis patients from other hospitals when the patients are transferred. First, this dissertation suggests that the existing pediatric readiness program may not influence the health and recovery of children with sepsis in the same way it improves survival for other diseases, like injuries. Second, sepsis hospital stays (including survival and the amount of days spent in the hospital) were not different for children that live very close compared to farther from hospitals with pediatric sepsis care. Finally, when older adult sepsis patients need to be transferred from one hospital to a different hospital, most hospitals use the same destination hospitals, and it is unclear if the destination hospitals being used are always the best available option. Overall, these three findings will help to improve how the health system, with many hospitals working together, care for children and older adults with sepsis.
- Academic Unit
- Epidemiology
- Record Identifier
- 9984424793002771
Metrics
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