Complex Sepsis Presentations, SEP-1 Compliance, and Outcomes

Chanu Rhee; Sarah E Train; Michael R Filbin; Steven T Park; Nicholas M Mohr; Anne Zepeski; Brett A Faine; David J Roach; Emily Porter; Claire N Shappell; Kamryn Plechot; Laura DelloStritto; Tingting Yu; Michael Klompas

doi:10.1001/jamanetworkopen.2025.1100

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Complex Sepsis Presentations, SEP-1 Compliance, and Outcomes

Journal article

Open access

Peer reviewed

Complex Sepsis Presentations, SEP-1 Compliance, and Outcomes

Chanu Rhee, Sarah E Train, Michael R Filbin, Steven T Park, Nicholas M Mohr, Anne Zepeski, Brett A Faine, David J Roach, Emily Porter, Claire N Shappell, …

JAMA network open, Vol.8(3), e251100

03/03/2025

DOI: 10.1001/jamanetworkopen.2025.1100

PMCID: PMC11923707

PMID: 40105841

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Abstract

The Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock Management Bundle (SEP-1) is supported by observational studies that report SEP-1 compliance is associated with lower mortality. Most studies, however, adjusted for limited confounders and provided little insight into why bundle-compliant care was not provided. To identify the clinical factors that complicate the diagnosis and management of sepsis and assess their association with SEP-1 compliance and mortality. This retrospective cohort study was conducted among 590 adults with sepsis in the emergency department of 4 academic hospitals from January 1, 2019, to December 31, 2022. Patients' medical records were reviewed between September 2022 and December 2023. Study outcomes were (1) characteristics of patients who received SEP-1-compliant care vs characteristics of patients who received noncompliant care and (2) association between SEP-1 compliance and hospital mortality using multivariable models to adjust for successively more potential confounders (first demographics and comorbidities, then infection source, then severity of illness, and then clinical markers of complexity). Of 590 patients with sepsis (median age, 65 years [IQR, 53-77 years]; 329 men [55.8%]), 335 (56.8%) received SEP-1-compliant care, and 225 (43.2%) received noncompliant care. Compared with patients in the compliant group, patients in the noncompliant group were more likely to be 65 years or older (142 [55.7%] vs 158 [47.2%]; odds ratio [OR], 1.41 [95% CI, 1.01-1.95]), to have multiple comorbidities (Elixhauser score >20: 99 [38.8%] vs 99 [29.6%]; OR, 1.51 [95% CI, 1.07-2.13]), and to have a higher incidence of septic shock (107 [42.0%] vs 107 [31.9%]; OR, 1.54 [95% CI, 1.10-2.16]), kidney dysfunction (87 [34.1%] vs 80 [23.9%]; OR, 1.65 [95% CI, 1.15-2.37]), and thrombocytopenia (43 [16.9%] vs 37 [11.0%]; OR, 1.16 [95% CI, 1.02-2.62]) on presentation. Compared with patients in the compliant group, those in the noncompliant group also had more nonfebrile presentations (136 [53.3%] vs 121 [36.1%]; OR, 2.02 [95% CI, 1.45-2.82]), impaired mental status (92 [36.1%] vs 94 [28.1%]; OR, 1.45 [95% CI, 1.02-2.05]), need for bedside procedures (57 [22.4%] vs 41 [12.2%]; OR, 2.06 [95% CI, 1.33-3.21]), acute concurrent noninfectious illnesses (140 [54.9%] vs 151 [45.1%]; OR, 1.48 [95% CI, 1.07-2.06]), and noninfectious illness as the primary factor associated with their presentation (84 [32.9%] vs 71 [21.2%]; OR, 1.82 [95% CI, 1.08-3.08]). SEP-1 compliance was associated with lower crude mortality rates compared with noncompliance (40 [11.9%] vs 41 [16.1%]; unadjusted OR, 0.60 [95% CI, 0.37-0.98]), but there was no statistically significant difference between groups after successively adjusting for demographics and comorbidities (adjusted OR [AOR], 0.71 [95% CI, 0.42-1.18]), infection source (AOR, 0.71 [95% CI, 0.43-1.20]), severity of illness (AOR, 0.86 [95% CI, 0.50-1.49]), and clinical markers of complexity (AOR, 1.08 [95% CI, 0.61-1.91]). In this cohort study of adults with sepsis, complex clinical presentations were more common among patients whose treatment was noncompliant with SEP-1. These nuances are poorly captured in most observational studies but confound the association between SEP-1 compliance and mortality.

Aged

Emergency Service, Hospital - statistics & numerical data

Female

Guideline Adherence - statistics & numerical data

Hospital Mortality

Humans

Male

Middle Aged

Patient Care Bundles

Retrospective Studies

Sepsis - epidemiology

Sepsis - mortality

Shock, Septic - mortality

United States - epidemiology

Details

Title: Subtitle: Complex Sepsis Presentations, SEP-1 Compliance, and Outcomes
Creators: Chanu Rhee - Brigham and Women's Hospital
Sarah E Train - Brigham and Women's Hospital
Michael R Filbin - Massachusetts General Hospital
Steven T Park - University of California, Irvine
Nicholas M Mohr - University of Iowa
Anne Zepeski - University of Iowa
Brett A Faine - University of Iowa
David J Roach - Brigham and Women's Hospital
Emily Porter - Massachusetts General Hospital
Claire N Shappell - Brigham and Women's Hospital
Kamryn Plechot - University of California, Irvine Medical Center
Laura DelloStritto - Harvard Pilgrim Health Care
Tingting Yu - Harvard Pilgrim Health Care
Michael Klompas - Harvard Pilgrim Health Care
Resource Type: Journal article
Publication Details: JAMA network open, Vol.8(3), e251100
DOI: 10.1001/jamanetworkopen.2025.1100
PMID: 40105841
PMCID: PMC11923707
NLM abbreviation: JAMA Netw Open
ISSN: 2574-3805
eISSN: 2574-3805
Publisher: AMER MEDICAL ASSOC
Grant note: Centers for Disease Control and Prevention: U54CK000611 Agency for Healthcare Research and Quality: K08HS029518
This work was funded by grant U54CK000611 from the Centers for Disease Control and Prevention and grant K08HS029518 from the Agency for Healthcare Research and Quality (Dr Shappell).
Language: English
Date published: 03/03/2025
Academic Unit: Epidemiology; Emergency Medicine; Pharmacy Practice and Science; Anesthesia; Injury Prevention Research Center
Record Identifier: 9984801891302771

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