Adherence to the SEP-1 Sepsis Bundle in Hospital-Onset v. Community-Onset Sepsis: a Multicenter Retrospective Cohort Study

Abstract

Background: Sepsis is the leading cause of in-hospital death. The SEP-1 sepsis bundle is a protocol for early sepsis care that requires providers to diagnose and treat sepsis quickly. Limited evidence suggests that adherence to the sepsis bundle is lower in cases of hospital-onset sepsis.

Objective: To compare sepsis bundle adherence in hospital-onset vs. community-onset sepsis.

Design: Retrospective cohort study using multivariable analysis of clinical data.

Participants: A total of 4658 inpatients age 18 or older were identified by diagnosis codes consistent with sepsis or disseminated infection.

Setting: Four university hospitals in California between 2014 and 2016.

Main outcomes and measures: The primary outcome was adherence to key components of the sepsis bundle defined by the Centers for Medicare and Medicaid Services in their core measure, SEP-1. Covariates included clinical characteristics related to the patient, infection, and pathogen.

Key results: Compared with community-onset, cases of hospital-onset sepsis were less likely to receive SEP-1 adherent care (relative risk 0.33, 95% confidence interval 0.29-0.38, p < 0.001). With the exception of vasopressors (RR 1.11, p = 0.002), each component of SEP-1 evaluated-blood cultures (RR 0.76, p < 0.001), serum lactate (RR 0.51, p < 0001), broad-spectrum antibiotics (RR 0.62, p < 0.001), intravenous fluids (0.47, p < 0.001), and follow-up lactate (RR 0.71, p < 0.001)-was less likely to be performed within the recommended time frame in hospital-onset sepsis. Within the hospital, cases of hospital-onset sepsis arising on the ward were less likely to receive SEP-1-adherent care than were cases arising in the intensive care unit (RR 0.68, p = 0.004).

Conclusions: Inpatients with hospital-onset sepsis receive different management than individuals with community-onset sepsis. It remains to be determined whether system-level factors, provider-level factors, or factors related to measurement explain the observed variation in care or whether variation in care affects outcomes.

Keywords: critical care; health services research; hospital medicine; infectious disease; performance measurement.

Figure 1

Patient flow diagram. Legend: CMS, The Centers for Medicare & Medicaid Services. SEP-1, Early Management Bundle, Severe Sepsis / Septic Shock.

Figure 2

Parts A–D. Time to 3-hour sepsis bundle and components. Legend: Curves have been truncated at 7 days. ED, emergency department. ICU, intensive care unit. Peri-op, perioperative area. IV, intravenous.