What Can We Learn from Differences in Hospitals’ Sepsis Care?

Sepsis remains a major cause of mortality and disability the world over. Death certificate analyses suggest that sepsis accounts for at least one in five deaths worldwide (1). There is considerable variation, however, in sepsis incidence and mortality between regions. Age-standardized sepsis mortality rate estimates are almost 20 times higher in sub-Saharan Africa than in Western Europe. There is also substantial variability within regions: Age-standardized mortality rates vary fourfold across Europe, ranging from 18.0 to 81.9 deaths per 100,000 persons (Finland and Moldova, respectively) (1).

The considerable variability in sepsis mortality rates within and between regions begs the question, “Why?” Is the variability due to differences in patient factors (comorbidities, infection types, pathogens, etc.), infrastructure (distance to hospital, hospital services, etc.), or care factors (sepsis screening and recognition, time to antibiotics, fluid resuscitation, etc.)? A comprehensive survey on sepsis care in over 1,000 hospitals, mainly in Europe, published in this issue of the Journal (pp. 587–599) provides welcome insight into differences in sepsis infrastructure and care protocols within Europe (2).

The European Sepsis Care Survey was a voluntary survey organized by the European Sepsis Alliance to assess hospitals’ adoption of Surviving Sepsis Campaign guideline recommendations and their infrastructure to support sepsis care. The survey was conducted between August 2021 and June 2022. Responses were received from 1,023 hospitals, 82% of which were in Europe. The authors identified substantial differences between hospitals in their processes of care, infrastructure, and data monitoring.

Key findings included the following. Less than one-third of surveyed hospitals had formal sepsis quality improvement programs. Almost 50% of emergency departments were not routinely using sepsis screening tools such as systemic inflammatory response syndrome criteria, quick Sequential Organ Failure Assessment criteria, or early warning scores. Only 57% of emergency departments had implemented standardized management bundles for patients with sepsis. Less than 5% of hospitals were providing targeted funding for a sepsis quality improvement program or specialized sepsis staff.

Similar gaps were apparent in hospitals’ infrastructure for timely sepsis diagnosis and management. About 90% of hospitals had round-the-clock access to computed tomography and magnetic resonance imaging, and 87% could access surgical services for source control at any time. Less than one-third of hospitals, however, had access to interventional radiology for source control whenever needed, and less than 10% of hospitals provided microbiology services such as blood culture inoculation, identification of pathogens, and result reporting outside of standard working hours. About three-fourths of hospitals provided local guidelines or standard operating procedures to guide antibiotic choices for patients with sepsis, but only two-thirds of hospitals had antimicrobial stewardship teams, and less than one-third had regular access to infectious disease specialists for consultation.

Likewise, most hospitals conducted very limited monitoring of sepsis rates, outcomes, and processes of care. Only about half monitored sepsis incidence and mortality. One-fifth monitored time to antibiotic administration. Less than one-fifth measured sepsis bundle compliance overall.

The considerable variability and low overall implementation of sepsis protocols, support services, and monitoring documented by the European Sepsis Care Survey is concerning. Sepsis is a leading cause of death worldwide that merits dedicated attention, resources, and expertise. The challenge all hospitals face, however, is determining how best to allocate their limited resources to maximize patient benefit. The European Sepsis Care Survey assessed a very broad range of potential screening strategies, care processes, and support infrastructure that may improve sepsis outcomes. There are very limited data, however, on which of these are most impactful and thus ought to be prioritized by hospitals working to improve their sepsis care and outcomes.

The U.S. experience with sepsis quality improvement is perhaps informative in this regard. Whereas barely one-third of hospitals in the European Sepsis Care Survey had sepsis quality improvement programs and only about half were actively screening patients for sepsis, more than three-fourths of U.S. hospitals have sepsis quality improvement programs, and more than 90% screen patients for sepsis (3). This large difference is almost certainly attributable to U.S. state and federal initiatives that require hospitals to implement sepsis screening and treatment protocols and/or report their compliance with sepsis management bundles. These initiatives have raised sepsis consciousness among providers, administrators, and members of the public and are helping to ensure that all hospitals develop formal pathways to improve sepsis recognition and initial care.

There is healthy debate, however, regarding the extent to which these initiatives have improved outcomes for patients. Studies that compare outcomes for patients who received bundle-compliant versus noncompliant care report that the compliant care is associated with lower mortality (4). Studies evaluating longitudinal trends in sepsis mortality rates in U.S. hospitals, however, report increases in lactate measurements and broad-spectrum antibiotic use but no change in sepsis mortality rates (5, 6).

Different solutions have been proposed to more definitively lower sepsis mortality rates. Possibilities include further increasing bundle adherence, shifting from a 3-hour bundle to a 1-hour bundle, introducing more rapid pathogen diagnostics, improving antibiotic stewardship, and using more aggressive measures to prevent hospital-acquired infections and other complications (7–10). As with our colleagues in Europe, then, we are also wondering what are the most critical and impactful system-level processes or infrastructure that hospitals need to implement or enhance to improve sepsis outcomes?

We believe a critical step toward answering this question is the deployment of standardized, objective sepsis surveillance metrics to enable us to compare sepsis incidence and risk-adjusted outcomes between hospitals. This will enable us to identify the best performing hospitals so that we can learn from their programs and processes, rigorously assess the association between different sepsis program components and sepsis outcomes, and enable hospitals and regulators to track the progress of sepsis infrastructure and quality improvement initiatives.

The Centers for Disease Control and Prevention and the Centers for Medicaid and Medicare Services are currently developing a sepsis outcome metric precisely to help hospitals better understand how their sepsis outcomes compare with peer institutions, identify modifiable factors associated with better outcomes, and catalyze further improvements in sepsis programs and processes (11). The new metric is modeled on the Centers for Disease Control and Prevention’s Adult Sepsis Event (ASE) criteria, which use clinical data extracted from electronic health records to identify patients with suspected infection and concurrent organ dysfunction in accordance with current consensus criteria for sepsis (12, 13). Outcomes will be risk adjusted using detailed clinical data on the sepsis population also drawn from the electronic health record (14).

The European Sepsis Care Survey highlights substantial gaps and variability in care processes and infrastructure between hospitals but provides little insight into which processes, protocols, programs, and infrastructure are most critical to improve sepsis outcomes. We hope that forthcoming risk-adjusted, objective sepsis outcome measures will provide the additional insights needed to help hospitals identify and prioritize the highest yield gaps to be addressed.