Table 2.

Two illustrative vignettes for each presepsis trajectory class

Low use

An 80-yr-old man with congestive heart failure, COPD, stage III CKD, and no hospitalizations in the preceding year presented to the emergency department with fevers, altered mental status, acute-on-chronic renal failure, and respiratory distress. He was intubated in the emergency department, started on mechanical ventilation, and admitted to the hospital with diagnoses of sepsis and respiratory failure.

A 60-yr-old man with poorly controlled type 2 diabetes presented with acute nausea, vomiting, abdominal pain, and confusion. He was diagnosed with acute cholecystitis and admitted to the hospital with a diagnosis of severe sepsis. In the prior year, he had been hospitalized for 3 d after a syncopal episode about 6 mo before sepsis hospitalization.

Rising use

A 75-yr-old man with coronary artery disease and ischemic cardiomyopathy was hospitalized for 1 wk with a heart failure exacerbation after several months of progressive lower extremity edema and weight gain. Three weeks later, he was rehospitalized with another heart failure exacerbation, this time with new atrial fibrillation with rapid ventricular response. After 2 wk, he was discharged to a nursing facility for rehabilitation owing to progressive deconditioning over the course of his hospitalizations. Two weeks later, he was transferred from the nursing facility back to the emergency department with acute confusion, hypotension, fever, and abdominal pain, at which point he was admitted to the hospital for presumed sepsis.

A 75-yr-old man with type 2 diabetes and diabetic neuropathy was hospitalized for a nonhealing diabetic foot ulcer and ultimately underwent a below-the-knee amputation. After 2 wk, he was discharged to a nursing facility for rehabilitation. One week later, he was transferred back to the hospital with fevers and somnolence, at which point he was diagnosed with severe sepsis secondary to healthcare-associated pneumonia.

High use

An 85-yr-old man with congestive heart failure and osteoarthritis underwent a total knee replacement surgery for knee osteoarthritis, followed by 2 months in a nursing facility for rehabilitation. Two months after discharge from rehabilitation, he presented to the emergency department with dysuria, leukocytosis, and acute renal failure, and he was admitted to the hospital with a diagnosis of urosepsis.

A 50-yr-old-man with end-stage cirrhosis had frequent hospitalizations for hepatic encephalopathy. After one hospitalization for decompensated cirrhosis and hepatic encephalopathy, he was discharged to a nursing facility for physical therapy and medical optimization. After spending 3 mo in the nursing facility, he was discharged to home. One month later, he had a short hospitalization for another bout of hepatic encephalopathy. Two and one-half months later, he presented to the emergency department with nausea, vomiting, fevers, and abdominal pain, at which point he was diagnosed with acute cholecystitis and severe sepsis.

Definition of abbreviations: CKD = chronic kidney disease; COPD = chronic obstructive pulmonary disease.

Vignettes were abstracted by chart review. Patient age was rounded to the nearest 5-year category to preserve patient anonymity.