Giuseppe
Emeritus
[Source: The Lancet, full text: (LINK). Abstract, edited.]
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The Lancet Infectious Diseases, Early Online Publication, 26 October 2012
doi:10.1016/S1473-3099(12)70239-6
Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort study
Original Text
Prof Mitchell M Levy MD a, Prof Antonio Artigas MD b, Gary S Phillips MAS c, Andrew Rhodes MBBS e, Richard Beale MBBS f, Tiffany Osborn MD g, Prof Jean-Louis Vincent MD h, Sean Townsend MD i, Prof Stanley Lemeshow PhD d, Prof R Phillip Dellinger MD j
Summary
Background
Mortality from severe sepsis and septic shock differs across continents, countries, and regions. We aimed to use data from the Surviving Sepsis Campaign (SSC) to compare models of care and outcomes for patients with severe sepsis and septic shock in the USA and Europe.
Methods
The SSC was introduced into more than 200 sites in Europe and the USA. All patients identified with severe sepsis and septic shock in emergency departments or hospital wards and admitted to intensive care units (ICUs), and those with sepsis in ICUs were entered into the SSC database. Patients entered into the database from its launch in January, 2005, through January, 2010, in units with at least 20 patients and 3 months of enrolment of patients were included in this analysis. Patients included in the cohort were limited to those entered in the first 4 years at every site. We used random-effects logistic regression to estimate the hospital mortality odds ratio (OR) for Europe relative to the USA. We used random-effects linear regression to find the relation between lengths of stay in hospital and ICU and geographic region.
Findings
25 375 patients were included in the cohort. The USA included 107 sites with 18 766 (74%) patients, and Europe included 79 hospital sites with 6609 (26%) patients. In the USA, 12 218 (65?1%) were admitted to the ICU from the emergency department whereas in Europe, 3405 (51?5%) were admitted from the wards. The median stay on the hospital wards before ICU admission was longer in Europe than in the USA (1?0 vs 0?1 days, difference 0?9, 95% CI 0?8?0?9). Raw hospital mortality was higher in Europe than in the USA (41?1% vs 28?3%, difference 12?8, 95% CI 11?5?14?7). The median length of stay in ICU (7?8 vs 4?2 days, 3?6, 3?3?3?7) and hospital (22?8 vs 10?5 days, 12?3, 11?9?12?8) was longer in Europe than in the USA. Adjusted mortality in Europe was not significantly higher than that in the USA (32?3% vs 31?3%, 1?0, −1?7 to 3?7, p=0?468). Complete compliance with all applicable elements of the sepsis resuscitation bundle was higher in the USA than in Europe (21?6% vs 18?4%, 3?2, 2?2?4?4).
Interpretation
The significant difference in unadjusted mortality and the fact that this difference disappears with severity adjustment raise important questions about the effect of the approach to critical care in Europe compared with that in the USA. The effect of ICU bed availability on outcomes in patients with severe sepsis and septic shock requires further investigation.
Funding
Eli Lilly Co, Baxter Lifesciences, Philips Medical Systems, the Society of Critical Care Medicine, and the European Society of Intensive Care Medicine.
a Division of Pulmonary and Critical Care Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA; b Area de Cr?ticos, Hospital de Sabadell, Sabadell, Spain; c Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA; d College of Public Health, The Ohio State University, Columbus, Ohio, USA; e St George's Hospital, London, UK; f Guy's and St Thomas? Hospital Trust, London, UK; g Department of Surgery and Division of Emergency Medicine Barnes-Jewish Hospital, St Louis, MO, USA; h Erasme University Hospital, Brussels, Belgium; i California Pacific Medical Center, San Francisco, CA, USA; j Department of Critical Care, Cooper University Hospital, Camden, NJ, USA
Correspondence to: Prof Mitchell M Levy, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02906, USA
-doi:10.1016/S1473-3099(12)70239-6
Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort study
Original Text
Prof Mitchell M Levy MD a, Prof Antonio Artigas MD b, Gary S Phillips MAS c, Andrew Rhodes MBBS e, Richard Beale MBBS f, Tiffany Osborn MD g, Prof Jean-Louis Vincent MD h, Sean Townsend MD i, Prof Stanley Lemeshow PhD d, Prof R Phillip Dellinger MD j
Summary
Background
Mortality from severe sepsis and septic shock differs across continents, countries, and regions. We aimed to use data from the Surviving Sepsis Campaign (SSC) to compare models of care and outcomes for patients with severe sepsis and septic shock in the USA and Europe.
Methods
The SSC was introduced into more than 200 sites in Europe and the USA. All patients identified with severe sepsis and septic shock in emergency departments or hospital wards and admitted to intensive care units (ICUs), and those with sepsis in ICUs were entered into the SSC database. Patients entered into the database from its launch in January, 2005, through January, 2010, in units with at least 20 patients and 3 months of enrolment of patients were included in this analysis. Patients included in the cohort were limited to those entered in the first 4 years at every site. We used random-effects logistic regression to estimate the hospital mortality odds ratio (OR) for Europe relative to the USA. We used random-effects linear regression to find the relation between lengths of stay in hospital and ICU and geographic region.
Findings
25 375 patients were included in the cohort. The USA included 107 sites with 18 766 (74%) patients, and Europe included 79 hospital sites with 6609 (26%) patients. In the USA, 12 218 (65?1%) were admitted to the ICU from the emergency department whereas in Europe, 3405 (51?5%) were admitted from the wards. The median stay on the hospital wards before ICU admission was longer in Europe than in the USA (1?0 vs 0?1 days, difference 0?9, 95% CI 0?8?0?9). Raw hospital mortality was higher in Europe than in the USA (41?1% vs 28?3%, difference 12?8, 95% CI 11?5?14?7). The median length of stay in ICU (7?8 vs 4?2 days, 3?6, 3?3?3?7) and hospital (22?8 vs 10?5 days, 12?3, 11?9?12?8) was longer in Europe than in the USA. Adjusted mortality in Europe was not significantly higher than that in the USA (32?3% vs 31?3%, 1?0, −1?7 to 3?7, p=0?468). Complete compliance with all applicable elements of the sepsis resuscitation bundle was higher in the USA than in Europe (21?6% vs 18?4%, 3?2, 2?2?4?4).
Interpretation
The significant difference in unadjusted mortality and the fact that this difference disappears with severity adjustment raise important questions about the effect of the approach to critical care in Europe compared with that in the USA. The effect of ICU bed availability on outcomes in patients with severe sepsis and septic shock requires further investigation.
Funding
Eli Lilly Co, Baxter Lifesciences, Philips Medical Systems, the Society of Critical Care Medicine, and the European Society of Intensive Care Medicine.
a Division of Pulmonary and Critical Care Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA; b Area de Cr?ticos, Hospital de Sabadell, Sabadell, Spain; c Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA; d College of Public Health, The Ohio State University, Columbus, Ohio, USA; e St George's Hospital, London, UK; f Guy's and St Thomas? Hospital Trust, London, UK; g Department of Surgery and Division of Emergency Medicine Barnes-Jewish Hospital, St Louis, MO, USA; h Erasme University Hospital, Brussels, Belgium; i California Pacific Medical Center, San Francisco, CA, USA; j Department of Critical Care, Cooper University Hospital, Camden, NJ, USA
Correspondence to: Prof Mitchell M Levy, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02906, USA
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