Background: Severe sepsis is a complex and high mortality condition. High-volume sepsis centers generally have improved sepsis outcomes, but even patients transferred to high-volume centers continue to have worse outcomes. These findings support a need for improved early identification, intervention, and risk stratification of patients with severe sepsis. Objective: The objective of this study was to identify hospital-specific factors associated with inter-hospital transfer and sepsis survival. We hypothesized that decreased inter-hospital transfer was associated with institutions that have a physician in-house 24-hours a day, intensive care units, the use of critical care telemedicine (CC), the ability to place and maintain central venous catheters (CVC), and formal sepsis protocols/care plans/order sets.
Methods: This study was a cross-sectional telephone survey/capabilities inventory of Iowa ED administrators (May-July 2017) combined with a retrospective cohort of adults seen in Iowa EDs for severe sepsis and septic shock between January 2005 and December 2013. Univariate comparisons were used to identify predictors of inter-hospital transfer, which were then included in a multivariate logistic regression model and reported in the form of unadjusted and adjusted odds ratios, respectively.
Results: One-hundred fourteen institutions provided data (response rate= 99%), and these institutions matched to a total of 150,845 visits for severe sepsis/septic shock. The adjusted multivariate model suggested that only having the capability to place CVCs and having a subscription to a CC-telemedicine service were independently associated with lower odds of inter-hospital transfer (aOR: 0.69, 95%CI: 0.54-0.86; aOR: 0.69, 95%CI: 0.54-0.88, respectively). A facility’s participation in a sepsis-specific quality improvement initiative was associated with 62% higher odds of transfer in the multivariate model (95%CI: 1.10-2.39).
Conclusion: Although many factors were associated with sepsis-specific inter-hospital transfer, the ability to place CVCs and the availability of CC-telemedicine were the only 2 factors independently associated with transfer behaviors. These factors suggest that sepsis capability indices could be developed to stratify hospitals on their ability to care for sepsis patients, as a first step in developing regional sepsis networks.