Comparing the demographic data and outcomes of septic shock patients presenting to teaching or non-teaching metropolitan hospitals in the United States

doi:10.5847/wjem.j.1920-8642.2022.101

Abstract

Abstract:

BACKGROUND: Studies looking at the effect of hospital teaching status on septic shock related in-hospital mortality are lacking. The aim of this study was to examine the effect of hospital teaching status on mortality in septic shock patients in the United States.

METHODS: This was a retrospective observational study, using the Nationwide Emergency Department Sample Database (released in 2018). All patients with septic shock were included. Complex sample logistic regression was performed to assess the impact of hospital teaching status on patient mortality.

RESULTS: A total of 388,552 septic shock patients were included in the study. The average age was 66.93 years and 51.7% were males. Most of the patients presented to metropolitan teaching hospitals (68.2%) and 31.8% presented to metropolitan non-teaching hospitals. Septic shock patients presenting to teaching hospitals were found to have a higher percentage of medical comorbidities, were more likely to be intubated and placed on mechanical ventilation (50.5% vs. 46.9%) and had a longer average length of hospital stay (12.47 d vs. 10.20 d). Septic shock patients presenting to teaching hospitals had greater odds of in-hospital mortality compared to those presenting to metropolitan non-teaching hospitals (adjusted odd ratio [OR]=1.295, 95% confidence interval [CI]: 1.256-1.335).

CONCLUSION: Septic shock patients presenting to metropolitan teaching hospitals had significantly higher risks of mortality than those presenting to metropolitan non-teaching hospitals. They also had higher rates of intubation and mechanical ventilation as well as longer lengths of hospital stay than those in non-teaching hospitals.

Key words: Sepsis, Septic shock, In-hospital mortality, Hospital teaching status, United States, Epidemiology, Outcome

Ralph Bou Chebl, Nadim Kattouf, Mohamad Assaf, Saadeddine Haidar, Gilbert Abou Dagher, Sarah Abdul Nabi, Rana Bachir, Mazen El Sayed. Comparing the demographic data and outcomes of septic shock patients presenting to teaching or non-teaching metropolitan hospitals in the United States[J]. World Journal of Emergency Medicine, 2022, 13(6): 433-440.

Figures/Tables 5

Figure 1.

Table 1.

The characteristics and disposition of the septic shock patients presenting to the emergency department

Variables	Frequency/mean (n=388,552)	Percentage (95%CI)/ 95%CI alone
Gender Male Female Missing = 144 (0.01%)	200,662 187,746	51.7 (51.4-52.0) 48.3 (48.0-48.6)
Average age of patients, years	66.93	66.84-67.03
Past medical history History of infectious and parasitic disease Malignancy Endocrine, nutritional, metabolic diseases and immunity disorders Diseases of blood and blood-forming organs Psychiatric disorders Diseases of the nervous system Diseases of the circulatory system Diseases of the respiratory system Diseases of the digestive system Diseases of the genitourinary system Diseases of the skin and subcutaneous tissue Diseases of the musculoskeletal system	380,129 70,087 360,963 245,795 183,053 224,667 339,981 310,263 224,493 326,819 93,019 118,864	97.8 (97.7-97.9) 18.0 (17.8-18.3) 92.9 (92.7-93.0) 63.3 (63.0-63.5) 47.1 (46.8-47.4) 57.8 (57.5-58.1) 87.5 (87.3-87.7) 79.9 (79.6-80.1) 57.8 (57.5-58.1) 84.1 (83.9-84.3) 23.9 (23.7-24.2) 30.6 (30.3-30.9)
Region of the hospital Northeast Midwest South West	76,219 74,802 148,958 88,573	19.6 (19.6-19.6) 19.3 (19.3-19.3) 38.3 (38.3-38.3) 22.8 (22.8-22.8)
Teaching status of hospital Metropolitan non-teaching Metropolitan teaching	123,731 264,821	31.8 (31.8-31.8) 68.2 (68.2-68.2)
Disposition of patient from emergency department Transfer to another short-term hospital Other transfers (including skilled nursing facility, intermediate care, and another type of facility) Admitted as an inpatient to this hospital Died in emergency department	2,414 635 383,372 2,131	0.6 (0.6-0.7) 0.2 (0.1-0.2) 98.7 (98.6-98.7) 0.5 (0.5-0.6)
Disposition of patient from hospital Discharged home Transfer to short-term hospital Other transfers (including skilled nursing facility, intermediate care, and another type of facility) Home health care Against medical advice Deceased Discharged alive with unknown destination Missing= 5,304 (1.4%)	64,363 15,557 133,917 47,893 2,988 118,471 59	16.8 (16.6-17.0) 4.1 (3.9-4.2) 34.9 (34.7-35.2) 12.5 (12.3-12.7) 0.8 (0.7-0.8) 30.9 (30.6-31.2) 0 (0-0)
In-hospital mortality No Yes	267,950 120,602	69.0 (68.7-69.2) 31.0 (30.8-31.3)
Average length of stay, d	11.76	11.67-11.84

Table 1.

Table 2.

Table 3.

The characteristics, disposition and hospital procedures of the septic shock patients presenting to the emergency department based on hospital teaching status

Variables	Metropolitan non-teaching hospital		Metropolitan teaching hospital		P-value
Variables	Frequency (n=123,730)	Percentage (95%CI) or mean (95%CI)	Frequency (n=264,822)	Percentage (95%CI) or mean (95%CI)	P-value
Gender Male Female	63,547 60,141	51.4 (50.9-51.9) 48.6 (48.1-49.1)	137,115 127,605	51.8 (51.4-52.2) 48.2 (47.8-48.6)	0.190
Average age, years	123,730	68.01 (67.86-68.17)	264,822	66.43 (66.32-66.54)	<0.001
Past medical history History infectious or parasitic disease Malignancy Endocrine, nutritional, metabolic diseases and immunity disorders Diseases of blood and blood-forming organs Psychiatric disorders Diseases of the nervous system Diseases of the circulatory system Diseases of the respiratory system Diseases of the digestive system Diseases of the genitourinary system Diseases of the skin and subcutaneous tissue Diseases of the musculoskeletal system	120,664 20,564 114,645 76,852 58,635 71,340 108,627 98,163 69,771 103,844 27,182 37,871	97.5 (97.4-97.7) 16.6 (16.2-17.0) 92.7 (92.4-92.9) 62.1 (61.6-62.6) 47.4 (46.9-47.9) 57.7 (57.1-58.2) 87.8 (87.5-88.1) 79.3 (78.9-79.8) 56.4 (55.9-56.9) 83.9 (83.5-84.3) 22.0 (21.5-22.4) 30.6 (30.1-31.1)	259,465 49,523 246,317 168,943 124,418 153,327 231,354 212,100 154,721 222,976 65,837 80,993	98.0 (97.9-98.1) 18.7 (18.4-19.0) 93.0 (92.8-93.2) 63.8 (63.5-64.1) 47.0 (46.6-47.3) 57.9 (57.5-58.2) 87.4 (87.1-87.6) 80.1 (79.8-80.4) 58.4 (58.1-58.8) 84.2 (83.9-84.5) 24.9 (24.6-25.2) 30.6 (30.3-30.9)	<0.001 <0.001 0.029 <0.001 0.201 0.444 0.042 0.003 <0.001 0.249 <0.001 0.936
Region of hospital Northeast Midwest South West	15,654 21,961 49,771 36,344	12.7 (12.7-12.7) 17.7 (17.7-17.7) 40.2 (40.2-40.2) 29.4 (29.4-29.4)	60,565 52,841 99,186 52,229	22.9 (22.9-22.9) 20.0 (20.0-20.0) 37.5 (37.5-37.5) 19.7 (19.7-19.7)	<0.001
Disposition of patient from emergency department Transfer to short-term hospital Other transfers (including skilled nursing facility, intermediate care, and another type of facility) Admitted as an inpatient to this hospital Died in emergency department	1,584 275 121,153 718	1.3 (1.2-1.4) 0.2 (0.2-0.3) 97.9 (97.8-98.1) 0.6 (0.5-0.7)	831 359 262,218 1,413	0.3 (0.3-0.4) 0.1 (0.1-0.2) 99.0 (98.9-99.1) 0.5 (0.5-0.6)	<0.001
Disposition of patient from hospital Discharged home or home health care Transfer to short-term hospital or other transfers (including skilled nursing facility, intermediate care, and another type of facility) Deceased Against medical advice or discharged alive with unknown destination	36,604 49,238 34,014 1,222	30.2 (29.8-30.7) 40.7 (40.2-41.2) 28.1 (27.6-28.6) 1.0 (0.9-1.1)	75,653 100,236 84,457 1,824	28.9 (28.5-29.2) 38.2 (37.9-38.6) 32.2 (31.9-32.5) 0.7 (0.6-0.8)	<0.001
In-hospital mortality No Yes	88,999 34,731	71.9 (71.5-72.4) 28.1 (27.6-28.5)	178,950 85,871	67.6 (67.2-67.9) 32.4 (32.1-32.8)	<0.001
Average length of stay, d	121,135	10.20 (10.09-10.31)	262,177	12.47 (12.37-12.58)	<0.001
Hospital procedures (for patients admitted to the same hospital of the emergency department) Small bowel resection Colorectal resection Appendectomy Fluoroscopy of the biliary and pancreatic ducts (ERCP, ERC and ERP) Cholecystectomy and common duct exploration Laparoscopy (GI only) Exploratory laparotomy Other non-operative upper GI therapeutic procedures Other operative upper GI therapeutic procedures Other non-operative lower GI therapeutic procedures Other operative lower GI therapeutic procedures Other gastrointestinal diagnostic procedures Other non-operative gastrointestinal therapeutic procedures Other operative gastrointestinal therapeutic procedures Respiratory intubation and mechanical ventilation	n=121,154 479 2,615 756 478 1,561 493 383 3,324 1,647 690 2,812 1,913 3,207 2,643 56,761	0.4 (0.3-0.5) 2.2 (2.0-2.3) 0.6 (0.5-0.7) 0.4 (0.3-0.5) 1.3 (1.2-1.4) 0.4 (0.3-0.5) 0.3 (0.3-0.4) 2.7 (2.6-2.9) 1.4 (1.2-1.5) 0.6 (0.5-0.7) 2.3 (2.2-2.5) 1.6 (1.5-1.7) 2.6 (2.5-2.8) 2.2 (2.0-2.3) 46.9 (46.3-47.4)	n=262,218 675 5,264 1,173 1,161 2,376 1,045 1,276 9,163 4,297 1,832 6,823 6,807 8,636 6,750 132,550	0.3 (0.2-0.3) 2.0 (1.9-2.1) 0.4 (0.4-0.5) 0.4 (0.4-0.5) 0.9 (0.8-1.0) 0.4 (0.4-0.4) 0.5 (0.4-0.5) 3.5 (3.4- 3.6) 1.6 (1.6-1.7) 0.7 (0.6-0.8) 2.6 (2.5-2.7) 2.6 (2.5-2.7) 3.3 (3.2-3.4) 2.6 (2.5-2.7) 50.5 (50.2-50.9)	<0.001 0.104 <0.001 0.260 <0.001 0.834 <0.001 <0.001 0.001 0.013 0.006 <0.001 <0.001 <0.001 <0.001

Table 3.

Table 4.

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Procedures	Frequency (n=383,372)	Percentage (95%CI)
Procedure class for inpatient procedure Minor diagnostic Minor therapeutic Major diagnostic Major therapeutic	167,559 318,419 11,771 73,161	43.7 (43.4-44.0) 83.1 (82.8-83.3) 3.1 (3.0-3.2) 19.1 (18.9-19.3)
Hospital procedures Small bowel resection Colorectal resection Appendectomy Fluoroscopy of the biliary and pancreatic ducts (ERCP, ERC and ERP) Cholecystectomy and common duct exploration Laparoscopy (GI only) Exploratory laparotomy Other non-operative upper GI therapeutic procedures Other operative upper GI therapeutic procedures Other non-operative lower GI therapeutic procedures Other operative lower GI therapeutic procedures Other gastrointestinal diagnostic procedures Other non-operative gastrointestinal therapeutic procedures Other operative gastrointestinal therapeutic procedures Respiratory intubation and mechanical ventilation	1,153 7,879 1,929 1,640 3,937 1,538 1,660 12,487 5,944 2,522 9,635 8,720 11,843 9,393 189,311	0.3 (0.3-0.3) 2.1 (2.0-2.1) 0.5 (0.5-0.5) 0.4 (0.4-0.5) 1.0 (1.0-1.1) 0.4 (0.4-0.4) 0.4 (0.4-0.5) 3.3 (3.2-3.4) 1.6 (1.5-1.6) 0.7 (0.6-0.7) 2.5 (2.4-2.6) 2.3 (2.2-2.4) 3.1 (3.0-3.2) 2.5 (2.4-2.5) 49.4 (49.1-49.7)

Teaching status of hospital	Crude				Adjusted*
Teaching status of hospital	OR	95% CI	P-value		OR	95% CI	P-value
Metropolitan non-teaching Metropolitan teaching	- 1.230	- 1.196-1.264	- <0.001		- 1.295	- 1.256-1.335	- <0.001

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