Intensive care unit (ICU) use varies significantly between the USA and Europe, raising important questions about approaches to the critical care of patients with severe sepsis and septic shock, say researchers.
Surviving Sepsis Campaign (SSC) data for the two populations show that while raw rates of hospital mortality were higher in Europe, there were significant differences in the origin of patients before ICU admission.
Indeed, more patients in the USA than Europe were admitted to the ICU directly from emergency departments, and the median length of stay in hospital before ICU admission was longer in Europe than in the USA.
"This might account for the mortality difference between the two regions, since patients with severe sepsis admitted to the wards in Europe who do well and are ultimately discharged are not recorded," suggest Mitchell Levy (Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA) and colleagues.
The team compared models of care and outcomes including compliance, mortality, and length of stay for 25,375 patients treated in ICUs in the USA and Europe for severe sepsis and/or septic shock, and whose data was recorded in the SSC database between January 2005 and January 2010.
Overall, 32.0% of patients died in hospital during the study period, with higher mortality rates in Europe than the USA, at 41.1% versus 28.3%.
However, after adjusting data for factors including sepsis origin, pulmonary infection, cardiovascular organ failure, and length of stay before ICU admission, the difference in mortality rates between regions was no longer significant.
More US patients were admitted to the ICU from emergency departments than their European counterparts (65.1 vs 32.7%), while more European than US patients went to the ICU from a general ward (51.5 vs 25.4%). The rate of nosocomial infections was higher in Europe compared with the USA (42.5 vs 18.7%), and the median length of stay in hospital before admission to ICU was longer in Europe (1.0 vs 0.1 days).
Overall lengths of stay in hospital and in the ICU were a significant 1.29 and 1.50 times longer in Europe than the USA, even after adjustment for potential confounders, note the researchers in The Lancet Infectious Diseases.
In an accompanying editorial, Julian Bion (Queen Elizabeth Hospital, Birmingham, UK) suggests that the findings support arguments against using standardized mortality ratios as a measure of healthcare adequacy or quality.
"Improvements in outcomes from a disorder such as sepsis, which has so many presentations, require a systems-wide human factors approach to quality improvement combined with awareness-raising."
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