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Bypassing Rural Hospitals for Severe Sepsis and Septic Shock Increases Mortality

Amesh A. Adalja, MD, FACP, FACEP, FIDSA, December 30, 2016

For over a decade, there has been an increasing emphasis on rapidly identifying and treating sepsis, severe sepsis, and septic shock, the dysregulated immune response to infection that is the final common pathway to death and disability in many infectious diseases. As part of this effort, guidelines, paradigms, and protocols have been developed with variable uptake among the more than 5,000 hospitals in the United States. For many conditions, high-volume centers are considered by patients and healthcare providers alike to be the top-tier treatment locations, and studies have generally supported that conclusion. However, there is a danger if people with life-threatening conditions bypass nearby hospitals to travel further to a high-volume center. A new study published in Critical Care Medicine attempts to address this question for severe sepsis and septic shock.


Mortality 5.6% Higher with Bypass of Rural Iowa Emergency Departments

In this study, Mohr and colleagues reviewed administrative billing claims for severe sepsis and septic shock from adult patients who were treated in an Iowa ED between 2005 and 2014. Using patient demographic data, they calculated driving distances between hospitals and zip code of residence. The aim of the study was to determine the percentage of rural patients who bypassed a local hospital and what impact that had on mortality.

The vast majority of patients (94.6%) sought care at their local hospital, and those that chose this route were more likely to survive their hospitalization than those who presented to a tertiary care center. The average distance traveled to reach another hospital was 51 miles. The mortality rate was 5.6% higher in that cohort of patients. Older individuals were less likely to bypass a rural hospital, and those with comorbid conditions or commercial insurance were more likely to bypass. Not surprisingly, the rate of transfer was lower in patients who bypassed a rural hospital, and, interestingly, those who were transferred after being admitted had a higher mortality rate than those transferred directly from the ED.


Implications for Regionalization of Care for Sepsis

This study has important implications for those studying how certain medical services should be regionalized. Regionalization of care has many important benefits and may be the best model to pursue in health care for some conditions. While regionalization efforts progress, certain services should be considered core functions for hospitals of all types by patients and providers alike. Basic resuscitation principles of severe sepsis and septic shock—a condition in which each hour’s delay in treatment worsens outcome—is one such condition. To improve sepsis-related mortality, patients need to know that all hospital EDs are prepared to initially diagnose and begin resuscitation (fluid, antibiotics, etc) for patients with severe sepsis and septic shock.  



Mohr NM, Harland KH, Shane DM, et al. Rural patients with severe sepsis who bypass rural hospitals have increased mortality: an instrumental variables approach. Crit Care Med 2016;45:85-93.