When it comes to comparing patient outcomes in sepsis, we antipodeans often smugly sit back and comment that “we don’t need no surviving sepsis campaign” (apologies to Pink Floyd) because our outcomes are compatible with, or better than those seen in the experimental arm of Rivers’ Early Goal Directed Therapy (EGDT) campaign. The survival rate in the EGDT study was 30.5%, compared with 35.3% in the comparator arm of the severe sepsis subgroup of the SAFE study and, more recently, 23.7% in the comparator arm of the sepsis subgroup of the CHEST study.
My personal smugness continued when I read the title of this early release article by Mitchell Levy et al from Lancet Infectious Diseases a few days ago; “Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort study.” So you can imagine my surprise when I got to the punchline and found out that the (unadjusted) hospital mortality (a secondary outcome of the study) was 41.1% in the European group 28.3% in the US group. Surely not? Maybe the sample size was too small. Nope, 25,375 patients. That’s pretty impressive. So what on earth was going on? Are European intensivists so busy rioting and watching Eurovision that they’re neglecting their patients? Let’s have a look.
The study was a large retrospective analysis of the surviving sepsis database across 107 ICUs in The USA and Europe. As mentioned, 25,375 patients with severe sepsis or septic shock were included, 74% from the US and 26% from Europe. The primary outcome was compliance with surviving sepsis guidelines in the first 6 hours and the first 24 hours. Secondary outcomes included hospital mortality and ICU length of stay. Interesting differences between the cohorts included the fact that 65% of US patients came to ICU via the ED, compared with only 32% of Europeans. Therefore 51% of European patients came to ICU via the ward, compared with only 25% of Americans. Regardless of origin, European patients had a longer hospital stay before arriving in the ICU (3.4 compared with 1.5 days for ward). This difference in patient origin has no doubt contributed to the difference seen in outcome data. Although no cause is apparent from the data, it seems appropriate to hypothesize that the lower number of ICU beds per capita in Europe (in general, with exceptions such as Germany and Belgium) means that patients who would go directly to ICU in the US end up going to the ward until they get sicker, making ICU admission more likely.
As a result of this, the European patients were a sicker group, with a higher SOFA score, a higher incidence of nosocomial sepsis, a longer ICU stay and a higher incidence of mechanical ventilation. This of course explains the higher unadjusted mortality. The US patients seemed to be a less sick cohort, with a much higher incidence of single organ dysfunction, particularly urosepsis, for example. Despite the striking difference in unadjusted mortality (OR 1.8) mentioned in the preamble, once the mortality is adjusted for severity this difference disappears (OR 1.05 but no longer significant). So it appears that the quality of intensive care is no different on either side of the Atlantic. What does appear to be different is that the inevitable triaging that must occur when ICU beds are in short supply seems to have an impact on mortality.
So where does this leave us. Particularly down under? I think it highlights the fact that sick patients need to be looked after in ICU, and shouldn’t have to wait for the privilege. I’ll be filing this study under politics rather than clinical medicine. I think it helps to show that, despite being an expensive resource, intensive care saves lives and it can’t be carried out ad-hoc by overworked doctors and nurses on medical wards. Critically ill patients with sepsis need to be in an ICU being looked after by intensivists and intensive care nurses. I suspect that a cost analysis of the cost of ICU care for the patients who died versus the cost society of them dying will show quite a saving.
Here’s the study if you want to have a look for yourself;
Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort study
Prof Mitchell M Levy MD,Prof Antonio Artigas MD,Gary S Phillips MAS,Andrew Rhodes MBBS,Richard Beale MBBS,Tiffany Osborn MD,Prof Jean-Louis Vincent MD,Sean Townsend MD,Prof Stanley Lemeshow PhD,Prof R Phillip Dellinger MD
The Lancet Infectious Diseases – 26 October 2012