Jeffrey M. Rohde, MD

Inappropriate antimicrobial use in hospitalized patients is a well‐recognized driver for the development of drug‐resistant organisms and antimicrobial‐related complications such as Clostridium difficile infection (CDI).[1, 2] Infection with C difficile affects nearly 500,000 people annually resulting in higher healthcare expenditures, longer lengths of hospital stay, and nearly 15,000 deaths.[3] Data from the Centers for Disease Control and Prevention (CDC) suggest that a 30% reduction in the use of broad‐spectrum antimicrobials, or a 5% reduction in the proportion of hospitalized patients receiving antimicrobials, could equate to a 26% reduction in CDI.[4] It is estimated that up to 50% of antimicrobial use in the hospital setting may be inappropriate.[5]

Since the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America published guidelines for developing formal, hospital‐based antimicrobial stewardship programs in 2007, stewardship practices have been adapted by frontline providers to fit day‐to‐day inpatient care.[5] A recent review by Hamilton et al. described several studies in which stewardship practices were imbedded into daily workflows by way of checklists, education reminders, and periodic review of antimicrobial usage, as well as a multicenter pilot of point‐of‐care stewardship interventions successfully implemented by various providers including nursing, pharmacists, and hospitalists.[6]

In response to the CDC's 2010 Get Smart for Healthcare campaign, which focused on stemming antimicrobial resistance and improving antimicrobial use, the Institute for Healthcare Improvement (IHI), in partnership with the CDC, brought together experts in the field to identify practical and feasible target practices for hospital‐based stewardship and created a Driver Diagram to guide implementation efforts (Figure 1). Rohde et al. described the initial pilot testing of these practices, the decision to more actively engage frontline providers, and the 3 key strategies identified as high‐yield improvement targets: enhancing the visibility of antimicrobial use at the point of care, creating easily accessible antimicrobial guidelines for common infections, and the implementation of a 72‐hour timeout after initiation of antimicrobials.[7]

Figure 1

In this article, we describe how, in partnership with the IHI and the CDC, the hospital medicine programs at 5 diverse hospitals iteratively tested these 3 strategies with a goal of identifying the barriers and facilitators to effective hospitalist‐led antimicrobial stewardship.

METHODS

Representatives from 5 hospital medicine programs, IHI, and the CDC attended a kick‐off meeting at the CDC in November 2012 to discuss the 3 proposed strategies, examples of prior testing, and ideas for implementation. Each hospitalist provided a high‐level summary of the current state of stewardship efforts at their respective institutions, identified possible future states related to the improvement strategies, and anticipated problems in achieving them. The 3 key strategies are described below.

RESULTS

Participating hospitals included 1 community nonteaching hospital, 2 community teaching hospitals, and 2 academic medical centers. All hospitals used computerized order entry and had prior quality improvement experience; 4 out of 5 hospitals used electronic medical records. Postintervention data on antimicrobial documentation and timeouts were compiled, shared, and successes identified. For example, 2 hospitals saw an increase in complete antimicrobial documentation from 4% and 8% to 51% and 65%, respectively, of medical records reviewed over a 3‐month period. Additionally, cumulative timeout data across all hospitals showed that out of 726 antimicrobial timeouts evaluated, optimization or discontinuation occurred 218 times or 30% of the time.

Each site's key implementation barriers and facilitators were collected. Examples were compiled and common themes emerged (Table 1).

DISCUSSION

We successfully brought together hospitalists from diverse institutions to undertake small tests of change aimed at 3 key antimicrobial use improvement strategies. Following our interventions, significant improvement in antimicrobial documentation occurred at 2 institutions focusing on this improvement strategy, and 72‐hour timeouts performed across all hospitals tailored antimicrobial use in 30% of the sessions. Through frequent collaborative discussions and information sharing, we were able to identify common barriers and facilitators to hospitalist‐centered stewardship efforts.

Each participating hospital medicine program noticed a gradual shift in thinking among their colleagues, from initial skepticism about embedding stewardship within their daily workflow, to general acceptance that it was a worthwhile and meaningful endeavor. We posited that this transition in belief and behavior evolved for several reasons. First, each group was educated about their own, personal prescribing practices from the outset rather than presenting abstract data. This allowed for ownership of the problem and buy‐in to improve it. Second, participants were able to experience the benefits at an individual level while the interventions were ongoing (eg, having other providers reciprocate structured documentation during patient handoffs, making antimicrobial plans clearer), reinforcing the achievability of stewardship practices within each group. Additionally, we focused on making small, manageable interventions that did not seem disruptive to hospitalists' daily workflow. For example, 1 group instituted antimicrobial timeouts during preexisting multidisciplinary rounds with clinical pharmacists. Last, project champions had both leadership and frontline roles within their groups and set the example for stewardship practices, which conveyed that this was a priority at the leadership level. These findings are in line with those of Charani et al., who evaluated behavior change strategies that influence antimicrobial prescribing in acute care. The authors found that behavioral determinants and social norms strongly influence prescribing practices in acute care, and that antimicrobial stewardship improvement projects should account for these influences.[8]

We also identified several barriers to antimicrobial stewardship implementation (Table 1) and proposed measures to address these barriers in future improvement efforts. For example, hospital medicine programs without a preexisting clinical pharmacy partnership asked hospitalist leadership for more direct clinical pharmacy involvement, recognizing the importance of a physician‐pharmacy alliance for stewardship efforts. To more effectively embed antimicrobial stewardship into daily routine, several hospitalists suggested standardized order sets for commonly encountered infections, as well as routine feedback on prescribing practices. Furthermore, although our simplified antimicrobial guideline pocket card enhanced access to this information, several colleagues suggested a smart phone application that would make access even easier and less cumbersome. Last, given the concern about the sustainability of antimicrobial stewardship initiatives, we recommended periodic reminders, random medical record review, and re‐education if necessary on our 3 strategies and their purpose.

Our study is not without limitations. Each participating hospitalist group enacted hospital‐specific interventions based on individual hospitalist program needs and goals, and although there was collective discussion, no group was tasked to undertake another group's initiative, thereby limiting generalizability. We did, however, identify common facilitators that could be adapted to a wide variety of hospitalist programs. We also note that our 3 main strategies were included in a recent review of quality indicators for measuring the success of antimicrobial stewardship programs; thus, although details of individual practice may vary, in principle these concepts can help identify areas for improvement within each unique stewardship program.[9] Importantly, we were unable to evaluate the impact of the 3 key improvement strategies on important clinical outcomes such as overall antimicrobial use, complications including CDI, and cost. However, others have found that improvement strategies similar to our 3 key processes are associated with meaningful improvements in clinical outcomes as well as reductions in healthcare costs.[10, 11] Last, long‐ term impact and sustainability were not evaluated. By choosing interventions that were viewed by frontline providers as valuable and attainable, however, we feel that each group will likely continue current practices beyond the initial evaluation timeframe.

Although these 5 hospitalist groups were able to successfully implement several aspects of the 3 key improvement strategies, we recognize that this is only the first step. Further effort is needed to quantify the impact of these improvement efforts on objective patient outcomes such as readmissions, length of stay, and antimicrobial‐related complications, which will better inform our local and national leaders on the inherent clinical and financial gains associated with hospitalist‐led stewardship work. Finally, creative ways to better integrate stewardship activities into existing provider workflows (eg, decision support and automation) will further accelerate improvement efforts.

In summary, hospitalists at 5 diverse institutions successfully implemented key antimicrobial improvement strategies and identified important implementation facilitators and barriers. Future efforts at hospitalist‐led stewardship should focus on strategies to scale‐up interventions and evaluate their impact on clinical outcomes and cost.

Disclosures: Dr. Flanders reports consulting fees or honoraria from the Institute for Healthcare Improvement, has provided consultancy to the Society of Hospital Medicine, has served as a reviewer for expert testimony, received honoraria as a visiting lecturer to various hospitals, and has received royalties from publisher John Wiley & Sons. He has also received grant funding from Blue Cross Blue Shield of Michigan and the Agency for Healthcare Research and Quality. Dr. Ko reports consultancy for the American Hospital Association and the Society of Hospital Medicine involving work with catheter‐associated urinary tract infections. Ms. Jacobsen reports grant funding from the Institute for Healthcare Improvement. Dr. Rosenberg reports consultancy for Bristol‐Myers Squibb, Forest Pharmaceuticals, and Pfizer. The funding source for this collaborative was through the Institute for Healthcare Improvement and Centers for Disease Control and Prevention. Funding was provided by the Department of Health and Human Services, the Centers for Disease Control and Prevention, the National Center for Emerging Zoonotic and Infectious Diseases, and the Division of Healthcare Quality Promotion/Office of the Director. Avaris Concepts served as the prime contractor and the Institute for Healthcare Improvement as the subcontractor for the initiative. The findings and conclusions in this report represent the views of the authors and might not reflect the views of the Centers for Disease Control and Prevention. The authors report no conflicts of interest.

Inappropriate antimicrobial use in hospitalized patients is a well‐recognized driver for the development of drug‐resistant organisms and antimicrobial‐related complications such as Clostridium difficile infection (CDI).[1, 2] Infection with C difficile affects nearly 500,000 people annually resulting in higher healthcare expenditures, longer lengths of hospital stay, and nearly 15,000 deaths.[3] Data from the Centers for Disease Control and Prevention (CDC) suggest that a 30% reduction in the use of broad‐spectrum antimicrobials, or a 5% reduction in the proportion of hospitalized patients receiving antimicrobials, could equate to a 26% reduction in CDI.[4] It is estimated that up to 50% of antimicrobial use in the hospital setting may be inappropriate.[5]

Since the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America published guidelines for developing formal, hospital‐based antimicrobial stewardship programs in 2007, stewardship practices have been adapted by frontline providers to fit day‐to‐day inpatient care.[5] A recent review by Hamilton et al. described several studies in which stewardship practices were imbedded into daily workflows by way of checklists, education reminders, and periodic review of antimicrobial usage, as well as a multicenter pilot of point‐of‐care stewardship interventions successfully implemented by various providers including nursing, pharmacists, and hospitalists.[6]

In response to the CDC's 2010 Get Smart for Healthcare campaign, which focused on stemming antimicrobial resistance and improving antimicrobial use, the Institute for Healthcare Improvement (IHI), in partnership with the CDC, brought together experts in the field to identify practical and feasible target practices for hospital‐based stewardship and created a Driver Diagram to guide implementation efforts (Figure 1). Rohde et al. described the initial pilot testing of these practices, the decision to more actively engage frontline providers, and the 3 key strategies identified as high‐yield improvement targets: enhancing the visibility of antimicrobial use at the point of care, creating easily accessible antimicrobial guidelines for common infections, and the implementation of a 72‐hour timeout after initiation of antimicrobials.[7]

Figure 1

In this article, we describe how, in partnership with the IHI and the CDC, the hospital medicine programs at 5 diverse hospitals iteratively tested these 3 strategies with a goal of identifying the barriers and facilitators to effective hospitalist‐led antimicrobial stewardship.

METHODS

Representatives from 5 hospital medicine programs, IHI, and the CDC attended a kick‐off meeting at the CDC in November 2012 to discuss the 3 proposed strategies, examples of prior testing, and ideas for implementation. Each hospitalist provided a high‐level summary of the current state of stewardship efforts at their respective institutions, identified possible future states related to the improvement strategies, and anticipated problems in achieving them. The 3 key strategies are described below.

RESULTS

Participating hospitals included 1 community nonteaching hospital, 2 community teaching hospitals, and 2 academic medical centers. All hospitals used computerized order entry and had prior quality improvement experience; 4 out of 5 hospitals used electronic medical records. Postintervention data on antimicrobial documentation and timeouts were compiled, shared, and successes identified. For example, 2 hospitals saw an increase in complete antimicrobial documentation from 4% and 8% to 51% and 65%, respectively, of medical records reviewed over a 3‐month period. Additionally, cumulative timeout data across all hospitals showed that out of 726 antimicrobial timeouts evaluated, optimization or discontinuation occurred 218 times or 30% of the time.

Each site's key implementation barriers and facilitators were collected. Examples were compiled and common themes emerged (Table 1).

DISCUSSION

We successfully brought together hospitalists from diverse institutions to undertake small tests of change aimed at 3 key antimicrobial use improvement strategies. Following our interventions, significant improvement in antimicrobial documentation occurred at 2 institutions focusing on this improvement strategy, and 72‐hour timeouts performed across all hospitals tailored antimicrobial use in 30% of the sessions. Through frequent collaborative discussions and information sharing, we were able to identify common barriers and facilitators to hospitalist‐centered stewardship efforts.

Each participating hospital medicine program noticed a gradual shift in thinking among their colleagues, from initial skepticism about embedding stewardship within their daily workflow, to general acceptance that it was a worthwhile and meaningful endeavor. We posited that this transition in belief and behavior evolved for several reasons. First, each group was educated about their own, personal prescribing practices from the outset rather than presenting abstract data. This allowed for ownership of the problem and buy‐in to improve it. Second, participants were able to experience the benefits at an individual level while the interventions were ongoing (eg, having other providers reciprocate structured documentation during patient handoffs, making antimicrobial plans clearer), reinforcing the achievability of stewardship practices within each group. Additionally, we focused on making small, manageable interventions that did not seem disruptive to hospitalists' daily workflow. For example, 1 group instituted antimicrobial timeouts during preexisting multidisciplinary rounds with clinical pharmacists. Last, project champions had both leadership and frontline roles within their groups and set the example for stewardship practices, which conveyed that this was a priority at the leadership level. These findings are in line with those of Charani et al., who evaluated behavior change strategies that influence antimicrobial prescribing in acute care. The authors found that behavioral determinants and social norms strongly influence prescribing practices in acute care, and that antimicrobial stewardship improvement projects should account for these influences.[8]

We also identified several barriers to antimicrobial stewardship implementation (Table 1) and proposed measures to address these barriers in future improvement efforts. For example, hospital medicine programs without a preexisting clinical pharmacy partnership asked hospitalist leadership for more direct clinical pharmacy involvement, recognizing the importance of a physician‐pharmacy alliance for stewardship efforts. To more effectively embed antimicrobial stewardship into daily routine, several hospitalists suggested standardized order sets for commonly encountered infections, as well as routine feedback on prescribing practices. Furthermore, although our simplified antimicrobial guideline pocket card enhanced access to this information, several colleagues suggested a smart phone application that would make access even easier and less cumbersome. Last, given the concern about the sustainability of antimicrobial stewardship initiatives, we recommended periodic reminders, random medical record review, and re‐education if necessary on our 3 strategies and their purpose.

Our study is not without limitations. Each participating hospitalist group enacted hospital‐specific interventions based on individual hospitalist program needs and goals, and although there was collective discussion, no group was tasked to undertake another group's initiative, thereby limiting generalizability. We did, however, identify common facilitators that could be adapted to a wide variety of hospitalist programs. We also note that our 3 main strategies were included in a recent review of quality indicators for measuring the success of antimicrobial stewardship programs; thus, although details of individual practice may vary, in principle these concepts can help identify areas for improvement within each unique stewardship program.[9] Importantly, we were unable to evaluate the impact of the 3 key improvement strategies on important clinical outcomes such as overall antimicrobial use, complications including CDI, and cost. However, others have found that improvement strategies similar to our 3 key processes are associated with meaningful improvements in clinical outcomes as well as reductions in healthcare costs.[10, 11] Last, long‐ term impact and sustainability were not evaluated. By choosing interventions that were viewed by frontline providers as valuable and attainable, however, we feel that each group will likely continue current practices beyond the initial evaluation timeframe.

Although these 5 hospitalist groups were able to successfully implement several aspects of the 3 key improvement strategies, we recognize that this is only the first step. Further effort is needed to quantify the impact of these improvement efforts on objective patient outcomes such as readmissions, length of stay, and antimicrobial‐related complications, which will better inform our local and national leaders on the inherent clinical and financial gains associated with hospitalist‐led stewardship work. Finally, creative ways to better integrate stewardship activities into existing provider workflows (eg, decision support and automation) will further accelerate improvement efforts.

In summary, hospitalists at 5 diverse institutions successfully implemented key antimicrobial improvement strategies and identified important implementation facilitators and barriers. Future efforts at hospitalist‐led stewardship should focus on strategies to scale‐up interventions and evaluate their impact on clinical outcomes and cost.

Disclosures: Dr. Flanders reports consulting fees or honoraria from the Institute for Healthcare Improvement, has provided consultancy to the Society of Hospital Medicine, has served as a reviewer for expert testimony, received honoraria as a visiting lecturer to various hospitals, and has received royalties from publisher John Wiley & Sons. He has also received grant funding from Blue Cross Blue Shield of Michigan and the Agency for Healthcare Research and Quality. Dr. Ko reports consultancy for the American Hospital Association and the Society of Hospital Medicine involving work with catheter‐associated urinary tract infections. Ms. Jacobsen reports grant funding from the Institute for Healthcare Improvement. Dr. Rosenberg reports consultancy for Bristol‐Myers Squibb, Forest Pharmaceuticals, and Pfizer. The funding source for this collaborative was through the Institute for Healthcare Improvement and Centers for Disease Control and Prevention. Funding was provided by the Department of Health and Human Services, the Centers for Disease Control and Prevention, the National Center for Emerging Zoonotic and Infectious Diseases, and the Division of Healthcare Quality Promotion/Office of the Director. Avaris Concepts served as the prime contractor and the Institute for Healthcare Improvement as the subcontractor for the initiative. The findings and conclusions in this report represent the views of the authors and might not reflect the views of the Centers for Disease Control and Prevention. The authors report no conflicts of interest.

Inappropriate antimicrobial use in hospitalized patients is a well‐recognized driver for the development of drug‐resistant organisms and antimicrobial‐related complications such as Clostridium difficile infection (CDI).[1, 2] Infection with C difficile affects nearly 500,000 people annually resulting in higher healthcare expenditures, longer lengths of hospital stay, and nearly 15,000 deaths.[3] Data from the Centers for Disease Control and Prevention (CDC) suggest that a 30% reduction in the use of broad‐spectrum antimicrobials, or a 5% reduction in the proportion of hospitalized patients receiving antimicrobials, could equate to a 26% reduction in CDI.[4] It is estimated that up to 50% of antimicrobial use in the hospital setting may be inappropriate.[5]

Since the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America published guidelines for developing formal, hospital‐based antimicrobial stewardship programs in 2007, stewardship practices have been adapted by frontline providers to fit day‐to‐day inpatient care.[5] A recent review by Hamilton et al. described several studies in which stewardship practices were imbedded into daily workflows by way of checklists, education reminders, and periodic review of antimicrobial usage, as well as a multicenter pilot of point‐of‐care stewardship interventions successfully implemented by various providers including nursing, pharmacists, and hospitalists.[6]

In response to the CDC's 2010 Get Smart for Healthcare campaign, which focused on stemming antimicrobial resistance and improving antimicrobial use, the Institute for Healthcare Improvement (IHI), in partnership with the CDC, brought together experts in the field to identify practical and feasible target practices for hospital‐based stewardship and created a Driver Diagram to guide implementation efforts (Figure 1). Rohde et al. described the initial pilot testing of these practices, the decision to more actively engage frontline providers, and the 3 key strategies identified as high‐yield improvement targets: enhancing the visibility of antimicrobial use at the point of care, creating easily accessible antimicrobial guidelines for common infections, and the implementation of a 72‐hour timeout after initiation of antimicrobials.[7]

Figure 1

In this article, we describe how, in partnership with the IHI and the CDC, the hospital medicine programs at 5 diverse hospitals iteratively tested these 3 strategies with a goal of identifying the barriers and facilitators to effective hospitalist‐led antimicrobial stewardship.

METHODS

Representatives from 5 hospital medicine programs, IHI, and the CDC attended a kick‐off meeting at the CDC in November 2012 to discuss the 3 proposed strategies, examples of prior testing, and ideas for implementation. Each hospitalist provided a high‐level summary of the current state of stewardship efforts at their respective institutions, identified possible future states related to the improvement strategies, and anticipated problems in achieving them. The 3 key strategies are described below.

RESULTS

Participating hospitals included 1 community nonteaching hospital, 2 community teaching hospitals, and 2 academic medical centers. All hospitals used computerized order entry and had prior quality improvement experience; 4 out of 5 hospitals used electronic medical records. Postintervention data on antimicrobial documentation and timeouts were compiled, shared, and successes identified. For example, 2 hospitals saw an increase in complete antimicrobial documentation from 4% and 8% to 51% and 65%, respectively, of medical records reviewed over a 3‐month period. Additionally, cumulative timeout data across all hospitals showed that out of 726 antimicrobial timeouts evaluated, optimization or discontinuation occurred 218 times or 30% of the time.

Each site's key implementation barriers and facilitators were collected. Examples were compiled and common themes emerged (Table 1).

DISCUSSION

We successfully brought together hospitalists from diverse institutions to undertake small tests of change aimed at 3 key antimicrobial use improvement strategies. Following our interventions, significant improvement in antimicrobial documentation occurred at 2 institutions focusing on this improvement strategy, and 72‐hour timeouts performed across all hospitals tailored antimicrobial use in 30% of the sessions. Through frequent collaborative discussions and information sharing, we were able to identify common barriers and facilitators to hospitalist‐centered stewardship efforts.

Each participating hospital medicine program noticed a gradual shift in thinking among their colleagues, from initial skepticism about embedding stewardship within their daily workflow, to general acceptance that it was a worthwhile and meaningful endeavor. We posited that this transition in belief and behavior evolved for several reasons. First, each group was educated about their own, personal prescribing practices from the outset rather than presenting abstract data. This allowed for ownership of the problem and buy‐in to improve it. Second, participants were able to experience the benefits at an individual level while the interventions were ongoing (eg, having other providers reciprocate structured documentation during patient handoffs, making antimicrobial plans clearer), reinforcing the achievability of stewardship practices within each group. Additionally, we focused on making small, manageable interventions that did not seem disruptive to hospitalists' daily workflow. For example, 1 group instituted antimicrobial timeouts during preexisting multidisciplinary rounds with clinical pharmacists. Last, project champions had both leadership and frontline roles within their groups and set the example for stewardship practices, which conveyed that this was a priority at the leadership level. These findings are in line with those of Charani et al., who evaluated behavior change strategies that influence antimicrobial prescribing in acute care. The authors found that behavioral determinants and social norms strongly influence prescribing practices in acute care, and that antimicrobial stewardship improvement projects should account for these influences.[8]

We also identified several barriers to antimicrobial stewardship implementation (Table 1) and proposed measures to address these barriers in future improvement efforts. For example, hospital medicine programs without a preexisting clinical pharmacy partnership asked hospitalist leadership for more direct clinical pharmacy involvement, recognizing the importance of a physician‐pharmacy alliance for stewardship efforts. To more effectively embed antimicrobial stewardship into daily routine, several hospitalists suggested standardized order sets for commonly encountered infections, as well as routine feedback on prescribing practices. Furthermore, although our simplified antimicrobial guideline pocket card enhanced access to this information, several colleagues suggested a smart phone application that would make access even easier and less cumbersome. Last, given the concern about the sustainability of antimicrobial stewardship initiatives, we recommended periodic reminders, random medical record review, and re‐education if necessary on our 3 strategies and their purpose.

Our study is not without limitations. Each participating hospitalist group enacted hospital‐specific interventions based on individual hospitalist program needs and goals, and although there was collective discussion, no group was tasked to undertake another group's initiative, thereby limiting generalizability. We did, however, identify common facilitators that could be adapted to a wide variety of hospitalist programs. We also note that our 3 main strategies were included in a recent review of quality indicators for measuring the success of antimicrobial stewardship programs; thus, although details of individual practice may vary, in principle these concepts can help identify areas for improvement within each unique stewardship program.[9] Importantly, we were unable to evaluate the impact of the 3 key improvement strategies on important clinical outcomes such as overall antimicrobial use, complications including CDI, and cost. However, others have found that improvement strategies similar to our 3 key processes are associated with meaningful improvements in clinical outcomes as well as reductions in healthcare costs.[10, 11] Last, long‐ term impact and sustainability were not evaluated. By choosing interventions that were viewed by frontline providers as valuable and attainable, however, we feel that each group will likely continue current practices beyond the initial evaluation timeframe.

Although these 5 hospitalist groups were able to successfully implement several aspects of the 3 key improvement strategies, we recognize that this is only the first step. Further effort is needed to quantify the impact of these improvement efforts on objective patient outcomes such as readmissions, length of stay, and antimicrobial‐related complications, which will better inform our local and national leaders on the inherent clinical and financial gains associated with hospitalist‐led stewardship work. Finally, creative ways to better integrate stewardship activities into existing provider workflows (eg, decision support and automation) will further accelerate improvement efforts.

In summary, hospitalists at 5 diverse institutions successfully implemented key antimicrobial improvement strategies and identified important implementation facilitators and barriers. Future efforts at hospitalist‐led stewardship should focus on strategies to scale‐up interventions and evaluate their impact on clinical outcomes and cost.

Disclosures: Dr. Flanders reports consulting fees or honoraria from the Institute for Healthcare Improvement, has provided consultancy to the Society of Hospital Medicine, has served as a reviewer for expert testimony, received honoraria as a visiting lecturer to various hospitals, and has received royalties from publisher John Wiley & Sons. He has also received grant funding from Blue Cross Blue Shield of Michigan and the Agency for Healthcare Research and Quality. Dr. Ko reports consultancy for the American Hospital Association and the Society of Hospital Medicine involving work with catheter‐associated urinary tract infections. Ms. Jacobsen reports grant funding from the Institute for Healthcare Improvement. Dr. Rosenberg reports consultancy for Bristol‐Myers Squibb, Forest Pharmaceuticals, and Pfizer. The funding source for this collaborative was through the Institute for Healthcare Improvement and Centers for Disease Control and Prevention. Funding was provided by the Department of Health and Human Services, the Centers for Disease Control and Prevention, the National Center for Emerging Zoonotic and Infectious Diseases, and the Division of Healthcare Quality Promotion/Office of the Director. Avaris Concepts served as the prime contractor and the Institute for Healthcare Improvement as the subcontractor for the initiative. The findings and conclusions in this report represent the views of the authors and might not reflect the views of the Centers for Disease Control and Prevention. The authors report no conflicts of interest.

The International Consensus Conference (ICC) for sepsis defines severe sepsis as an infection leading to acute organ dysfunction.[1, 2] Severe sepsis afflicts over 1 million patients each year in Medicare alone, and is substantially more common among older Americans than acute myocardial infarction.[3, 4, 5] Recently, the Agency for Healthcare Research and Quality identified severe sepsis as the single most expensive cause of hospitalization in the United States.[6] The incidence of severe sepsis continues to rise.[4, 5]

Severe sepsis is often mischaracterized as a diagnosis cared for primarily in the intensive care unit (ICU). Yet, studies indicate that only 32% to 50% of patients with severe sepsis require ICU care, leaving the majority on the general care wards.[7, 8] These studies also reveal mortality rates of 26% to 30% among patients with severe sepsis who are not admitted to an ICU compared to 11% to 33% in the ICU.[7, 8]

Although a number of epidemiologic and interventional studies have focused on severe sepsis in the ICU,[3, 9, 10] much less is known about patients cared for on the general medicine wards. Without this information, clinicians cannot make informed choices about important management decisions such as targeted diagnostic testing, empirical antimicrobials, and other therapies. To this end, we sought to further characterize the infectious etiologies and resultant organ system dysfunctions in the subset of patients with severe sepsis admitted to non‐ICU medical services at a tertiary academic medical center.

METHODS

RESULTS

Of 23,288 hospitalizations examined from 2009 through 2010, the ICD‐9based automated screen for severe sepsis was positive for 3,146 (14 %). A random sample of 111 medical records, of which 92 had screened positive for severe sepsis and 19 had screened negative, was reviewed in detail. After review by the hospitalists, 64 of these 111 hospitalizations were judged to have severe sepsis, 61 of the 92 screened positive cases (66%), and 3 of the 19 screened negative cases (16%). The 3 reviewers had a kappa of 0.70, indicating good agreement.

Characteristics of the 64 patients with severe sepsis are shown in Table 2. The mean age was 63 years old (standard deviation [SD]=17.7), and 41% were male. The mean length of stay was 13.7 days (SD=20.8). Thirty‐nine percent (95% CI, 27%‐52%) of patients (25/64) were immunosuppressed. Of patients initially admitted to the general medical ward, 25% (16/64; 95% CI, 15%‐37%) ultimately required ICU care during their admission. The overall in‐hospital mortality rate was 13% (8/64; 95% CI, 6%‐23%). Immunosuppressed patients had a mortality rate of 20% and nonimmunosuppressed patients had a mortality rate of 8%. Only 47% (30/64; 95% CI, 34%‐60%) of the medical records had explicit clinician documentation of severe sepsis.

The most common site of infection was found to be the genitourinary system, occurring in 41% (26/64; 95% CI, 29%‐54%) of patients (Table 3). Pulmonary and intra‐abdominal sites were also common, accounting for 14% (95% CI, 6.6%‐25%) and 13% (95% CI, 5.6%‐23%) of sites, respectively. An infecting organism was identified by culture in 66% (42/64; 95% CI, 53%‐77%) of case patients with specific pathogens listed in Table 4. Among patients with positive culture results, the majority grew Gram‐negative organisms (57%; 95% CI, 41%‐72%). Non‐Clostridium difficile Gram‐positive organisms were also prominent and identified in 48% (95% CI, 32%‐64%) of positive cultures. Candida was less common (12%, 95% CI, 4.0%‐26%). Fourteen cases (22%, 95% CI, 10%‐30%) had 2 or more concomitant infectious pathogens.

All 64 patients had at least 1 organ dysfunction, as required by the ICC definition of severe sepsis. Organ dysfunction in 2 or more organ systems occurred in 77% (95% CI, 64%‐86%) of the cases (49/64). The incidence for each organ system dysfunction is presented in Table 5, as well as its relationship to both mortality and ICU admission. The most common organ system dysfunctions were found to be cardiovascular (hypotension) and renal dysfunction occurring in 66% and 64% of the cases, respectively. In this non‐ICU population, pulmonary dysfunction occurred in 30% of cases, but was frequently associated with transfer to the ICU, as 63% of the patients with pulmonary failure required ICU care. Patients with more organ systems affected were more likely to be transferred to the ICU and to die.

DISCUSSION

Severe sepsis was common among patients admitted to the general medical ward in this tertiary care center. Our patient cohort differed in important ways from previously described typical cases of severe sepsis among ICU populations. Severe sepsis on the general medical wards was more commonly associated with Gram‐negative pathogens in the setting of genitourinary tract infections. This is in contrast to Gram‐positive organisms and respiratory tract infections, which are more common in the ICU.[3, 10] Renal and cardiac dysfunction were commonly observed organ failures, whereas in the ICU, severe sepsis has been reported to more likely involve respiratory failure. These results suggest that hospitalists seeking to provide evidence‐based care to prevent postsepsis morbidity and mortality for their non‐ICU patients need to heighten their index of suspicion when caring for an infected patient and appreciate that many severe sepsis patients may not fit neatly into traditional sepsis treatment algorithms.

Studies characterizing severe sepsis in the ICU setting indicate a predominance of pulmonary infections and respiratory failure with occurrence rates of 74% to 95% and 54% to 61%, respectively.[3, 12, 13] Given that either shock or pulmonary dysfunction is often required for admission to many ICUs, it is perhaps not surprising that these rates are dramatically different on the general medicine ward, with a relative scarcity of pulmonary infections (14%) and respiratory dysfunction (30%). Instead, genitourinary infections were noted in 41% (95% CI, 29%‐54%) of the cases, in contrast to the rates of genitourinary infections in ICU patients with severe sepsis, which have rates of 5.4% to 9.1%.[3, 10] Likely as a result of this, a Gram‐negative predominance is noted in the associated microbiology. Furthermore, our study indicates that C difficile and vancomycin‐resistant Enterococcus (VRE) species appear to represent an emerging cause of severe sepsis on the general medicine wards, as they have not been noted to be causative micro‐organisms in previous studies of sepsis. This is concordant with other studies showing increases in incidence and severity of disease for C difficile as well as VRE.[14, 15]

Previous epidemiologic studies of severe sepsis originating outside the ICU are lacking, but some work has been done. One study on the epidemiology of sepsis both with and without organ dysfunction aggregated all hospitalized patients and included those both admitted to the general medicine wards and directly to the ICU.[7] Similar to our study, this study also found a predominance of Gram‐negative causative organisms, as well as comparable in‐hospital mortality rates (12.8% vs 13%). Additionally, genitourinary infections were noted in 20% of the patients, notably higher than rates reported to have been found in patients with severe sepsis in the ICU, but not the magnitude found in our study, perhaps as a result of the combined ICU‐ward population studied. A similar high prevalence of genitourinary infections was also noted in a recent administrative data‐based study of emergency medical services‐transported patients with severe sepsis, half of whom required intensive care during their hospitalization.[16]

Our study is unique in that it focuses on severe sepsis in patients, commonly cared for by hospitalists, who were admitted to the general medical ward, and uses patient level data to elucidate more characteristics of the defining organ dysfunction. Furthermore, our results suggest that severe sepsis was poorly documented in this setting, indicating a potential impact on billing, coding, case mix index, and hospital mortality statistics that rely on very specific wording, as well as a possible need for increased awareness among hospitalists. Without this awareness, an opportunity may be missed for improved patient care via specific sepsis‐targeted measures,[13, 17, 18] including more aggressive resuscitative measures[19] or intensive physical and occupational therapy interventions aimed at impacting the cognitive and functional debilities[20] that result from severe sepsis. Highlighting this growing need to better assist clinicians assess the severity of septic patients and recognize these complex cases on the general medicine wards, 1 recent study evaluated the fitness of several clinical disease‐severity scoring systems for patients with sepsis in general internal medicine departments.[21] Perhaps with the help of tools such as these, which are being piloted in some hospitals, the care of this growing population can be enhanced.

Our study has a number of limitations that should be kept in mind. First, this is a single center study performed at an academic tertiary care center with a relatively high incidence of immunosuppression, which may influence the spectrum of infecting organisms. Our center also has a relatively large, closed‐model ICU, which often operates at near capacity, potentially affecting the severity of our non‐ICU population. Second, although we screened a large number of patients, as necessitated by our intensive and detailed review of clinical information, our sample size with hospitalist‐validated severe sepsis is relatively small. With this small sample size, less prevalent infections, patient characteristics, and organ dysfunctions may by chance have been under or over‐represented, and one could expect some variance in the occurrence rates of organ system dysfunction and infection rates by sampling error alone. Further larger scale studies are warranted to confirm these data and their generalizability. Third, the data necessary to calculate sequential organ failure assessment or multiple organ dysfunction score were not collected. This may limit the ability to directly compare the organ dysfunction noted in this study with others. Additionally, given the ICC definitions of organ dysfunction, some of the organ dysfunction noted, particularly for neurological dysfunction, was reliant on subjective clinical findings documented in the record. Finally, we relied on the lack of specific terminology to indicate a lack of documentation of sepsis, which does not necessarily indicate a lack of recognition or undertreatment of this condition. However, these limitations are offset by the strengths of this study, including the patient‐level medical record validation of severe sepsis by trained hospitalist physicians, high kappa statistic, and strict application of guideline‐based definitions.

This work has important implications for both clinicians and for future research on severe sepsis. The results suggest that severe sepsis may be quite common outside the ICU, and that patients presenting with this condition who are admitted to general medical wards are not routinely characterized by the profound hypoxemia and refractory shock of iconic cases. Certainly, further study looking at larger numbers of cases is needed to better understand the specifics and nuances of this important topic as well as to further evaluate clinicians' ability to recognize and treat such patients in this setting. Furthermore, future research on the treatment of severe sepsis, including both antimicrobials and disease‐modifying agents (eg, anti‐inflammatories) must continue to include and even focus on this large population of non‐ICU patients with severe sepsis, as the risk/benefit ratios of such potential treatments may vary with severity of illness.

In conclusion, severe sepsis was commonly found in patients admitted on the general medicine wards. The epidemiology of the infections and resultant organ dysfunction appears to differ from that found in the ICU. More studies are needed to provide a deeper understanding of this disease process, as this will enable clinicians to better recognize and treat patients thus afflicted, no matter the setting.

The International Consensus Conference (ICC) for sepsis defines severe sepsis as an infection leading to acute organ dysfunction.[1, 2] Severe sepsis afflicts over 1 million patients each year in Medicare alone, and is substantially more common among older Americans than acute myocardial infarction.[3, 4, 5] Recently, the Agency for Healthcare Research and Quality identified severe sepsis as the single most expensive cause of hospitalization in the United States.[6] The incidence of severe sepsis continues to rise.[4, 5]

Severe sepsis is often mischaracterized as a diagnosis cared for primarily in the intensive care unit (ICU). Yet, studies indicate that only 32% to 50% of patients with severe sepsis require ICU care, leaving the majority on the general care wards.[7, 8] These studies also reveal mortality rates of 26% to 30% among patients with severe sepsis who are not admitted to an ICU compared to 11% to 33% in the ICU.[7, 8]

Although a number of epidemiologic and interventional studies have focused on severe sepsis in the ICU,[3, 9, 10] much less is known about patients cared for on the general medicine wards. Without this information, clinicians cannot make informed choices about important management decisions such as targeted diagnostic testing, empirical antimicrobials, and other therapies. To this end, we sought to further characterize the infectious etiologies and resultant organ system dysfunctions in the subset of patients with severe sepsis admitted to non‐ICU medical services at a tertiary academic medical center.

METHODS

RESULTS

Of 23,288 hospitalizations examined from 2009 through 2010, the ICD‐9based automated screen for severe sepsis was positive for 3,146 (14 %). A random sample of 111 medical records, of which 92 had screened positive for severe sepsis and 19 had screened negative, was reviewed in detail. After review by the hospitalists, 64 of these 111 hospitalizations were judged to have severe sepsis, 61 of the 92 screened positive cases (66%), and 3 of the 19 screened negative cases (16%). The 3 reviewers had a kappa of 0.70, indicating good agreement.

Characteristics of the 64 patients with severe sepsis are shown in Table 2. The mean age was 63 years old (standard deviation [SD]=17.7), and 41% were male. The mean length of stay was 13.7 days (SD=20.8). Thirty‐nine percent (95% CI, 27%‐52%) of patients (25/64) were immunosuppressed. Of patients initially admitted to the general medical ward, 25% (16/64; 95% CI, 15%‐37%) ultimately required ICU care during their admission. The overall in‐hospital mortality rate was 13% (8/64; 95% CI, 6%‐23%). Immunosuppressed patients had a mortality rate of 20% and nonimmunosuppressed patients had a mortality rate of 8%. Only 47% (30/64; 95% CI, 34%‐60%) of the medical records had explicit clinician documentation of severe sepsis.

The most common site of infection was found to be the genitourinary system, occurring in 41% (26/64; 95% CI, 29%‐54%) of patients (Table 3). Pulmonary and intra‐abdominal sites were also common, accounting for 14% (95% CI, 6.6%‐25%) and 13% (95% CI, 5.6%‐23%) of sites, respectively. An infecting organism was identified by culture in 66% (42/64; 95% CI, 53%‐77%) of case patients with specific pathogens listed in Table 4. Among patients with positive culture results, the majority grew Gram‐negative organisms (57%; 95% CI, 41%‐72%). Non‐Clostridium difficile Gram‐positive organisms were also prominent and identified in 48% (95% CI, 32%‐64%) of positive cultures. Candida was less common (12%, 95% CI, 4.0%‐26%). Fourteen cases (22%, 95% CI, 10%‐30%) had 2 or more concomitant infectious pathogens.

All 64 patients had at least 1 organ dysfunction, as required by the ICC definition of severe sepsis. Organ dysfunction in 2 or more organ systems occurred in 77% (95% CI, 64%‐86%) of the cases (49/64). The incidence for each organ system dysfunction is presented in Table 5, as well as its relationship to both mortality and ICU admission. The most common organ system dysfunctions were found to be cardiovascular (hypotension) and renal dysfunction occurring in 66% and 64% of the cases, respectively. In this non‐ICU population, pulmonary dysfunction occurred in 30% of cases, but was frequently associated with transfer to the ICU, as 63% of the patients with pulmonary failure required ICU care. Patients with more organ systems affected were more likely to be transferred to the ICU and to die.

DISCUSSION

Severe sepsis was common among patients admitted to the general medical ward in this tertiary care center. Our patient cohort differed in important ways from previously described typical cases of severe sepsis among ICU populations. Severe sepsis on the general medical wards was more commonly associated with Gram‐negative pathogens in the setting of genitourinary tract infections. This is in contrast to Gram‐positive organisms and respiratory tract infections, which are more common in the ICU.[3, 10] Renal and cardiac dysfunction were commonly observed organ failures, whereas in the ICU, severe sepsis has been reported to more likely involve respiratory failure. These results suggest that hospitalists seeking to provide evidence‐based care to prevent postsepsis morbidity and mortality for their non‐ICU patients need to heighten their index of suspicion when caring for an infected patient and appreciate that many severe sepsis patients may not fit neatly into traditional sepsis treatment algorithms.

Studies characterizing severe sepsis in the ICU setting indicate a predominance of pulmonary infections and respiratory failure with occurrence rates of 74% to 95% and 54% to 61%, respectively.[3, 12, 13] Given that either shock or pulmonary dysfunction is often required for admission to many ICUs, it is perhaps not surprising that these rates are dramatically different on the general medicine ward, with a relative scarcity of pulmonary infections (14%) and respiratory dysfunction (30%). Instead, genitourinary infections were noted in 41% (95% CI, 29%‐54%) of the cases, in contrast to the rates of genitourinary infections in ICU patients with severe sepsis, which have rates of 5.4% to 9.1%.[3, 10] Likely as a result of this, a Gram‐negative predominance is noted in the associated microbiology. Furthermore, our study indicates that C difficile and vancomycin‐resistant Enterococcus (VRE) species appear to represent an emerging cause of severe sepsis on the general medicine wards, as they have not been noted to be causative micro‐organisms in previous studies of sepsis. This is concordant with other studies showing increases in incidence and severity of disease for C difficile as well as VRE.[14, 15]

Previous epidemiologic studies of severe sepsis originating outside the ICU are lacking, but some work has been done. One study on the epidemiology of sepsis both with and without organ dysfunction aggregated all hospitalized patients and included those both admitted to the general medicine wards and directly to the ICU.[7] Similar to our study, this study also found a predominance of Gram‐negative causative organisms, as well as comparable in‐hospital mortality rates (12.8% vs 13%). Additionally, genitourinary infections were noted in 20% of the patients, notably higher than rates reported to have been found in patients with severe sepsis in the ICU, but not the magnitude found in our study, perhaps as a result of the combined ICU‐ward population studied. A similar high prevalence of genitourinary infections was also noted in a recent administrative data‐based study of emergency medical services‐transported patients with severe sepsis, half of whom required intensive care during their hospitalization.[16]

Our study is unique in that it focuses on severe sepsis in patients, commonly cared for by hospitalists, who were admitted to the general medical ward, and uses patient level data to elucidate more characteristics of the defining organ dysfunction. Furthermore, our results suggest that severe sepsis was poorly documented in this setting, indicating a potential impact on billing, coding, case mix index, and hospital mortality statistics that rely on very specific wording, as well as a possible need for increased awareness among hospitalists. Without this awareness, an opportunity may be missed for improved patient care via specific sepsis‐targeted measures,[13, 17, 18] including more aggressive resuscitative measures[19] or intensive physical and occupational therapy interventions aimed at impacting the cognitive and functional debilities[20] that result from severe sepsis. Highlighting this growing need to better assist clinicians assess the severity of septic patients and recognize these complex cases on the general medicine wards, 1 recent study evaluated the fitness of several clinical disease‐severity scoring systems for patients with sepsis in general internal medicine departments.[21] Perhaps with the help of tools such as these, which are being piloted in some hospitals, the care of this growing population can be enhanced.

Our study has a number of limitations that should be kept in mind. First, this is a single center study performed at an academic tertiary care center with a relatively high incidence of immunosuppression, which may influence the spectrum of infecting organisms. Our center also has a relatively large, closed‐model ICU, which often operates at near capacity, potentially affecting the severity of our non‐ICU population. Second, although we screened a large number of patients, as necessitated by our intensive and detailed review of clinical information, our sample size with hospitalist‐validated severe sepsis is relatively small. With this small sample size, less prevalent infections, patient characteristics, and organ dysfunctions may by chance have been under or over‐represented, and one could expect some variance in the occurrence rates of organ system dysfunction and infection rates by sampling error alone. Further larger scale studies are warranted to confirm these data and their generalizability. Third, the data necessary to calculate sequential organ failure assessment or multiple organ dysfunction score were not collected. This may limit the ability to directly compare the organ dysfunction noted in this study with others. Additionally, given the ICC definitions of organ dysfunction, some of the organ dysfunction noted, particularly for neurological dysfunction, was reliant on subjective clinical findings documented in the record. Finally, we relied on the lack of specific terminology to indicate a lack of documentation of sepsis, which does not necessarily indicate a lack of recognition or undertreatment of this condition. However, these limitations are offset by the strengths of this study, including the patient‐level medical record validation of severe sepsis by trained hospitalist physicians, high kappa statistic, and strict application of guideline‐based definitions.

This work has important implications for both clinicians and for future research on severe sepsis. The results suggest that severe sepsis may be quite common outside the ICU, and that patients presenting with this condition who are admitted to general medical wards are not routinely characterized by the profound hypoxemia and refractory shock of iconic cases. Certainly, further study looking at larger numbers of cases is needed to better understand the specifics and nuances of this important topic as well as to further evaluate clinicians' ability to recognize and treat such patients in this setting. Furthermore, future research on the treatment of severe sepsis, including both antimicrobials and disease‐modifying agents (eg, anti‐inflammatories) must continue to include and even focus on this large population of non‐ICU patients with severe sepsis, as the risk/benefit ratios of such potential treatments may vary with severity of illness.

In conclusion, severe sepsis was commonly found in patients admitted on the general medicine wards. The epidemiology of the infections and resultant organ dysfunction appears to differ from that found in the ICU. More studies are needed to provide a deeper understanding of this disease process, as this will enable clinicians to better recognize and treat patients thus afflicted, no matter the setting.

The International Consensus Conference (ICC) for sepsis defines severe sepsis as an infection leading to acute organ dysfunction.[1, 2] Severe sepsis afflicts over 1 million patients each year in Medicare alone, and is substantially more common among older Americans than acute myocardial infarction.[3, 4, 5] Recently, the Agency for Healthcare Research and Quality identified severe sepsis as the single most expensive cause of hospitalization in the United States.[6] The incidence of severe sepsis continues to rise.[4, 5]

Severe sepsis is often mischaracterized as a diagnosis cared for primarily in the intensive care unit (ICU). Yet, studies indicate that only 32% to 50% of patients with severe sepsis require ICU care, leaving the majority on the general care wards.[7, 8] These studies also reveal mortality rates of 26% to 30% among patients with severe sepsis who are not admitted to an ICU compared to 11% to 33% in the ICU.[7, 8]

Although a number of epidemiologic and interventional studies have focused on severe sepsis in the ICU,[3, 9, 10] much less is known about patients cared for on the general medicine wards. Without this information, clinicians cannot make informed choices about important management decisions such as targeted diagnostic testing, empirical antimicrobials, and other therapies. To this end, we sought to further characterize the infectious etiologies and resultant organ system dysfunctions in the subset of patients with severe sepsis admitted to non‐ICU medical services at a tertiary academic medical center.

METHODS

RESULTS

Of 23,288 hospitalizations examined from 2009 through 2010, the ICD‐9based automated screen for severe sepsis was positive for 3,146 (14 %). A random sample of 111 medical records, of which 92 had screened positive for severe sepsis and 19 had screened negative, was reviewed in detail. After review by the hospitalists, 64 of these 111 hospitalizations were judged to have severe sepsis, 61 of the 92 screened positive cases (66%), and 3 of the 19 screened negative cases (16%). The 3 reviewers had a kappa of 0.70, indicating good agreement.

Characteristics of the 64 patients with severe sepsis are shown in Table 2. The mean age was 63 years old (standard deviation [SD]=17.7), and 41% were male. The mean length of stay was 13.7 days (SD=20.8). Thirty‐nine percent (95% CI, 27%‐52%) of patients (25/64) were immunosuppressed. Of patients initially admitted to the general medical ward, 25% (16/64; 95% CI, 15%‐37%) ultimately required ICU care during their admission. The overall in‐hospital mortality rate was 13% (8/64; 95% CI, 6%‐23%). Immunosuppressed patients had a mortality rate of 20% and nonimmunosuppressed patients had a mortality rate of 8%. Only 47% (30/64; 95% CI, 34%‐60%) of the medical records had explicit clinician documentation of severe sepsis.

The most common site of infection was found to be the genitourinary system, occurring in 41% (26/64; 95% CI, 29%‐54%) of patients (Table 3). Pulmonary and intra‐abdominal sites were also common, accounting for 14% (95% CI, 6.6%‐25%) and 13% (95% CI, 5.6%‐23%) of sites, respectively. An infecting organism was identified by culture in 66% (42/64; 95% CI, 53%‐77%) of case patients with specific pathogens listed in Table 4. Among patients with positive culture results, the majority grew Gram‐negative organisms (57%; 95% CI, 41%‐72%). Non‐Clostridium difficile Gram‐positive organisms were also prominent and identified in 48% (95% CI, 32%‐64%) of positive cultures. Candida was less common (12%, 95% CI, 4.0%‐26%). Fourteen cases (22%, 95% CI, 10%‐30%) had 2 or more concomitant infectious pathogens.

All 64 patients had at least 1 organ dysfunction, as required by the ICC definition of severe sepsis. Organ dysfunction in 2 or more organ systems occurred in 77% (95% CI, 64%‐86%) of the cases (49/64). The incidence for each organ system dysfunction is presented in Table 5, as well as its relationship to both mortality and ICU admission. The most common organ system dysfunctions were found to be cardiovascular (hypotension) and renal dysfunction occurring in 66% and 64% of the cases, respectively. In this non‐ICU population, pulmonary dysfunction occurred in 30% of cases, but was frequently associated with transfer to the ICU, as 63% of the patients with pulmonary failure required ICU care. Patients with more organ systems affected were more likely to be transferred to the ICU and to die.

DISCUSSION

Severe sepsis was common among patients admitted to the general medical ward in this tertiary care center. Our patient cohort differed in important ways from previously described typical cases of severe sepsis among ICU populations. Severe sepsis on the general medical wards was more commonly associated with Gram‐negative pathogens in the setting of genitourinary tract infections. This is in contrast to Gram‐positive organisms and respiratory tract infections, which are more common in the ICU.[3, 10] Renal and cardiac dysfunction were commonly observed organ failures, whereas in the ICU, severe sepsis has been reported to more likely involve respiratory failure. These results suggest that hospitalists seeking to provide evidence‐based care to prevent postsepsis morbidity and mortality for their non‐ICU patients need to heighten their index of suspicion when caring for an infected patient and appreciate that many severe sepsis patients may not fit neatly into traditional sepsis treatment algorithms.

Studies characterizing severe sepsis in the ICU setting indicate a predominance of pulmonary infections and respiratory failure with occurrence rates of 74% to 95% and 54% to 61%, respectively.[3, 12, 13] Given that either shock or pulmonary dysfunction is often required for admission to many ICUs, it is perhaps not surprising that these rates are dramatically different on the general medicine ward, with a relative scarcity of pulmonary infections (14%) and respiratory dysfunction (30%). Instead, genitourinary infections were noted in 41% (95% CI, 29%‐54%) of the cases, in contrast to the rates of genitourinary infections in ICU patients with severe sepsis, which have rates of 5.4% to 9.1%.[3, 10] Likely as a result of this, a Gram‐negative predominance is noted in the associated microbiology. Furthermore, our study indicates that C difficile and vancomycin‐resistant Enterococcus (VRE) species appear to represent an emerging cause of severe sepsis on the general medicine wards, as they have not been noted to be causative micro‐organisms in previous studies of sepsis. This is concordant with other studies showing increases in incidence and severity of disease for C difficile as well as VRE.[14, 15]

Previous epidemiologic studies of severe sepsis originating outside the ICU are lacking, but some work has been done. One study on the epidemiology of sepsis both with and without organ dysfunction aggregated all hospitalized patients and included those both admitted to the general medicine wards and directly to the ICU.[7] Similar to our study, this study also found a predominance of Gram‐negative causative organisms, as well as comparable in‐hospital mortality rates (12.8% vs 13%). Additionally, genitourinary infections were noted in 20% of the patients, notably higher than rates reported to have been found in patients with severe sepsis in the ICU, but not the magnitude found in our study, perhaps as a result of the combined ICU‐ward population studied. A similar high prevalence of genitourinary infections was also noted in a recent administrative data‐based study of emergency medical services‐transported patients with severe sepsis, half of whom required intensive care during their hospitalization.[16]

Our study is unique in that it focuses on severe sepsis in patients, commonly cared for by hospitalists, who were admitted to the general medical ward, and uses patient level data to elucidate more characteristics of the defining organ dysfunction. Furthermore, our results suggest that severe sepsis was poorly documented in this setting, indicating a potential impact on billing, coding, case mix index, and hospital mortality statistics that rely on very specific wording, as well as a possible need for increased awareness among hospitalists. Without this awareness, an opportunity may be missed for improved patient care via specific sepsis‐targeted measures,[13, 17, 18] including more aggressive resuscitative measures[19] or intensive physical and occupational therapy interventions aimed at impacting the cognitive and functional debilities[20] that result from severe sepsis. Highlighting this growing need to better assist clinicians assess the severity of septic patients and recognize these complex cases on the general medicine wards, 1 recent study evaluated the fitness of several clinical disease‐severity scoring systems for patients with sepsis in general internal medicine departments.[21] Perhaps with the help of tools such as these, which are being piloted in some hospitals, the care of this growing population can be enhanced.

Our study has a number of limitations that should be kept in mind. First, this is a single center study performed at an academic tertiary care center with a relatively high incidence of immunosuppression, which may influence the spectrum of infecting organisms. Our center also has a relatively large, closed‐model ICU, which often operates at near capacity, potentially affecting the severity of our non‐ICU population. Second, although we screened a large number of patients, as necessitated by our intensive and detailed review of clinical information, our sample size with hospitalist‐validated severe sepsis is relatively small. With this small sample size, less prevalent infections, patient characteristics, and organ dysfunctions may by chance have been under or over‐represented, and one could expect some variance in the occurrence rates of organ system dysfunction and infection rates by sampling error alone. Further larger scale studies are warranted to confirm these data and their generalizability. Third, the data necessary to calculate sequential organ failure assessment or multiple organ dysfunction score were not collected. This may limit the ability to directly compare the organ dysfunction noted in this study with others. Additionally, given the ICC definitions of organ dysfunction, some of the organ dysfunction noted, particularly for neurological dysfunction, was reliant on subjective clinical findings documented in the record. Finally, we relied on the lack of specific terminology to indicate a lack of documentation of sepsis, which does not necessarily indicate a lack of recognition or undertreatment of this condition. However, these limitations are offset by the strengths of this study, including the patient‐level medical record validation of severe sepsis by trained hospitalist physicians, high kappa statistic, and strict application of guideline‐based definitions.

This work has important implications for both clinicians and for future research on severe sepsis. The results suggest that severe sepsis may be quite common outside the ICU, and that patients presenting with this condition who are admitted to general medical wards are not routinely characterized by the profound hypoxemia and refractory shock of iconic cases. Certainly, further study looking at larger numbers of cases is needed to better understand the specifics and nuances of this important topic as well as to further evaluate clinicians' ability to recognize and treat such patients in this setting. Furthermore, future research on the treatment of severe sepsis, including both antimicrobials and disease‐modifying agents (eg, anti‐inflammatories) must continue to include and even focus on this large population of non‐ICU patients with severe sepsis, as the risk/benefit ratios of such potential treatments may vary with severity of illness.

In conclusion, severe sepsis was commonly found in patients admitted on the general medicine wards. The epidemiology of the infections and resultant organ dysfunction appears to differ from that found in the ICU. More studies are needed to provide a deeper understanding of this disease process, as this will enable clinicians to better recognize and treat patients thus afflicted, no matter the setting.