(1563) Impact of Complex Sepsis Presentations on SEP-1 Compliance and Outcomes

Introduction: CMS instituted the SEP-1 measure because observational studies suggest sepsis bundle compliance is associated with lower mortality. Most studies, however, adjusted for few confounders and failed to provide insight into why bundle-compliant care was not rendered.

Methods: We reviewed medical records at 4 academic hospitals to characterize patients who did and did not receive SEP-1 compliant care in the ED between 2019-2021. We then assessed associations between SEP-1 compliance and hospital mortality using multivariable models adjusted for successively more covariates: first demographics and comorbidities, then infection source, then severity-of-illness, and then markers of complexity (e.g., impaired mental status, difficult venous access, need for bedside procedures, concurrent non-bacterial illness).

Results: The cohort included 590 patients with sepsis, of whom 335 (56.8%) received SEP-1 compliant care. The non-compliant group was older (median age 67 vs 63), had more comorbidities (median Elixhauser score 14 vs 10), presented with fever less often (47% vs 64%), and had higher rates of primary bacteremia (10% vs 5%), septic shock (42% vs 32%), renal failure (34% vs 24%, and thrombocytopenia (17% vs 11%) (p < 0.05 for all). They also were more likely to have impaired mental status (36% vs 28%), need bedside procedures (22% vs 12%), have acute concurrent illnesses (55% vs 45%; most commonly new/progressive malignancy and acute cardiac disease), and have acute concurrent illnesses as the primary driver of their presentation (32.9% vs 21.2%) (p < 0.05 for all). In-hospital mortality was 11.9% in the compliant group vs 16.1% in the non-compliant group (OR 0.60, 95% CI 0.37-0.98). The point estimate for the association between SEP-1 compliance and mortality was attenuated after adjusting for demographics, comorbidities, infection source, and severity-of-illness (OR 0.86, 95% CI 0.50-1.49) and after additionally adjusting for clinical markers of complexity (OR 1.08, 95% CI 0.61-1.91).

Conclusions: Patients with sepsis who receive SEP-1 non-compliant care tend to be more severely ill and have more complex clinical presentations. These factors are poorly captured in SEP-1 documentation and in most observational studies but may confound the association between SEP-1 compliance and mortality.