Urban-Rural Disparities in Case Fatality of Community-Acquired Sepsis in Germany: A Retrospective Cohort Study.

BACKGROUND: We aimed to examine urban-rural disparities in sepsis case fatality rates among patients with community-acquired sepsis in Germany. METHODS: Retrospective cohort study using de-identified data of the nationwide statutory health insurance AOK, covering approx. 30% of the German population. We compared in-hospital- and 12-month case fatality between rural and urban sepsis patients. We calculated odds ratios (OR) with 95% confidence intervals and the estimated adjusted odds ratio (ORadj) using logistic regression models to account for potential differences in the distribution of age, comorbidities, and sepsis characteristics between rural and urban citizens. RESULTS: We identified 118,893 hospitalized patients with community-acquired sepsis in 2013-2014 with direct hospital admittance. Sepsis patients from rural areas had lower in-hospital case fatality rates compared to their urban counterparts (23.7% vs. 25.5%, p < 0.001, Odds Ratio (OR) = 0.91 (95% CI 0.88, 0.94), ORadj = 0.89 (95% CI 0.86, 0.92)). Similar differences were observable for 12-month case fatalities (45.8% rural vs. 47.0% urban 12-month case fatality, p < 0.001, OR = 0.95 (95% CI 0.93, 0.98), ORadj = 0.92 (95% CI 0.89, 0.94)). Survival benefits were also observable in rural patients with severe community-acquired sepsis or patients admitted as emergencies. Rural patients of <40 years had half the odds of dying in hospital compared to urban patients in this age bracket (ORadj = 0.49 (95% CI 0.23, 0.75), p = 0.002). CONCLUSION: Rural residence is associated with short- and long-term survival benefits in patients with community-acquired sepsis. Further research on patient, community, and health-care system factors is needed to understand the causative mechanisms of these disparities.

Crossing the handover chasm: Clinicians' perceptions of barriers to the early detection and timely management of severe sepsis and septic shock.

PURPOSE: The purpose was to identify barriers to the early detection and timely management of severe sepsis throughout the emergency department (ED), general ward (GW), intermediate care unit (IMC), and the intensive care unit (ICU). MATERIALS AND METHODS: Five multicenter focus group discussions with 29 clinicians were conducted. Discussions were based on a moderation guide were recorded and transcribed. Qualitative analysis was performed according to the principles of the concept mapping method and the framework approach. RESULTS: The major causes of the delayed detection and treatment could be summarized in a framework of communication errors and handover difficulties throughout patients' course of treatment, which can be divided into 5 core areas: inadequate histories before hospital admission; poorly coordinated handovers between the ambulance service and the ED; delayed patient transfer between the ED and the GW as well as delays in patient transfers between the GW and the ICU by, for example, a lack of bed capacity and a shortage of staff. Generally, participants from all wards mentioned that the urgency with which septic patients needed to be treated was not communicated. CONCLUSIONS: Our study shows the need to improve intra- and interunit handover processes in hospital care, which would ensure a holistic treatment concept, thereby improving patient care.

Barriers and supportive conditions to improve quality of care for critically ill patients: A team approach to quality improvement.

PURPOSE: Despite the fact that Quality Improvement (QI) teams are widespread tools for improving performance in medical settings, little is known about what makes teams effective and successful. The goal of this study was to identify barriers and supportive conditions for QI teams to implement an effective and successful QI project to improve quality of care. MATERIALS AND METHODS: Multicenter expert interviews with 17 team leaders were conducted in a cluster randomized trial. Interviews were based on a semistructured interview guide and were recorded and transcribed. Qualitative analysis was performed according to the principles of grounded theory. RESULTS: The major findings of our study can be summarized in a framework of conditions that support the implementation of changes by QI teams. This framework can be divided into 5 core categories: the availability of external support, an interdisciplinary QI team, staff characteristics such as dedicated employees who are aware and experienced, and generally supportive structural circumstances. Furthermore, the interviewees reported that changes should be disseminated through, for example, repeating key elements or addressing employees directly. CONCLUSIONS: Using a grounded theory-based qualitative approach, we identified a framework of conditions supportive of QI-related change, which can help project initiators to create environments that are supportive of change.