Original ArticleClinical and microbiological features of maternal sepsis: a retrospective study
Introduction
In well-resourced countries, sepsis has become a leading cause of maternal death.1, 2 In the USA, infection accounted for 14% and sepsis 4.3% of all maternal deaths between 2006 and 2010.1 In the UK between 2006 and 2012, genital tract sepsis accounted for 7% of all maternal deaths.2 Although the incidence of sepsis in the non-obstetric population continues to increase, hospital mortality has decreased slightly.3 The decrease is most likely due to adoption of aggressive treatment guidelines such as those published by the Surviving Sepsis Campaign with the aim of early goal-directed therapy.4 However, septicemia was the most expensive condition treated in USA hospitals in 2011, costing $20.3 billion (5% of national costs).5
Recent epidemiologic studies have provided important data on the incidence and risk factors associated with maternal sepsis.6, 7 These studies relied upon administrative datasets to identify women with maternal sepsis. However, it is uncertain how reliable these sources are for accurately identifying women with sepsis, especially as maternal physiological and laboratory indices may mimic criteria used to diagnose sepsis.8 Furthermore, there are limited data on the clinical and microbiological features that accompany maternal sepsis.9 Few studies have examined these characteristics in women diagnosed with maternal sepsis. A better understanding of the characteristics may assist in improving the clinical diagnosis of sepsis.
The International Classification of Diseases (ICD) is used to assign codes to diagnoses and procedures associated with inpatient, outpatient and physician-office utilization in the USA.10 Errors can occur between the patient’s actual diagnosis and the diagnostic codes entered by coders for reimbursement. Because administrative and billing data are often employed to determine the incidence and trends of uncommon conditions and morbidities, it is vital to determine the accuracy of coding for specific obstetric morbidities.
The primary aim of this descriptive study was to examine clinical and laboratory characteristics of women diagnosed with maternal sepsis, severe sepsis or septic shock in a single tertiary obstetric center. Because our cohort was initially identified using ICD-9 codes for maternal sepsis, severe sepsis, and septic shock (Appendix A), in our secondary analysis we determined the positive predictive values (PPVs) of these codes.
Section snippets
Methods
We obtained Institutional Review Board approval from Stanford University before commencing the study. Our source population comprised women who delivered an infant, live or stillborn, at Lucile Packard Children’s Hospital (LPCH) Stanford, between January 1st, 2007 and December 31st, 2013 and who had at least one sepsis-related ICD-9 code for a pregnancy-related hospitalization and/or up to 42 days postpartum. At LPCH, trained medical coders use ICD-9 Clinical Modification (CM) codes for billing
Results
In our initial search of the clinical data warehouse, 190 women were identified with sepsis-related ICD-9 CM codes. Following complete review of the individual medical records, only 35 (18%) women met the criteria for a clinical diagnosis of sepsis, severe sepsis or septic shock (Fig. 1). Based on chart review, diagnostic criteria for sepsis, severe sepsis and septic shock were met by 22 patients, six patients, and seven patients, respectively.
Demographic, medical and obstetric data for the 35
Discussion
This study describes patient characteristics, clinical features, laboratory indices, and microbiological findings of a cohort of women with ICD-9 codes for maternal sepsis, severe sepsis or septic shock. The study findings highlight the marked heterogeneity in patient and clinical characteristics of women with these conditions, and how challenging the clinical diagnosis of women with sepsis-related conditions can be. More accurate ICD coding may enhance our understanding of maternal and
Disclosure
This study received no external funding and the authors have no conflicts of interest to declare.
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