Is In-Hospital Sepsis Mortality a Fair Assessment?


  • In-Hospital mortality is a key indicator of quality of care within a system, and influenced by a variety of factors.

  • Safety Net Hospitals are those with a disproportionately high number of low income and underserved patients.

  • Patient factors and hospital factors, including transfer practices impact in-patient mortality.


  • Nursing care levels (patient care needs) and Nurse staffing levels are just 2 factors which impact in-hospital mortality.

  • Hospitals which transfer patients to other sites, may impact in-hospital mortality rates by shifting death from hospitals to other sites.

  • 30-day mortality rates are less dependent of transfer practices.

  • Safety net hospitals play a crucial role in our healthcare system by providing care to underserved patients.

  • However, safety net hospitals experience greater challenges than non-safety net hospitals such as:

    • Having fewer resources

    • Narrower operating margins

    • Patients with less access to preventative care

    • More complex disease states

  • Recently, 2.5 million patients over age 65 years with an ICU sepsis admission were reviewed.

    • 650,749 safety net hospital sepsis patients

    • 1,900,994 non-safety net hospital sepsis patients

  • Areas of evaluation:

    • In-hospital mortality

    • 30-day mortality

    • DNR orders

    • In-hospital palliative care

    • Discharge facility

    • Discharge to Hospice


  • Differences seen in mortality between safety net and non-safety net hospitals.

    • In-Hospital mortality much greater in safety net hospitals vs 30-day mortality greater in non-safety net hospitals.
  • Safety net hospitals were adept at shifting the mortality burden to other sites

  • In-Hospital sepsis mortality may not be an appropriate indicator of care of patients without factoring in safety net vs non-safety net status.


  • Sepsis programs should evaluate more than in-hospital mortality, since safety net hospitals may be unfairly penalized.

  • Using a time-dependent factor (i.e. 30-day) mortality rate may provide a more even assessment.

  • In-hospital vs 30-day mortality may become increasingly relevant as CMS moves to value based prospective payments based on SEP-1 criteria.

  • There maybe a role for telemedicine palliative care consults to improve end of life care.


  • A difference was seen between in-hospital mortality and 30-day mortality between safety net and non-safety net hospitals.

  • The difference may not be an actual difference in clinical outcomes as it appears Safety net hospitals are more adept at moving patients to hospice care. Less palliative care is delivered in hospital in safety net hospitals with a greater degree of palliative care delivered in non-safety net hospitals.

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Erkan Hassan is the Co-Founder & Chief Clinical Officer of Sepsis Program Optimization where he designs & oversees the implementation of solutions to optimize sepsis programs.

To discuss your organization’s Barriers of Effective Sepsis Care, contact Erkan by phone (844) 4SEPSIS (844-473-7747), email (, or video chat.