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1651: COST ANALYSIS OF ADJUNCTIVE HYDROCORTISONE THERAPY FOR SEPTIC SHOCK FROM THE U.S. PAYER PERSPECTIVE

Learning Objectives: Sepsis outcomes are affected by timeliness of appropriate antibiotics and resuscitation in those with impending shock. We hypothesize that fluid responsive sepsis can be safely managed in a Medical Intermediate Care (MIMC) unit using pre-specified selection criteria. Methods: We performed a retrospective study of all patients admitted to the MIMC with sepsis between October 2016 and June 2017. Septic patients were those with a known source of infection or a high suspicion without a known source. Data collected included demographics, comorbidities, severity of illness using the Acute Physiology and Chronic Health Evaluation (APACHE) II score, in-hospital mortality and uptriage rate. Uptriage was defined as those transferred to the ICU within 48 hours. Primary outcomes were all cause in-hospital mortality and uptriage rate. Secondary outcomes were factors associated with mortality and uptriage. Chi-square and t-tests were used to analyze parametric variable; Fisher’s exact test and Mann-Whitney-U were used for nonparametric variables. Multivariate logistic regression was performed to determine variables associated with mortality and uptriage. Univariate terms included in the model were those with a p-value<0.10. The Hosmer Lemeshow c-statistic was used to determine goodness of fit. All tests were two tailed; p-value<0.05 was considered statistically significant. Results: The cohort included 231 patients (age: 64.5+/-6.6 years, male: 48.1%, APACHE: 13.9+/-5.8, pneumonia: 32%). Most (73.2%) were admitted from the ED. Mean lactate was 2.49+/-1.4; 9.1% had a lactate >4. The MIMC mortality rate was 2.2% but inhospital mortality was 8.2%; the uptriage rate was 8.2%. No clinical variables were significantly associated with uptriage rates. A high A-a gradient significantly increased risk of in-hospital death by 1.03 (95% CI: 1.01-1.06) on multivariate analysis. Mean arterial pressure <65 (28.6% vs. 6.9%, p=0.004) and lactate >4 (23.8% vs. 6.7%, p=0.006) were significant on univariate analysis but not after regression analysis. Conclusions: MIMC sepsis mortality rate was low while in-hospital mortality was close to the national average. Despite high uptriage rates, the mortality rate was not affected. Pre-selected septic patients with impending shock can be managed safely in a MIMC. A high A-a gradient may represent impending respiratory failure leading to uptriage rates.