51
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Tan EM, Nagpal A, DeSimone DC, Anderson B, Linderbaum J, De Ziel T, Li Z, Sohail MR, Cha YM, Loomis E, Espinosa R, Friedman PA, Greason K, Schiller H, Virk A, Wilson WR, Steckelberg JM, Baddour LM. Impacts of a care process model and inpatient electrophysiology service on cardiovascular implantable electronic device infections: a preliminary evaluation. J Interv Card Electrophysiol 2017; 50:117-124. [PMID: 28844107 DOI: 10.1007/s10840-017-0282-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 08/10/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE Cardiovascular implantable electronic device infection (CIEDI) rates are rising. To improve outcomes, our institution developed an online care process model (CPM) and a specialized inpatient heart rhythm service (HRS). METHODS This retrospective review compared hospital length of stay (LOS), mortality, and times to subspecialty consultation and procedures before and after CPM and HRS availability. RESULTS CPM use was associated with shortened time to surgical consultation (median 2 days post-CPM vs. 3 days pre-CPM, p = 0.0152), pocket closure (median 4 vs. 5 days, p < 0.0001), and days to new CIED implant (median 7 vs. 8 days, p = 0.0126). Post-HRS patients were more likely to have a surgical consultation (OR 7.01, 95% CI 1.56-31.5, p = 0.011) and shortened time to pocket closure (coefficient - 2.21 days, 95% CI - 3.33 to - 1.09, p < 0.001), compared to pre-HRS. CONCLUSIONS The CPM and HRS were associated with favorable outcomes, but further integration of CPM features into hospital workflow is needed.
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Affiliation(s)
- Eugene M Tan
- Division of Infectious Diseases, Mayo Clinic, 200 First St S.W., Rochester, MN, 55905, USA.
| | - Avish Nagpal
- Infectious Diseases, Sanford Health, Fargo, ND, USA
| | - Daniel C DeSimone
- Division of Infectious Diseases, Mayo Clinic, 200 First St S.W., Rochester, MN, 55905, USA
| | - Brenda Anderson
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, MN, USA
| | | | - Thomas De Ziel
- Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Zhuo Li
- Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - Muhammad R Sohail
- Division of Infectious Diseases, Mayo Clinic, 200 First St S.W., Rochester, MN, 55905, USA
| | - Yong-Mei Cha
- Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Erica Loomis
- Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN, USA
| | - Raul Espinosa
- Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | - Kevin Greason
- Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Henry Schiller
- Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN, USA
| | - Abinash Virk
- Division of Infectious Diseases, Mayo Clinic, 200 First St S.W., Rochester, MN, 55905, USA
| | - Walter R Wilson
- Division of Infectious Diseases, Mayo Clinic, 200 First St S.W., Rochester, MN, 55905, USA
| | - James M Steckelberg
- Division of Infectious Diseases, Mayo Clinic, 200 First St S.W., Rochester, MN, 55905, USA
| | - Larry M Baddour
- Division of Infectious Diseases, Mayo Clinic, 200 First St S.W., Rochester, MN, 55905, USA
- Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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52
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Semler MW, Wanderer JP, Ehrenfeld JM, Stollings JL, Self WH, Siew ED, Wang L, Byrne DW, Shaw AD, Bernard GR, Rice TW. Balanced Crystalloids versus Saline in the Intensive Care Unit. The SALT Randomized Trial. Am J Respir Crit Care Med 2017; 195:1362-1372. [PMID: 27749094 DOI: 10.1164/rccm.201607-1345oc] [Citation(s) in RCA: 159] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Saline is the intravenous fluid most commonly administered to critically ill adults, but it may be associated with acute kidney injury and death. Whether use of balanced crystalloids rather than saline affects patient outcomes remains unknown. OBJECTIVES To pilot a cluster-randomized, multiple-crossover trial using software tools within the electronic health record to compare saline to balanced crystalloids. METHODS This was a cluster-randomized, multiple-crossover trial among 974 adults admitted to a tertiary medical intensive care unit from February 3, 2015 to May 31, 2015. The intravenous crystalloid used in the unit alternated monthly between saline (0.9% sodium chloride) and balanced crystalloids (lactated Ringer's solution or Plasma-Lyte A). Enrollment, fluid delivery, and data collection were performed using software tools within the electronic health record. The primary outcome was the difference between study groups in the proportion of isotonic crystalloid administered that was saline. The secondary outcome was major adverse kidney events within 30 days (MAKE30), a composite of death, dialysis, or persistent renal dysfunction. MEASUREMENTS AND MAIN RESULTS Patients assigned to saline (n = 454) and balanced crystalloids (n = 520) were similar at baseline and received similar volumes of crystalloid by 30 days (median [interquartile range]: 1,424 ml [500-3,377] vs. 1,617 ml [500-3,628]; P = 0.40). Saline made up a larger proportion of the isotonic crystalloid given in the saline group than in the balanced crystalloid group (91% vs. 21%; P < 0.001). MAKE30 did not differ between groups (24.7% vs. 24.6%; P = 0.98). CONCLUSIONS An electronic health record-embedded, cluster-randomized, multiple-crossover trial comparing saline with balanced crystalloids can produce well-balanced study groups and separation in crystalloid receipt. Clinical trial registered with www.clinicaltrials.gov (NCT 02345486).
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Affiliation(s)
| | | | - Jesse M Ehrenfeld
- 2 Department of Anesthesiology.,3 Department of Biomedical Informatics
| | | | | | - Edward D Siew
- 6 Vanderbilt Center for Kidney Disease and Integrated Program for AKI, Division of Nephrology and Hypertension, and
| | - Li Wang
- 7 Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel W Byrne
- 7 Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Todd W Rice
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine
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53
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Heard A, Toner AJ, Evans JR, Aranda Palacios AM, Lauer S. Apneic Oxygenation During Prolonged Laryngoscopy in Obese Patients. Anesth Analg 2017; 124:1162-1167. [DOI: 10.1213/ane.0000000000001564] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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54
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Harrison AM, Thongprayoon C, Aakre CA, Jeng JY, Dziadzko MA, Gajic O, Pickering BW, Herasevich V. Comparison of methods of alert acknowledgement by critical care clinicians in the ICU setting. PeerJ 2017; 5:e3083. [PMID: 28316887 PMCID: PMC5354075 DOI: 10.7717/peerj.3083] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 02/12/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Electronic Health Record (EHR)-based sepsis alert systems have failed to demonstrate improvements in clinically meaningful endpoints. However, the effect of implementation barriers on the success of new sepsis alert systems is rarely explored. OBJECTIVE To test the hypothesis time to severe sepsis alert acknowledgement by critical care clinicians in the ICU setting would be reduced using an EHR-based alert acknowledgement system compared to a text paging-based system. STUDY DESIGN In one arm of this simulation study, real alerts for patients in the medical ICU were delivered to critical care clinicians through the EHR. In the other arm, simulated alerts were delivered through text paging. The primary outcome was time to alert acknowledgement. The secondary outcomes were a structured, mixed quantitative/qualitative survey and informal group interview. RESULTS The alert acknowledgement rate from the severe sepsis alert system was 3% (N = 148) and 51% (N = 156) from simulated severe sepsis alerts through traditional text paging. Time to alert acknowledgement from the severe sepsis alert system was median 274 min (N = 5) and median 2 min (N = 80) from text paging. The response rate from the EHR-based alert system was insufficient to compare primary measures. However, secondary measures revealed important barriers. CONCLUSION Alert fatigue, interruption, human error, and information overload are barriers to alert and simulation studies in the ICU setting.
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Affiliation(s)
- Andrew M. Harrison
- Medical Scientist Training Program, Mayo Clinic, Rochester, MN, United States of America
| | - Charat Thongprayoon
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, United States of America
| | - Christopher A. Aakre
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Jack Y. Jeng
- Mayo Medical School, Mayo Clinic, Rochester, MN, United States of America
| | - Mikhail A. Dziadzko
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, United States of America
| | - Ognjen Gajic
- Division of Pulmonology and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Brian W. Pickering
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, United States of America
| | - Vitaly Herasevich
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, United States of America
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55
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Zhang Z, Hong Y, Smischney NJ, Kuo HP, Tsirigotis P, Rello J, Kuan WS, Jung C, Robba C, Taccone FS, Leone M, Spapen H, Grimaldi D, Van Poucke S, Simpson SQ, Honore PM, Hofer S, Caironi P. Early management of sepsis with emphasis on early goal directed therapy: AME evidence series 002. J Thorac Dis 2017; 9:392-405. [PMID: 28275488 PMCID: PMC5334094 DOI: 10.21037/jtd.2017.02.10] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Severe sepsis and septic shock are major causes of morbidity and mortality in patients entering the emergency department (ED) or intensive care unit (ICU). Despite substantial efforts to improve patient outcome, treatment of sepsis remains challenging to clinicians. In this context, early goal directed therapy (EGDT) represents an important concept emphasizing both early recognition of sepsis and prompt initiation of a structured treatment algorithm. As part of the AME evidence series on sepsis, we conducted a systematic review of all randomized controlled EGDT trials. Focus was laid on the setting (emergency department versus ICU) where EGDT was carried out. Early recognition of sepsis, through clinical or automated systems for early alert, together with well-timed initiation of the recommended therapy bundles may improve patients' outcome. However, the original "EGDT" protocol by Rivers and coworkers has been largely modified in subsequent trials. Currently, many investigators opt for an "expanded" EGDT (as suggested by the Surviving Sepsis Campaign). Evidence is also presented on the effectiveness of automated systems for early sepsis alert. Early recognition of sepsis and well-timed initiation of the SSC bundle may improve patient outcome.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | | | - Han-Pin Kuo
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan
| | - Panagiotis Tsirigotis
- 2nd Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Jordi Rello
- CIBERES, Vall d’Hebron Institute of Research, Universitat Autonoma de Barcelona, Spain
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore and the Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Christian Jung
- University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Division of Cardiology, Pulmonology and Vascular Medicine, Düsseldorf, Germany
| | - Chiara Robba
- Neurosciences Critical Care Unit, Box 1, Addenbrooke’s Hospital, Cambridge, UK
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Marc Leone
- Service d’anesthésie et de réanimation, Hôpital Nord, Assistance Publique – Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Herbert Spapen
- Intensive Care Department, University Hospital, Vrije Universiteit, Brussels, Belgium
| | - David Grimaldi
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Sven Van Poucke
- Department of Anesthesiology, Emergency Medicine, Critical Care and Pain Therapy, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Steven Q. Simpson
- Division of Pulmonary and Critical Care Medicine, University of Kansas, Kansas, USA
| | - Patrick M. Honore
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel Brussels, Brussels, Belgium
| | - Stefan Hofer
- Department of Anesthesiology, University of Heidelberg, Heidelberg, Germany
| | - Pietro Caironi
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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Aaronson EL, Filbin MR, Brown DFM, Tobin K, Mort EA. New Mandated Centers for Medicare and Medicaid Services Requirements for Sepsis Reporting: Caution from the Field. J Emerg Med 2016; 52:109-116. [PMID: 27720289 DOI: 10.1016/j.jemermed.2016.08.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 08/05/2016] [Accepted: 08/17/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The release of the Center for Medicare and Medicaid Service's (CMS) latest quality measure, Severe Sepsis/Septic Shock Early Management Bundle (SEP-1), has intensified the long-standing debate over optimal care for severe sepsis and septic shock. Although the last decade of research has demonstrated the importance of comprehensive bundled care in conjunction with compliance mechanisms to reduce patient mortality, it is not clear that SEP-1 achieves this aim. The heterogeneous and often cryptic presentation of severe sepsis and septic shock, along with the multifaceted criteria for the definition of this clinical syndrome, pose a particular challenge for fitting requirements to this disease, and implementation could have unintended consequences. OBJECTIVE Following a simulated reporting exercise, in which 50 charts underwent expert review, we aimed to detail the challenges of, and offer suggestions on how to rethink, measuring performance in severe sepsis and septic shock care. DISCUSSION There were several challenges associated with the design and implementation of this measure. The ambiguous definition of severe sepsis and septic shock, prescriptive fluid volume requirements, rigid reassessment, and complex abstraction logic all raise significant concern. CONCLUSIONS Although SEP-1 represents an important first step in requiring hospitals to improve outcomes for patients with severe sepsis and septic shock, the current approach must be revisited. The volume and complexity of the currently required SEP-1 reporting elements deserve serious consideration and revision before they are used as measures of accountability and tied to reimbursement.
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Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David F M Brown
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kathy Tobin
- Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts
| | - Elizabeth A Mort
- Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts; Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Manaktala S, Claypool SR. Evaluating the impact of a computerized surveillance algorithm and decision support system on sepsis mortality. J Am Med Inform Assoc 2016; 24:88-95. [PMID: 27225197 PMCID: PMC7654083 DOI: 10.1093/jamia/ocw056] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 03/11/2016] [Accepted: 03/21/2016] [Indexed: 12/29/2022] Open
Abstract
Objective: We created a system using a triad of change management, electronic surveillance, and algorithms to detect sepsis and deliver highly sensitive and specific decision support to the point of care using a mobile application. The investigators hypothesized that this system would result in a reduction in sepsis mortality. Methods: A before-and-after model was used to study the impact of the interventions on sepsis-related mortality. All patients admitted to the study units were screened per the Institute for Healthcare Improvement Surviving Sepsis Guidelines using real-time electronic surveillance. Sepsis surveillance algorithms that adjusted clinical parameters based on comorbid medical conditions were deployed for improved sensitivity and specificity. Nurses received mobile alerts for all positive sepsis screenings as well as severe sepsis and shock alerts over a period of 10 months. Advice was given for early goal-directed therapy. Sepsis mortality during a control period from January 1, 2011 to September 30, 2013 was used as baseline for comparison. Results: The primary outcome, sepsis mortality, decreased by 53% (P = 0.03; 95% CI, 1.06-5.25). The 30-day readmission rate reduced from 19.08% during the control period to 13.21% during the study period (P = 0.05; 95% CI, 0.97-2.52). No significant change in length of hospital stay was noted. The system had observed sensitivity of 95% and specificity of 82% for detecting sepsis compared to gold-standard physician chart review. Conclusion: A program consisting of change management and electronic surveillance with highly sensitive and specific decision support delivered to the point of care resulted in significant reduction in deaths from sepsis.
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Affiliation(s)
- Sharad Manaktala
- Wolters Kluwer Health, 800 Washington Ave. N. STE 400, Minneapolis, MN 55401, USA.
| | - Stephen R Claypool
- Wolters Kluwer Health, 800 Washington Ave. N. STE 400, Minneapolis, MN 55401, USA
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58
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Semler MW, Rice TW, Ehrenfeld JM. Leveraging Clinical Informatics in the Conduct of Clinical Trials. J Med Syst 2016; 39:112. [PMID: 26276019 DOI: 10.1007/s10916-015-0317-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Matthew W Semler
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University, Nashville, TN, USA
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Harrison AM, Gajic O, Pickering BW, Herasevich V. Development and Implementation of Sepsis Alert Systems. Clin Chest Med 2016; 37:219-29. [PMID: 27229639 DOI: 10.1016/j.ccm.2016.01.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Development and implementation of sepsis alert systems is challenging, particularly outside the monitored intensive care unit (ICU) setting. Barriers to wider use of sepsis alerts include evolving clinical definitions of sepsis, information overload, and alert fatigue, due to suboptimal alert performance. Outside the ICU, barriers include differences in health care delivery models, charting behaviors, and availability of electronic data. Current evidence does not support routine use of sepsis alert systems in clinical practice. Continuous improvement in the afferent and efferent aspects will help translate theoretic advantages into measurable patient benefit.
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Affiliation(s)
- Andrew M Harrison
- Medical Scientist Training Program, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Ognjen Gajic
- Division of Pulmonology and Critical Care Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Brian W Pickering
- Department of Anesthesiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Vitaly Herasevich
- Department of Anesthesiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Enzymatic changes in myosin regulatory proteins may explain vasoplegia in terminally ill patients with sepsis. Biosci Rep 2016; 36:BSR20150207. [PMID: 26772992 PMCID: PMC4776626 DOI: 10.1042/bsr20150207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 01/07/2016] [Indexed: 02/06/2023] Open
Abstract
The current study was conducted with the hypothesis that failure of maintenance of the vascular tone may be central to failure of the peripheral circulation and spiralling down of blood pressure in sepsis. Namely, we examined the balance between expression of myosin light chain (MLC) phosphatase and kinase, enzymes that regulate MLCs dephosphorylation and phosphorylation with a direct effect on pharmacomechanical coupling for smooth muscle relaxation and contraction respectively. Mechanical recordings and enzyme immunoassays of vascular smooth muscle lysates were used as the major methods to examine arterial biopsy samples from terminally ill sepsis patients. The results of the present study provide evidence that genomic alteration of expression of key regulatory proteins in vascular smooth muscles may be responsible for the relentless downhill course in sepsis. Down-regulation of myosin light chain kinase (MLCK) and up-regulation of MLCK may explain the loss of tone and failure to mount contractile response in vivo during circulation. The mechanical studies demonstrated the inability of the arteries to develop tone when stimulated by phenylephrine in vitro. The results of our study provide indirect hint that control of inflammation is a major therapeutic approach in sepsis, and may facilitate to ameliorate the progressive cardiovascular collapse.
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Automated Sepsis Detection, Alert, and Clinical Decision Support: Act on It or Silence the Alarm? Crit Care Med 2015; 43:1776-7. [PMID: 26181117 DOI: 10.1097/ccm.0000000000001099] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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