An Electronic Tool for the Evaluation and Treatment of Sepsis in the ICU: A Randomized Controlled Trial

Impacts of a care process model and inpatient electrophysiology service on cardiovascular implantable electronic device infections: a preliminary evaluation

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.

Balanced Crystalloids versus Saline in the Intensive Care Unit. The SALT Randomized Trial

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).

Comparison of methods of alert acknowledgement by critical care clinicians in the ICU setting

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.

Early management of sepsis with emphasis on early goal directed therapy: AME evidence series 002

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.

New Mandated Centers for Medicare and Medicaid Services Requirements for Sepsis Reporting: Caution from the Field

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.

Evaluating the impact of a computerized surveillance algorithm and decision support system on sepsis mortality

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.

Development and Implementation of Sepsis Alert Systems

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.

Enzymatic changes in myosin regulatory proteins may explain vasoplegia in terminally ill patients with sepsis

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.