Effect of performance improvement programs on compliance with sepsis bundles and mortality: a systematic review and meta-analysis of observational studies

Double inter-hospital transfer in Sepsis patients presenting to the ED does not worsen mortality compared to single inter-hospital transfer

PURPOSE

Sepsis is a leading cause of hospital deaths. Inter-hospital transfer is frequent in sepsis and is associated with increased mortality. Some sepsis patients undergo two inter-hospital transfers (double transfer). This study assessed the (1) prevalence, (2) associated risk factors, (3) associated mortality, and (4) hospital length-of-stay and costs of double-transfer of sepsis patients.

MATERIALS AND METHODS

Retrospective cohort study using 2005-2014 administrative claims data in Iowa. Multivariable generalized estimating equations adjusted for potential confounding variables, with a primary outcome of mortality. Secondary outcomes included hospital length-of-stay and costs. Hospital-specific cost-to-charge ratios estimated hospital costs. Hospitals were categorized into quintiles based on sepsis-volume.

RESULTS

Of 15,182 sepsis subjects, there were 45.2% non-transfers and 2.1% double-transfers. Double-transfers had worse mortality than non-transfers but not single-transfers. Of the non-transfers, 44.9% presented to a top sepsis-volume hospital compared to 22.8% of double-transfers and 25.1% of single-transfers. After transfer from first to second hospital, 93.4% of the single-transfers and 92.2% of the double-transfers were at a top sepsis-volume hospital. Double-transfers had longer length-of-stay and more in total hospital costs than single-transfers.

CONCLUSIONS

Double-transfer occurs in 2.1% of Iowa sepsis patients. Double-transfers had similar mortality and increased length of stay and costs compared to single-transfers.

Improving sepsis care for hospital inpatients using existing medical emergency response systems

BACKGROUND

Sepsis is a medical emergency; timely management has been shown to reduce mortality. We aimed to improve the care of inpatients who developed sepsis after hospital admission by integrating a sepsis bundle with an existing medical emergency team (MET).

METHODS

We performed a before-and-after study at an Australian institution. A multimodal intervention was implemented including formation of a working group, development of a guideline, standard documentation, education, audit and feedback. The primary outcome was the proportion of MET calls where there was compliance with the sepsis resuscitation bundle within one hour of MET call.

RESULTS

There was an improvement in completion of the entire resuscitation bundle (OR 2.33, 95%, CI: 1.23 - 4.41) and lactate measurement (OR 2.72, CI: 1.53, 4.84) within one hour of MET call. There was a non-significant reduction in the median time to antibiotic administration in patients where antibiotics were initiated or changed at the MET call (60 mins vs. 44 mins, p = 0.8). In hospital mortality was observed to fall from 22.1% to 11.4%, but after adjusting for age and baseline illness severity this differences was not statistically significant (OR 0.52, CI: 0.23, 1.19, p = 0.12).

CONCLUSION

The implementation of a multimodal sepsis bundle and the utilisation of an existing MET call system demonstrated an increase in the overall uptake of a sepsis bundle. This was associated with an observed reduction in all-cause in-hospital mortality, although this difference was not statistically significant after adjustment for confounders. Further interventions with a focus on nursing education and engagement may improve timely antibiotic administration.

Molecular and biomarker-based diagnostics in early sepsis: current challenges and future perspectives

Introduction: Sepsis, defined as a life-threatening organ dysfunction resulting from dysregulated host response to infection, is still a major challenge for healthcare systems. Early diagnosis is highly needed, yet challenging, due to the non-specificity of clinical symptoms. Rapid and targeted application of therapy strategies is crucial for patient's outcome.Areas covered: Faster and better diagnostics with high accuracy is promised by novel host response biomarkers and a wide variety of direct pathogen identification technologies, which have emerged over the last years. This review will cover both - host response-guided diagnostics and methods for direct pathogen detection. Some of the markers and technologies are already market-ready, others are more likely aspirants. We will discuss them in terms of their performance and benefit for use in clinical diagnostics.Expert opinion: Latest technological advances enable the development of promising diagnostic tests, detecting the host response as well as identifying pathogens without the need of cultivation. However, the syndrome's heterogeneity makes it difficult to develop a universal test suitable for routine use. Moreover, the robustness of the biomarkers and technologies still has to be verified. Combining these technologies and clinical routine parameters with bioinformatic methods (e.g., machine-learning algorithms) may revolutionize sepsis diagnostics.

Delay Within the 3-Hour Surviving Sepsis Campaign Guideline on Mortality for Patients With Severe Sepsis and Septic Shock

OBJECTIVES

To specify when delays of specific 3-hour bundle Surviving Sepsis Campaign guideline recommendations applied to severe sepsis or septic shock become harmful and impact mortality.

DESIGN

Retrospective cohort study.

SETTING

One health system composed of six hospitals and 45 clinics in a Midwest state from January 01, 2011, to July 31, 2015.

PATIENTS

All adult patients hospitalized with billing diagnosis of severe sepsis or septic shock.

INTERVENTIONS

Four 3-hour Surviving Sepsis Campaign guideline recommendations: 1) obtain blood culture before antibiotics, 2) obtain lactate level, 3) administer broad-spectrum antibiotics, and 4) administer 30 mL/kg of crystalloid fluid for hypotension (defined as "mean arterial pressure" < 65) or lactate (> 4).

MEASUREMENTS AND MAIN RESULTS

To determine the effect of t minutes of delay in carrying out each intervention, propensity score matching of "baseline" characteristics compensated for differences in health status. The average treatment effect in the treated computed as the average difference in outcomes between those treated after shorter versus longer delay. To estimate the uncertainty associated with the average treatment effect in the treated metric and to construct 95% CIs, bootstrap estimation with 1,000 replications was performed. From 5,072 patients with severe sepsis or septic shock, 1,412 (27.8%) had in-hospital mortality. The majority of patients had the four 3-hour bundle recommendations initiated within 3 hours. The statistically significant time in minutes after which a delay increased the risk of death for each recommendation was as follows: lactate, 20.0 minutes; blood culture, 50.0 minutes; crystalloids, 100.0 minutes; and antibiotic therapy, 125.0 minutes.

CONCLUSIONS

The guideline recommendations showed that shorter delays indicates better outcomes. There was no evidence that 3 hours is safe; even very short delays adversely impact outcomes. Findings demonstrated a new approach to incorporate time t when analyzing the impact on outcomes and provide new evidence for clinical practice and research.

A nonsurgical and nonpharmacological care bundle for preventing upper urinary tract damage in patients with spinal cord injury and neurogenic bladder

AIM

To establish a care bundle in spinal cord injury patients with neurogenic bladder to avoid upper urinary tract damage and to provide guidance for health care staff in use of nonsurgical and nonpharmacological adjunctive strategies to improve patients' clinical outcomes.

BACKGROUND

Prevention of upper urinary tract damage is critical in the management of spinal cord injury patients with a neurogenic bladder, but there are no authoritative guidelines or high-quality randomized controlled trials.

DESIGN

The study was conducted on the basis of Fulbrook and Mooney's seven-step method for care bundle development.

DATA SOURCES

The databases PubMed, Embase, Science Citation Index, the Cumulative Index to Nursing and Allied Health Literature, the National Guideline Clearinghouse, the Cochrane Library, China Biology Medicine, China National Knowledge Infrastructure, and China Dissertation Database were searched from the date of each database's inception to April 2017.

REVIEW METHODS

We evaluated the literature according to the Joanna Briggs Institute evidence pre-ranking and grade recommendation system (2014 version). The results were examined using a self-designed data extraction.

RESULTS

A three-element cluster including clean intermittent catheterization, bladder function training, and transcutaneous low-frequency pulsed electrical stimulation was formed.

CONCLUSION

The development of this bundle can provide a scientific basis for effective prevention of neurogenic upper urinary tract damage in clinical practice.

Health inequities in the diagnosis and outcome of sepsis in Argentina: a prospective cohort study

Background

Socioeconomic variables impact health outcomes but have rarely been evaluated in critical illness. Low- and middle-income countries bear the highest burden of sepsis and also have significant health inequities. In Argentina, public hospitals serve the poorest segment of the population, while private institutions serve patients with health coverage. Our objective was to analyze differences in mortality between public and private hospitals, using Sepsis-3 definitions.

Methods

This is a multicenter, prospective cohort study including patients with sepsis admitted to 49 Argentine ICUs lasting 3 months, beginning on July 1, 2016. Epidemiological, clinical, and socioeconomic status variables and hospital characteristics were compared between patients admitted to both types of institutions.

Results

Of the 809 patients included, 367 (45%) and 442 (55%) were admitted to public and private hospitals, respectively. Those in public institutions were younger (56 ± 18 vs. 64 ± 18; p < 0.01), with more comorbidities (Charlson score 2 [0–4] vs. 1 [0–3]; p < 0.01), fewer education years (7 [7–12] vs. 12 [10–16]; p < 0.01), more frequently unemployed/informally employed (30% vs. 7%; p < 0.01), had similar previous self-rated health status (70 [50–90] vs. 70 [50–90] points; p = 0.30), longer pre-admission symptoms (48 [24–96] vs. 24 [12–48] h; p < 0.01), had been previously evaluated more frequently in any healthcare venue (28 vs. 20%; p < 0.01), and had higher APACHE II, SOFA, lactate levels, and mechanical ventilation utilization. ICU admission as septic shock was more frequent in patients admitted to public hospitals (47 vs. 35%; p < 0.01), as were infections caused by multiresistant microorganisms. Sepsis management in the ICU showed no differences. Twenty-eight-day mortality was higher in public hospitals (42% vs. 24%; p < 0.01) as was hospital mortality (47% vs. 30%; p < 0.01). Admission to a public hospital was an independent predictor of mortality together with comorbidities, lactate, SOFA, and mechanical ventilation; in an alternative prediction model, it acted as a correlate of pre-hospital symptom duration and infections caused by multiresistant microorganisms.

Conclusions

Patients in public hospitals belonged to a socially disadvantaged group and were sicker at admission, had septic shock more frequently, and had higher mortality. Unawareness of disease severity and delays in the health system might be associated with late admission. This marked difference in outcome between patients served by public and private institutions constitutes a state of health inequity.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2522-6) contains supplementary material, which is available to authorized users.

A Snapshot of Compliance with the Sepsis Six Care Bundle in Two Acute Hospitals in the West Midlands, UK

BACKGROUND

The sepsis six care bundle has been adopted by hospitals in England and Wales for the management of patients with sepsis, with the aim of increasing survival when all elements of the bundle are achieved.

AIM

To assess compliance with the Sepsis Six Care Bundle in two acute NHS hospitals in the West Midlands.

MATERIALS AND METHODS

Adults admitted to hospital over a 24-hour period were screened for sepsis. Sepsis was identified using the Systemic Inflammatory Response (SIRS) criteria and the quick sequential organ failure assessment (qSOFA) score. Adherence to the Sepsis Six Care Bundle was assessed.

RESULTS

249 patients were screened and 24 patients were identified as having sepsis (9.6%). One patient received all six elements of the bundle. Compliance was highest for giving intravenous fluids (58.3%) and antibiotics (58.3%), and lowest for measuring urine output (16.7%).

CONCLUSIONS

Further research is needed to establish the reasons for low compliance.

HOW TO CITE THIS ARTICLE

Frankling C, Patel J, Sharif B, Melody T, Yeung J, Gao F, et al. A Snapshot of Compliance with the Sepsis Six Care Bundle in Two Acute Hospitals in the West Midlands, UK. Indian J Crit Care Med 2019;23(7):310-315.

Rules of anti-infection therapy for sepsis and septic shock

Objective:

Sepsis is a deadly infection that causes injury to tissues and organs. Infection and anti-infective treatment are the eternal themes of sepsis. The successful control of infection is a key factor of resuscitation for sepsis and septic shock. This review examines evidence for the treatment of sepsis. This evidence is combined with clinical experiments to reveal the rules and a standard flowchart of anti-infection therapy for sepsis.

Data Sources:

We retrieved information from the PubMed database up to October 2018 using various search terms and their combinations, including sepsis, septic shock, infection, antibiotics, and anti-infection.

Study Selection:

We included data from peer-reviewed journals printed in English on the relationships between infections and antibiotics.

Results:

By combining the literature review and clinical experience, we propose a 6Rs rule for sepsis and septic shock management: right patients, right time, right target, right antibiotics, right dose, and right source control. This rule encompasses rational decisions regarding the timing of treatment, the identification of the correct pathogen, the selection of appropriate antibiotics, the formulation of a scientifically based antibiotic dosage regimen, and the adequate control of infectious foci.

Conclusions:

This review highlights how to recognize and treat sepsis and septic shock and provides rules and a standard flowchart for anti-infection therapy for sepsis and septic shock for use in the clinical setting.

Does Gender Matter in Septic Patient Outcomes?

PURPOSE

The purpose of this study was to examine potential gender disparities in relation to factors associated with sepsis management among a cohort of patients admitted through an emergency department with a discharge diagnosis of severe sepsis or septic shock. Sepsis is one of the leading causes of death globally, with significant associated costs. Predictors of survival for those with sepsis-related diagnoses are complex.

DESIGN AND METHODS

The study had a retrospective, descriptive cross-sectional design. The sample (N = 482) included patients 18 years of age or older who presented to the emergency department of a nonprofit, Magnet-recognized, acute care hospital located in southern California. Subjects included those who subsequently met the criteria for a discharge diagnosis of severe sepsis or septic shock as defined by the Surviving Sepsis Campaign. Patient characteristics, clinical variables, care management processes, and outcomes were extracted from the electronic health record. A multivariate model was analyzed.

FINDINGS

The sample included 234 women (48.5%) and 248 men (51.5%). Logistic regression with eight independent variables (discharge diagnosis, age, comorbidities, length of hospital stay, source of infection, first serum lactate level measured, recommended fluids administered, and gender) reliably predicted odds for patient survival, ϰ² (12) = 118.38, p < .001, and correctly classified 77.3% of cases. All eight independent variables significantly contributed to the model. Men had a higher likelihood of hospital survival than women (odds ratio 1.68; 95% confidence interval 1.01-2.79; p = .045).

CONCLUSIONS

The Surviving Sepsis Campaign has provided a clear pathway for care of patients with sepsis-related diagnoses. Therapeutic strategies should be developed to address differences in outcome by gender. The adoption of more aggressive applications of evidence-based interventions for these patients may result in better patient outcomes.

CLINICAL RELEVANCE

Providers should understand the importance of adhering to sepsis protocols, minimizing treatment disparities, and recognizing gender differences.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

BACKGROUND

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

RESULTS

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Additional Telemedicine Rounds as a Successful Performance-Improvement Strategy for Sepsis Management: Observational Multicenter Study

Background

Sepsis is a major health care problem with high morbidity and mortality rates and affects millions of patients. Telemedicine, defined as the exchange of medical information via electronic communication, improves the outcome of patients with sepsis and decreases the mortality rate and length of stay in the intensive care unit (ICU). Additional telemedicine rounds could be an effective component of performance-improvement programs for sepsis, especially in underserved rural areas and hospitals without ready access to critical care physicians.

Objective

Our aim was to evaluate the impact of additional daily telemedicine rounds on adherence to sepsis bundles. We hypothesized that additional telemedicine support may increase adherence to sepsis guidelines and improve the detection rates of sepsis and septic shock.

Methods

We conducted a retrospective, observational, multicenter study between January 2014 and July 2015 with one tele-ICU center and three ICUs in Germany. We implemented telemedicine as part of standard care and collected data continuously during the study. During the daily telemedicine rounds, routine screening for sepsis was conducted and adherence to the Surviving Sepsis Campaign’s 3-hour and 6-hour sepsis bundles were evaluated.

Results

In total, 1168 patients were included in this study, of which 196 were positive for severe sepsis and septic shock. We found that additional telemedicine rounds improved adherence to the 3-hour (Quarter 1, 35% vs Quarter 6, 76.2%; P=.01) and 6-hour (Quarter 1, 50% vs Quarter 6, 95.2%; P=.001) sepsis bundles. In addition, we noted an increase in adherence to the item “Administration of fluids when hypotension” (Quarter 1, 80% vs Quarter 6, 100%; P=.049) of the 3-hour bundle and the item “Remeasurement of lactate” (Quarter 1, 65% vs Quarter 6, 100%, P=.003) of the 6-hour bundle. The ICU length of stay after diagnosis of severe sepsis and septic shock remained unchanged over the observation period. Due to a higher number of patients with sepsis in Quarter 5 (N=60) than in other quarters, we observed stronger effects of the additional rounds on mortality in this quarter (Quarter 1, 50% vs Quarter 5, 23.33%, P=.046).

Conclusions

Additional telemedicine rounds are an effective component of and should be included in performance-improvement programs for sepsis management.

Six-hour sepsis bundle decreases mortality: Truth or illusion – A prospective observational study

Aim:

The aim of the study is to evaluate whether 6-h sepsis bundle component compliance (complete vs. incomplete) decreases mortality in pediatric patients with severe sepsis and septic shock.

Methodology:

The study was conducted at a tertiary care hospital. Patients aged 1 month–13 years admitted to pediatric intensive care unit with severe sepsis, or septic shock were prospectively enrolled. The clinical data and blood investigations required for sepsis bundle were recorded. Predicted mortality was calculated at admission by the online pediatric index of mortality-2 (PIM-2) score calculator. Patients who fulfilled all the components of 6-h sepsis bundle were taken as compliant while failure to fulfill even a single component rendered them noncompliant. The outcome was recorded as died or discharged.

Results:

Of 116 patients, 90 (77.59%) had 100% sepsis bundle component compliance and were taken into the compliant group while the rest 26 (22.41%) were noncompliant. Forty out of 90 patients (44.4%) died in compliant group in comparison to 5 out of 26 (19.3%) in noncompliant group, P = 0.020. The pre- and post-interventional lactates were significantly higher in compliant group as compared to the noncompliant group, P < 0.0001 and 0.019, respectively. Rising lactate level parallels increasing predicted mortality by PIM-2 score in compliant group, but this association failed to reach significance in noncompliant group which can be attributed to less number of subjects available in this group.

Conclusion:

Irrespective of sepsis bundle compliance (complete/incomplete), outcome depends on the severity of illness reflected by high lactate and predicted mortality.

Characteristics, management, and in-hospital mortality among patients with severe sepsis in intensive care units in Japan: the FORECAST study

Background

Sepsis is a leading cause of death and long-term disability in developed countries. A comprehensive report on the incidence, clinical characteristics, and evolving management of sepsis is important. Thus, this study aimed to evaluate the characteristics, management, and outcomes of patients with severe sepsis in Japan.

Methods

This is a cohort study of the Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome, Sepsis, and Trauma (FORECAST) study, which was a multicenter, prospective cohort study conducted at 59 intensive care units (ICUs) from January 2016 to March 2017. We included adult patients with severe sepsis based on the sepsis-2 criteria.

Results

In total, 1184 patients (median age 73 years, interquartile range (IQR) 64–81) with severe sepsis were admitted to the ICU during the study period. The most common comorbidity was diabetes mellitus (23%). Moreover, approximately 63% of patients had septic shock. The median Sepsis-related Organ Failure Assessment (SOFA) score was 9 (IQR 6–11). The most common site of infection was the lung (31%). Approximately 54% of the participants had positive blood cultures. The compliance rates for the entire 3-h bundle, measurement of central venous pressure, and assessment of central venous oxygen saturation were 64%, 26%, and 7%, respectively. A multilevel logistic regression model showed that closed ICUs and non-university hospitals were more compliant with the entire 3-h bundle. The in-hospital mortality rate of patients with severe sepsis was 23% (21–26%). Older age, multiple comorbidities, suspected site of infection, and increasing SOFA scores correlated with in-hospital mortality, based on the generalized estimating equation model. The length of hospital stay was 24 (12–46) days. Approximately 37% of the patients were discharged home after recovery.

Conclusion

Our prospective study showed that sepsis management in Japan was characterized by a high compliance rate for the 3-h bundle and low compliance rate for central venous catheter measurements. The in-hospital mortality rate in Japan was comparable to that of other developed countries. Only one third of the patients were discharged home, considering the aging population with multiple comorbidities in the ICUs in Japan.

Trial registration

UMIN-CTR, UMIN000019742. Registered on 16 November 2015.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2186-7) contains supplementary material, which is available to authorized users.

Effects of a multifaceted intervention QI program to improve ICU performance

BACKGROUND

To benefit from the increasing clinical evidence, organisational changes have been among the main drivers behind the reduction of ICU mortality during the last decade. Increasing demand, costs and complexity, amplifies the need for optimisation of clinical processes and resource utilisation. Thus, multidisciplinary teamwork and critical care processes needs to be adapted to profit from increased availability of human skill and technical resources in a cost-effective manner. Inadequate clinical performance and outcome data compelled us to design a quality improvement project to address current work processes and competence utilisation.

METHODS

During revision period, clinical processes, professional performance and clinical competence were targeted using "scientific production management methodology" approach. As part of the project, an intensivist training program was instituted, and full time intensivist coverage was obtained in the process of creating multi-professional teams, composed of certified intensivists, critical care nurses, assistant nurses, physiotherapists and social counsellors. The use of staff resources and clinical work-processes were optimised in accordance with the outcome of a "value stream mapping". In this process, efforts to enhance the personal dynamics and performance within the teams were paramount. Clinical and economic outcome data were analysed during a seven year follow up period.

RESULTS

• Consecutive reduced overall ICU (24%) and long-term (600 days) mortality. The effect on ICU mortality was especially pronounced in the subgroup of patients > 65 years (30%) • Consecutive reduced length of stay (43%, septic patients) and time on ventilator (for septic patients and patients > 65 years of age (23 resp.52%). • Substantial increase in life years gained (13,140 life years) as well as quality-adjusted life-years (9593 QALY: s) over the study period. • High cost-effectiveness as ICU costs were  reduced while patient outcomes were improved. Disregarding the cost reduction in ICU, the intervention is highly cost effective with cost- effectiveness ratios of (75€/QALY) and (55€ / life year) CONCLUSIONS: We have shown favourable results of a QI project aiming to improve the clinical performance and quality through the development of multi-professional interaction, teamwork and systematic revisions of work processes. The economic evaluation shows that the intervention is highly cost-effective and potentially dominating.

Challenges in assessing the burden of sepsis and understanding the inequalities of sepsis outcomes between National Health Systems: secular trends in sepsis and infection incidence and mortality in Germany

Purpose

Sepsis contributes considerably to global morbidity and mortality, while reasons for its increasing incidence remain unclear. We assessed risk adjusted secular trends in sepsis and infection epidemiology in Germany.

Methods

Retrospective cohort study using nationwide German hospital discharge data. We assessed incidence, outcomes and trends of hospital-treated sepsis and infections between 2010 and 2015. Sepsis was identified by explicit ICD-10 sepsis codes. As sensitivity analysis, results were compared with sepsis cases identified by implicit sepsis coding (combined infection and organ dysfunction codes).

Results

Among 18 664 877 hospital admissions in 2015, 4 213 116 (22.6%) patients had at least one infection code. There were 320 198 patients that had explicit sepsis codes including 136 542 patients with severe sepsis and septic shock; 183 656 patients were coded as sepsis without organ dysfunction. For patients with explicitly coded sepsis (including severe sepsis), or with severe sepsis alone, mortality rates over the period 2010–2015 decreased from 26.6 to 23.5%, and from 47.8 to 41.7%, respectively.

Conclusions

Sepsis and infection remain significant causes of hospital admission and death in Germany. Sepsis-related mortality is higher and has declined to a lesser degree than in other high-income countries. Although infection rates steadily increased, the observed annual increase of sepsis cases seems to result, to a considerable degree, from improved coding of sepsis.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5377-4) contains supplementary material, which is available to authorized users.

[Bacterial sepsis : Diagnostics and calculated antibiotic therapy]

The mortality of patients with sepsis and septic shock is still unacceptably high. An effective antibiotic treatment within 1 h of recognition of sepsis is an important target of sepsis treatment. Delays lead to an increase in mortality; therefore, structured treatment concepts form a rational foundation, taking relevant diagnostic and treatment steps into consideration. In addition to the assumed focus and individual risks of each patient, local resistance patterns and specific problem pathogens must be taken into account for selection of anti-infection treatment. Many pathophysiological alterations influence the pharmacokinetics of antibiotics during sepsis. The principle of standard dosing should be abandoned and replaced by an individual treatment approach with stronger weighting of the pharmacokinetics/pharmacodynamics (PK/PD) index of the substance groups. Although this is not yet the clinical standard, prolonged (or continuous) infusion of beta-lactam antibiotics and therapeutic drug monitoring (TDM) can help to achieve defined PK targets. Prolonged infusion is sufficient without TDM but for continuous infusion TDM is basically necessary. A further argument for individual PK/PD-oriented antibiotic approaches is the increasing number of infections due to multidrug resistant pathogens (MDR) in the intensive care unit. For effective treatment antibiotic stewardship teams (ABS team) are becoming more established. Interdisciplinary cooperation of the ABS team with infectiologists, microbiologists and clinical pharmacists leads not only to a rational administration of antibiotics but also has a positive influence on the outcome. The gold standards for pathogen detection are still culture-based detection and microbiological resistance testing for the various antibiotic groups. Despite the rapid investigation time, novel polymerase chain reaction (PCR)-based procedures for pathogen identification and resistance determination, are currently only an adjunct to routine sepsis diagnostics due to the limited number of studies, high costs and limited availability. In complicated septic courses with multiple anti-infective treatment or recurrent sepsis, PCR-based procedures can be used in addition to therapy monitoring and diagnostics. Novel antibiotics represent potent alternatives in the treatment of MDR infections. Due to the often defined spectrum of pathogens and the practically absent resistance, they are suitable for targeted treatment of severe MDR infections (therapy escalation).

Implementation of a whole of hospital sepsis clinical pathway in a cancer hospital: impact on sepsis management, outcomes and costs

Infection and sepsis are common problems in cancer management affecting up to 45% of patients and are associated with significant morbidity, mortality and healthcare utilisation.

Objective

To develop and implement a whole of hospital clinical pathway for the management of sepsis (SP) in a specialised cancer hospital and to measure the impact on patient outcomes and healthcare utilisation.

Methods

A multidisciplinary sepsis working party was established. Process mapping of practices for recognition and management of sepsis was undertaken across all clinical areas. A clinical pathway document that supported nurse-initiated sepsis care, prompt antibiotic and fluid resuscitation was implemented. Process and outcome measures for patients with sepsis were collected preimplementation (April-December 2012), postimplementation cohorts (April-December 2013), and from January to December 2014.

Results

323 patients were evaluated (111 preimplementation, 212 postimplementation). More patients with sepsis had lactate measured (75.0% vs 17.2%) and appropriate first dose antibiotic (90.1% vs 76.1%) (all p<0.05). Time to antibiotics was halved (55 vs 110 min, p<0.05). Patients with sepsis had lower rates of intensive care unit admission (17.1% vs 35.5%), postsepsis length of stay (7.5 vs 9.9 days), and sepsis-related mortality (5.0% vs 16.2%) (all p<0.05). Mean total hospital admission costs were lower in the SP cohort, with a significant difference in admission costs between historical and SP non-surgical groups of $A8363 (95% CI 81.02 to 16645.32, p=0.048) per patient on the pathway. A second cohort of 449 patients with sepsis from January to December 2014 demonstrated sustained improvement.

Conclusions

The SP was associated with significant improvement in patient outcomes and reduced costs. The SP has been sustained since 2013, and has been successfully implemented in another hospital with further implementations underway in Victoria.

Sooner is better: use of a real-time automated bedside dashboard improves sepsis care

BACKGROUND

Minimizing the interval between diagnosis of sepsis and administration of antibiotics improves patient outcomes. We hypothesized that a commercially available bedside clinical surveillance visualization system (BSV) would hasten antibiotic administration and decrease length of stay (LOS) in surgical intensive care unit (SICU) patients.

METHODS

A BSV, integrated with the electronic medical record and displayed at bedside, was implemented in our SICU in July 2016. A visual sepsis screen score (SSS) was added in July 2017. All patients admitted to SICU beds with bedside displays equipped with a BSV were analyzed to determine mean SSS, maximum SSS, time from positive SSS to antibiotic administration, SICU LOS, and mortality.

RESULTS

During the study period, 232 patients were admitted to beds equipped with the clinical surveillance visualization system. Thirty patients demonstrated positive SSS followed by confirmed sepsis (23 Pre-SSS versus 7 Post-SSS). Mean and maximum SSS were similar. Time from positive SSS to antibiotic administration was decreased in patients with a visual SSS (55.3 ± 15.5 h versus 16.2 ± 9.2 h; P < 0.05). ICU and hospital LOS was also decreased (P < 0.01).

CONCLUSIONS

Implementation of a visual SSS into a BSV led to a decreased time interval between the positive SSS and administration of antibiotics and was associated with shorter SICU and hospital LOS. Integration of a visual decision support system may help providers adhere to Surviving Sepsis Guidelines.

Persistent Increased Frequency of Genomic Instability in Women Diagnosed with Breast Cancer: Before, during, and after Treatments

This study aimed to evaluate DNA damage in patients with breast cancer before treatment (background) and after chemotherapy (QT) and radiotherapy (RT) treatment using the Comet assay in peripheral blood and the micronucleus test in buccal cells. We also evaluated repair of DNA damage after the end of RT, as well as the response of patient's cells before treatment with an oxidizing agent (H2O2; challenge assay). Fifty women with a mammographic diagnosis negative for cancer (control group) and 100 women with a diagnosis of breast cancer (followed up during the treatment) were involved in this study. The significant DNA damage was observed by increasing in the index and frequency of damage along with the increasing of the frequency of micronuclei in peripheral blood and cells of the buccal mucosa, respectively. Despite the variability of the responses of breast cancer patients, the individuals presented lesions on the DNA, detected by the Comet assay and micronucleus Test, from the diagnosis until the end of the oncological treatment and were more susceptible to oxidative stress. We can conclude that the damages were due to clastogenic and/or aneugenic effects related to the neoplasia itself and that they increased, especially after RT.

Implementation of the Surviving Sepsis Campaign guidelines

PURPOSE OF REVIEW

Early identification and appropriate management of sepsis improves outcomes. Despite convincing data showing the benefits of early recognition and treatment of sepsis and septic shock, implementation of such evidence-based therapy is suboptimal. This review describes methods that have been shown to improve bedside application of the evidence-based guidelines.

RECENT FINDINGS

The Surviving Sepsis Campaign (SSC) has developed guidelines for the management of severe sepsis and septic shock. The initial SSC guidelines were published in 2004; as evidence continued to evolve, the guidelines were updated, with the most recent iteration published in 2016. Guidelines by themselves can take years to change clinical practice. To affect more rapid change, the SSC guidelines are filtered into bundles to impact behavior change in a simple and uniform way.

SUMMARY

Implementation of the SSC bundles revolves around practice improvement measures. Hospitals that have successfully implemented these bundles have consistently shown improved outcomes and reductions in healthcare spending. Finally, the Centers for Medicare and Medicaid Services has approved SSC bundle compliance as a core measure, and hospitals in the United States are mandated to collect and report their data regularly to Centers for Medicare and Medicaid Services.

Infectious Diseases Team for the Early Management of Severe Sepsis and Septic Shock in the Emergency Department

Background

The impact on patient survival of an infectious disease (ID) team dedicated to the early management of severe sepsis/septic shock (SS/SS) in Emergency Department (ED) has yet to be assessed.

Methods

A quasiexperimental pre-post study was performed at the general ED of our hospital. During the pre phase (June 2013-July 2014), all consecutive adult patients with SS/SS were managed according to the standard of care, data were prospectively collected. During the post phase (August 2014-October 2015), patients were managed in collaboration with a dedicated ID team performing a bedside patient evaluation within 1 hour of ED arrival.

Results

Overall, 382 patients were included, 195 in the pre phase and 187 in the post phase. Median age was 82 years (interquartile range, 70-88). The most common infection sources were lung (43%) and urinary tract (17%); in 22% of cases, infection source remained unknown. During the post phase, overall compliance with the Surviving Sepsis Campaign (SSC) bundle and appropriateness of initial antibiotic therapy improved from 4.6% to 32% (P < .001) and from 30% to 79% (P < .001), respectively. Multivariate analysis showed that predictors of all-cause 14-day mortality were quick sepsis-related organ failure assessment ≥2 (hazard ratio [HR], 1.68; 95% confidence interval [CI], 1.15-2.45; P = .007), serum lactate ≥2 mmol/L (HR, 2.13; 95% CI, 1.39-3.25; P < .001), and unknown infection source (HR, 2.07; 95% CI, 1.42-3.02; P < .001); being attended during the post phase was a protective factor (HR, 0.64; 95% CI, 0.43-0.94; P = .026).

Conclusion

Implementation of an ID team for the early management of SS/SS in the ED improved the adherence to SSC recommendations and patient survival.

[International guidelines from the Surviving Sepsis Campaign : 2016 update]

An update to the international guidelines for sepsis therapy was published by the Surviving Sepsis Campaign (SSC) in March 2017. The guidelines have been completely restructured and comprehensively deal with new evidence. The guidelines discuss sepsis-specific therapeutic measures and provide detailed recommendations on general intensive care measures for sepsis. This article summarizes the most important amendments and suggests delving deeper into the guidelines.

EFFECTS OF Wnt / β-CATENIN SIGNALING PATHWAY AND STAR D7 ON TESTOSTERONE SYNTHESIS

BACKGROUND

This study aimed to assess the mechanism through which Wnt/ beta - catenin signaling pathway, and StarD7, prometes testosterone synthesis, and to explore a new pathway for the regulation of testosterone synthesis.

ANIMALS AND METHODS

Leydig cells were isolated from male Sprague-Dawley rats divided into four groups and treated with Annexin 5 in concentration of 0, 0.1, 1 and 10 nmol/L. Testosterone secretion, expression of StarD7, StarD7 mRNA, β-catenin and changes of β - catenin localization in Leydig cells of testis of rats were tested in the four groups.

RESULTS

mRNA and protein levels of StarD7 and β-catenin increased significantly, upon stimulation with 1 nmol/L annexin 5. Accumulation of β-catenin inside the cells and the nucleus, was observed by immunofluorescence staining, in cells treated with annexin 5. These findings indicate a possible role of StarD7 and β-catenin in the process of annexin5-mediated stimulation of testosterone synthesis.

CONCLUSIONS

Wnt/β-catenin signaling pathway and StarD7 are involved in the process of annexin5 stimulation of testosterone synthesis. Activation of Wnt/ β-catenin signaling pathway by Annexin5, and increase in StarD7 expression lead to elevated expression of key regulatory enzymes in testosterone synthesis, thus promoting testosterone synthesis.

Sepsis as a model for improving diagnosis

Diagnostic safety could theoretically be improved by high-level interventions, such as improving clinical reasoning or eliminating system-related defects in care, or by focusing more specifically on a single problem or disease. In this review, we consider how the timely diagnosis of sepsis has evolved and improved as an example of the disease-focused approach. This progress has involved clarifying and revising the definitions of sepsis, efforts to raise awareness, faster and more reliable laboratory tests and a host of practice-level improvements based on health services research findings and recommendations. We conclude that this multi-faceted approach incorporating elements of the 'learning health system' model has improved the early recognition and treatment of sepsis, and propose that this model could be productively applied to improve timely diagnosis in other time-sensitive conditions.

Removal of totally implanted venous access ports for suspected infection in the intensive care unit: a multicenter observational study

Background

While no data support this practice, international guidelines recommend the removal of totally implanted venous access ports (TIVAPs) in patients with suspicion of TIVAP-related bloodstream infection admitted in the intensive care unit (ICU) for a life-threatening sepsis.

Methods

During this multicenter, retrospective and observational study, we included all patients admitted in five ICU for a life-threatening sepsis in whom a TIVAP was removed between January 2012 and December 2014. We aimed (1) at determining the proportion of confirmed TIVAP-related infections and (2) at assessing short- and long-term survival of patients with and without TIVAP-related infections.

Results

One hundred and fifty-one patients (58 ± 14 years, 62% males) were included between 2012 and 2014. TIVAP-related infections were confirmed in 68 patients (45%). Demographic characteristics were similar between patients with and without TIVAP-related infections. SOFA score on admission per point increase [odd ratio (OR), 0.86 interval confidence (IC) 95% (0.8–0.9), p < 0.01] and local signs of infection [OR 4.0, IC 95% (1.1–15.6), p = 0.04] were significantly associated with TIVAP-related infection. Patients with TIVAP-related infection had lower ICU and 6-month mortality as compared to their counterparts (9 vs. 40%, respectively, p < 0.01; and 50 vs. 66%, respectively, p = 0.04). TIVAP-related infection was significantly associated with ICU survival [OR 0.2, IC 95% (0.05–0.5), p < 0.01].

Conclusions

TIVAP-related infection was confirmed in nearly one out of two cases of life-threatening sepsis in patients in whom it has been removed. TIVAP-related infection was associated with a good prognosis, as compared to patients with other causes of infection.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0383-9) contains supplementary material, which is available to authorized users.

A risk-model for hospital mortality among patients with severe sepsis or septic shock based on German national administrative claims data

BACKGROUND

Sepsis is a major cause of preventable deaths in hospitals. Feasible and valid methods for comparing quality of sepsis care between hospitals are needed. The aim of this study was to develop a risk-adjustment model suitable for comparing sepsis-related mortality between German hospitals.

METHODS

We developed a risk-model using national German claims data. Since these data are available with a time-lag of 1.5 years only, the stability of the model across time was investigated. The model was derived from inpatient cases with severe sepsis or septic shock treated in 2013 using logistic regression with backward selection and generalized estimating equations to correct for clustering. It was validated among cases treated in 2015. Finally, the model development was repeated in 2015. To investigate secular changes, the risk-adjusted trajectory of mortality across the years 2010-2015 was analyzed.

RESULTS

The 2013 deviation sample consisted of 113,750 cases; the 2015 validation sample consisted of 134,851 cases. The model developed in 2013 showed good validity regarding discrimination (AUC = 0.74), calibration (observed mortality in 1st and 10th risk-decile: 11%-78%), and fit (R2 = 0.16). Validity remained stable when the model was applied to 2015 (AUC = 0.74, 1st and 10th risk-decile: 10%-77%, R2 = 0.17). There was no indication of overfitting of the model. The final model developed in year 2015 contained 40 risk-factors. Between 2010 and 2015 hospital mortality in sepsis decreased from 48% to 42%. Adjusted for risk-factors the trajectory of decrease was still significant.

CONCLUSIONS

The risk-model shows good predictive validity and stability across time. The model is suitable to be used as an external algorithm for comparing risk-adjusted sepsis mortality among German hospitals or regions based on administrative claims data, but secular changes need to be taken into account when interpreting risk-adjusted mortality.

Hospital Readmission in Total Hip Replacement Patients in 2009 and 2014

OBJECTIVE

To document changes in 30-day hospital readmission rates and causes for returning to the hospital for care in THR patients.

DESIGN

Retrospective cross-sectional descriptive design.

SETTING

Community-based acute care hospitals.

PARTICIPANTS

Total sample size (N=142,022) included THR patients (identified as ICD-9-CM procedure code 81.51) in 2009 (n=31,232) and (n=32,863) in 2014.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

30-Day hospital readmission.

RESULTS

The overall readmission rate decreased by 1.3% from 2009 to 2014. The decrease in readmission rates varied by groups, with lesser improvements seen in THR patients who were younger, with private insurance, and residing in lower-income and rural communities. Device complications were the leading cause of readmission in THR patients, increasing from 19.8% in 2009 to 23.9% in 2014.

CONCLUSIONS

There has been little decrease in hospital 30-day readmission rates for US community hospitals between 2009 and 2014. Findings from this brief report indicate patient groups at greater risk for 30-day hospital readmission as well as leading causes for readmission in THR patients which can inform the development of tailored interventions for reduction.

The German Quality Network Sepsis: study protocol for the evaluation of a quality collaborative on decreasing sepsis-related mortality in a quasi-experimental difference-in-differences design

BACKGROUND

While sepsis-related mortality decreased substantially in other developed countries, mortality of severe sepsis remained as high as 44% in Germany. A recent German cluster randomized trial was not able to improve guideline adherence and decrease sepsis-related mortality within the participating hospitals, partly based on lacking support by hospital management and lacking resources for documentation of prospective data. Thus, more pragmatic approaches are needed to improve quality of sepsis care in Germany. The primary objective of the study is to decrease sepsis-related hospital mortality within a quality collaborative relying on claims data.

METHOD

The German Quality Network Sepsis (GQNS) is a quality collaborative involving 75 hospitals. This study protocol describes the conduction and evaluation of the start-up period of the GQNS running from March 2016 to August 2018. Democratic structures assure participatory action, a study coordination bureau provides central support and resources, and local interdisciplinary quality improvement teams implement changes within the participating hospitals. Quarterly quality reports focusing on risk-adjusted hospital mortality in cases with sepsis based on claims data are provided. Hospitals committed to publish their individual risk-adjusted mortality compared to the German average. A complex risk-model is used to control for differences in patient-related risk factors. Hospitals are encouraged to implement a bundle of interventions, e.g., interdisciplinary case analyses, external peer-reviews, hospital-wide staff education, and implementation of rapid response teams. The effectiveness of the GQNS is evaluated in a quasi-experimental difference-in-differences design by comparing the change of hospital mortality of cases with sepsis with organ dysfunction from a retrospective baseline period (January 2014 to December 2015) and the intervention period (April 2016 to March 2018) between the participating hospitals and all other German hospitals. Structural and process quality indicators of sepsis care as well as efforts for quality improvement are monitored regularly.

DISCUSSION

The GQNS is a large-scale quality collaborative using a pragmatic approach based on claims data. A complex risk-adjustment model allows valid quality comparisons between hospitals and with the German average. If this study finds the approach to be useful for improving quality of sepsis care, it may also be applied to other diseases.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02820675.

Tokyo Guidelines 2018: management bundles for acute cholangitis and cholecystitis

Management bundles that define items or procedures strongly recommended in clinical practice have been used in many guidelines in recent years. Application of these bundles facilitates the adaptation of guidelines and helps improve the prognosis of target diseases. In Tokyo Guidelines 2013 (TG13), we proposed management bundles for acute cholangitis and cholecystitis. Here, in Tokyo Guidelines 2018 (TG18), we redefine the management bundles for acute cholangitis and cholecystitis. Critical parts of the bundles in TG18 include the diagnostic process, severity assessment, transfer of patients if necessary, and therapeutic approach at each time point. Observance of these items and procedures should improve the prognosis of acute cholangitis and cholecystitis. Studies are now needed to evaluate the dissemination of these TG18 bundles and their effectiveness. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

The effects of care bundles on patient outcomes: a systematic review and meta-analysis

BACKGROUND

Care bundles are a set of three to five evidence-informed practices performed collectively and reliably to improve the quality of care. Care bundles are used widely across healthcare settings with the aim of preventing and managing different health conditions. This is the first systematic review designed to determine the effects of care bundles on patient outcomes and the behaviour of healthcare workers in relation to fidelity with care bundles.

METHODS

This systematic review is reported in line with the PRISMA statement for reporting systematic reviews and meta-analyses. A total of 5796 abstracts were retrieved through a systematic search for articles published between January 1, 2001, to February 4, 2017, in the Cochrane Central Register for Controlled Trials, MEDLINE, EMBASE, British Nursing Index, CINAHL, PsychInfo, British Library, Conference Proceeding Citation Index, OpenGrey trials (including cluster-randomised trials) and non-randomised studies (comprising controlled before-after studies, interrupted time series, cohort studies) of care bundles for any health condition and any healthcare settings were considered. Following the removal of duplicated studies, two reviewers independently screen 3134 records. Three authors performed data extraction independently. We compared the care bundles with usual care to evaluate the effects of care bundles on the risk of negative patient outcomes. Random-effect models were used to further explore the effects of subgroups.

RESULTS

In total, 37 studies (6 randomised trials, 31 controlled before-after studies) were eligible for inclusion. The effect of care bundles on patient outcomes is uncertain. For randomised trial data, the pooled relative risk of negative effects between care bundle and control groups was 0.97 [95% CI 0.71 to 1.34; 2049 participants]. The relative risk of negative patient outcomes from controlled before-after studies favoured the care bundle treated groups (0.66 [95% CI 0.59 to 0.75; 119,178 participants]). However, using GRADE, we assessed the certainty of all of the evidence to be very low (downgraded for risk of bias, inconsistency, indirectness).

CONCLUSIONS

Very low quality evidence from controlled before-after studies suggests that care bundles may reduce the risk of negative outcomes when compared with usual care. By contrast, the better quality evidence from six randomised trials is more uncertain.

TRIAL REGISTRATION

PROSPERO, CRD42016033175.

Resource availability for the management of maternal sepsis in Malawi, other low-income countries, and lower-middle-income countries

OBJECTIVE

To assess the availability of key resources for the management of maternal sepsis and evaluate the feasibility of implementing the Surviving Sepsis Campaign (SSC) recommendations in Malawi and other low-resource settings.

METHODS

A cross-sectional study was conducted at health facilities in Malawi, other low-income countries, and lower-middle-income countries during January-March 2016. English-speaking healthcare professionals (e.g. doctors, nurses, midwives, and administrators) completed a questionnaire/online survey to assess the availability of resources for the management of maternal sepsis.

RESULTS

Healthcare centers (n=23) and hospitals (n=13) in Malawi showed shortages in the resources for basic monitoring (always available in 5 [21.7%] and 10 [76.9%] facilities, respectively) and basic infrastructure (2 [8.7%] and 7 [53.8%], respectively). The availability of antibiotics varied between Malawian healthcare centers (9 [39.1%]), Malawian hospitals (8 [61.5%]), hospitals in other low-income countries (10/17 [58.8%]), and hospitals in lower-middle-income countries (39/41 [95.1%]). The percentage of SSC recommendations that could be implemented was 33.3% at hospitals in Malawi, 30.3% at hospitals in other low-income countries, and 68.2% at hospitals in lower-middle-income countries.

CONCLUSION

The implementation of existing SSC recommendations is unrealistic in low-income countries because of resource limitations. New maternal sepsis care bundles must be developed that are applicable to low-resource settings.

Sepsis in Internal Medicine wards: current knowledge, uncertainties and new approaches for management optimization

Sepsis represents a global health problem in terms of morbidity, mortality, social and economic costs. Although usually managed in Intensive Care Units, sepsis showed an increased prevalence among Internal Medicine wards in the last decade. This is substantially due to the ageing of population and to multi-morbidity. These characteristics represent both a risk factor for sepsis and a relative contra-indication for the admission to Intensive Care Units. Although there is a lack of literature on the management of sepsis in Internal Medicine, the outcome of these patients seems to be gradually improving. This is due to Internists' increased adherence to guidelines and "bundles". The routine use of SOFA score helps physicians in the definition of septic patients, even if the optimal score has still to come. Point-of-care ultrasonography, lactates, procalcitonin and beta-d-glucan are of help for treatment optimization. The purpose of this narrative review is to focus on the management of sepsis in Internal Medicine departments, particularly on crucial concepts regarding diagnosis, risk assessment and treatment. Key Messages Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. The prevalence of sepsis is constantly increasing, affecting more hospital patients than any other disease. At least half of patients affected by sepsis are admitted to Internal Medicine wards. Adherence to guidelines, routine use of clinical and lab scores and point-of-care ultrasonography are of help for early recognition of septic patients and treatment optimization.

A Multicenter Survey of House Staff Knowledge About Sepsis and the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock"

BACKGROUND

We aimed to assess the knowledge, attitudes, and perceptions of resident physicians regarding sepsis in general and the Surviving Sepsis Campaign Guidelines in particular.

METHODS

After institutional review board approval, we surveyed internal medicine (IM) and emergency medicine (EM) house staff from 3 separate institutions. House staff were notified of the survey via e-mail from their residency director or chief resident. The survey was Internet-based (using http://www.surveymonkey.com ), voluntary, and anonymous. The Surviving Sepsis Campaign Guidelines were used to develop the survey. The survey was open between December 2015 and April 2016. No incentives for participation were given. Reminder e-mails were sent approximately every 3 to 4 weeks to all eligible participants. Comparisons of responses were evaluated using the N-1 2-proportion test.

RESULTS

A total of 133 responses were received. These included 84 from IM house staff, 27 from EM house staff, and 22 who selected "other." Eighty (101/126) percent reported managing at least 1 patient with sepsis in the preceding 30 days, 85% (97/114) rated their knowledge of the Surviving Sepsis Guidelines as "very familiar" or at least "somewhat familiar," and 84% (91/108) believed their training in the diagnosis and management of sepsis was "excellent" or at least "good." However, 43% (47/108) reported not receiving any feedback on their treatment of patients with sepsis in the last 30 days, while 24% (26/108) received feedback once. Both IM and EM house staff received comparable rates of feedback (62% vs 48%, respectively; P = .21). For the 3 questions that directly tested knowledge of the guidelines, the scores of the IM and EM house staff were similar. Notably, <20% of both groups correctly identified diagnostic criteria for sepsis.

CONCLUSION

Additional education of IM and EM house staff on the Surviving Sepsis Campaign Guidelines is warranted, along with more consistent feedback regarding their diagnosis and management of sepsis.

Implementation of sepsis bundles in public hospitals in Brazil: a prospective study with heterogeneous results

Background

Public hospitals in emerging countries pose a challenge to quality improvement initiatives in sepsis. Our objective was to evaluate the results of a quality improvement initiative in sepsis in a network of public institutions and to assess potential differences between institutions that did or did not achieve a reduction in mortality.

Methods

We conducted a prospective study of patients with sepsis or septic shock. We collected baseline data on compliance with the Surviving Sepsis Campaign 6-h bundles and mortality. Afterward, we initiated a multifaceted quality improvement initiative for patients with sepsis or septic shock in all hospital sectors. The primary outcome was hospital mortality over time. The secondary outcomes were the time to sepsis diagnosis and compliance with the entire 6-h bundles throughout the intervention. We defined successful institutions as those where the mortality rates decreased significantly over time, using a logistic regression model. We analyzed differences over time in the secondary outcomes by comparing the successful institutions with the nonsuccessful ones. We assessed the predictors of in-hospital mortality using logistic regression models. All tests were two-sided, and a p value less than 0.05 indicated statistical significance.

Results

We included 3435 patients from the emergency departments (50.7%), wards (34.1%), and intensive care units (15.2%) of 9 institutions. Throughout the intervention, there was an overall reduction in the risk of death, in the proportion of septic shock, and the time to sepsis diagnosis, as well as an improvement in compliance with the 6-h bundle. The time to sepsis diagnosis, but not the compliance with bundles, was associated with a reduction in the risk of death. However, there was a significant reduction in mortality in only two institutions. The reduction in the time to sepsis diagnosis was greater in the successful institutions. By contrast, the nonsuccessful sites had a greater increase in compliance with the 6-h bundle.

Conclusions

Quality improvement initiatives reduced sepsis mortality in public Brazilian institutions, although not in all of them. Early recognition seems to be a more relevant factor than compliance with the 6-h bundle.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1858-z) contains supplementary material, which is available to authorized users.

The effect of adiponectin on LPS-induced inflammation via autophagy in RAW 264.7 macrophages

Mitochondrial dysfunction is involved in the process of sepsis and leads to the accumulation of reactive oxygen species (ROS), which breaks cellular homeostasis and activates the downstream inflammatory cascade. The autophagic removal of ROS is a well-established cellular adaptive mechanism. Adiponectin is an adipocytokine that plays an important role in metabolic and inflammatory regulation. In this study, we investigated the anti-inflammatory effect of adiponectin in a sepsis model and its potential association with autophagy. We induced RAW 264.7 macrophages with lipopolysaccharide (LPS) to set up the sepsis model and treated them with adiponectin, an inhibitor of the nucleotide-binding domain and leucine-rich repeat containing family pyrin domain–containing 3 (NLRP3), ROS, Complex I, and an autophagy inhibitor. Flow cytometry and western blot analysis were performed to detect the expression levels of ROS, NLRP3, interleukin-1 beta (IL-1β), microtubule-associated protein 1A/1B-light chain 3II/I (LC3II/I), and adenosine monophosphate–activated protein kinase (AMPK). Expression levels of NLRP3, IL-1β, and ROS were significantly increased following LPS induction, and adiponectin reversed this up-regulation. Meanwhile, adiponectin also enhanced the expression of LC3II/I, an autophagosome marker, but an autophagy inhibitor and AMPK inhibitor depleted (reversed) the anti-inflammatory and antioxidant effect of adiponectin. Taken together, in the LPS-induced sepsis model, adiponectin alleviated the inflammatory reaction by reducing ROS production, possibly by enhancing autophagy via the AMPK pathway. The activation of autophagy may therefore be a key mechanism by which adiponectin ameliorates the inflammatory reactions of sepsis.

Impact of an electronic sepsis initiative on antibiotic use and health care facility-onset Clostridium difficile infection rates

BACKGROUND

Although integrated, electronic sepsis screening and treatment protocols are thought to improve patient outcomes, less is known about their unintended consequences. We aimed to determine if the introduction of a sepsis initiative coincided with increases in broad-spectrum antibiotic use and health care facility-onset (HCFO) Clostridium difficile infection (CDI) rates.

METHODS

We used interrupted time series data from a large, tertiary, urban academic medical center including all adult inpatients on 4 medicine wards (June 2011-July 2014). The main exposure was implementation of the sepsis screening program; the main outcomes were the use of broad-spectrum antibiotics (including 3 that were part of an order set designed for the sepsis initiative) and HCFO CDI rates. Segmented regression analyses compared outcomes in 3 time segments: before (11 months), during (14 months), and after (12 months) implementation of a sepsis initiative.

RESULTS

Antibiotic use and HFCO CDI rates increased during the period of implementation and the period after implementation compared with baseline; these increases were highest in the period after implementation (level change, 50.4 days of therapy per 1,000 patient days for overall antibiotic use and 10.8 HCFO CDIs per 10,000 patient days; P < .05). Remarkably, the main drivers of overall antibiotic use were not those included in the sepsis order set.

CONCLUSIONS

The implementation of an electronic sepsis screening and treatment protocol coincided with increased broad-spectrum antibiotic use and HCFO CDIs. Because these protocols are increasingly used, further study of their unintended consequences is warranted.

Clinical Application of the Quick Sepsis-Related Organ Failure Assessment Score at Intensive Care Unit Admission in Patients with Bacteremia: A Single-Center Experience of Korea

Background

We evaluated the clinical usefulness of the quick Sepsis-Related Organ Failure Assessment (qSOFA) score (based on the 2016 definition of sepsis) at intensive care unit admission in Korean patients with bacteremia.

Methods

We retrospectively analyzed clinical data from 236 patients between March 2011 and February 2016. In addition to the qSOFA, the Modified Early Warning score (MEWS) and systemic inflammatory response syndrome (SIRS) criteria were calculated.

Results

The patients' median age was 69 years, and 61.0% were male. Of the patients, 127 (53.8%) had a qSOFA score ≥2 points. They had significantly higher rates of septic shock, thrombocytopenia, and hyperlactatemia, and increased requirements for ventilator care, neuromuscular blocking agents, vasopressors, and hemodialysis within 72 hours after intensive care unit admission. They also had a significantly higher 28-day mortality rate. When analyzed using common thresholds (MEWS ≥5 and ≥2 SIRS criteria), patients with a MEWS ≥5 had the same results as those with a qSOFA score ≥2 (P < 0.05). However, patients with ≥2 SIRS criteria showed no significant differences.

Conclusions

Our results show that a qSOFA score ≥2 at admission is a useful screening tool for predicting disease severity and medical resource usage within 72 hours after admission, and for predicting 28-day mortality rates in patients with bacteremia. In addition, qSOFA scores may be more useful than SIRS criteria in terms of prognostic utility.

Mortality, intensive care treatment, and cost evaluation: Role of a polymerase chain reaction assay in patients with sepsis

Objective

We examined whether patients with a positive SeptiFast (SF) assay (LightCycler SeptiFast; Roche Diagnostics, Basel, Switzerland) developed higher long-term mortality, a more difficult course of treatment, and a higher antimicrobial treatment cost than patients with a negative SF assay.

Methods

We performed a post-hoc analysis of data collected in a 1-year prospective interventional study of adults with severe sepsis and septic shock. In addition to the standard treatment, an additional 5 ml of blood was obtained for an SF assay, and the antimicrobial treatment was changed according to the SF results.

Results

We included 57 patients, and the SF assay was positive (SF+) in 10 (17.5%) and negative (SF−) in 47 (82.5%) patients. A trend toward a higher 6-month, 1-year, and 2-year mortality rate was observed in the SF+ group. In the SF+ group, we observed a significantly greater need for second-line vasopressor therapy, a higher initial procalcitonin concentration, and higher maximum C-reactive protein and lactate concentrations. We found no significant differences in cost of antimicrobial treatment between the SF+ and SF− groups.

Conclusions

We observed a trend toward higher long-term mortality and a more difficult course of treatment but no difference in the cost of antimicrobial treatment.