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Monti G, Rezoagli E, Calini A, Nova A, Marchesi S, Nattino G, Carrara G, Morra S, Cortellaro F, Savioli M, Capra Marzani F, Tresoldi M, Villa P, Greco S, Bonfanti P, Spitoni MG, Vesconi S, Caironi P, Fumagalli R. Effect of a quality improvement program on compliance to the sepsis bundle in non-ICU patients: a multicenter prospective before and after cohort study. Front Med (Lausanne) 2023; 10:1215341. [PMID: 38020128 PMCID: PMC10680451 DOI: 10.3389/fmed.2023.1215341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Objective Sepsis and septic shock are major challenges and economic burdens to healthcare, impacting millions of people globally and representing significant causes of mortality. Recently, a large number of quality improvement programs focused on sepsis resuscitation bundles have been instituted worldwide. These educational initiatives have been shown to be associated with improvements in clinical outcomes. We aimed to evaluate the impact of a multi-faceted quality implementing program (QIP) on the compliance of a "simplified 1-h bundle" (Sepsis 6) and hospital mortality of severe sepsis and septic shock patients out of the intensive care unit (ICU). Methods Emergency departments (EDs) and medical wards (MWs) of 12 academic and non-academic hospitals in the Lombardy region (Northern Italy) were involved in a multi-faceted QIP, which included educational and organizational interventions. Patients with a clinical diagnosis of severe sepsis or septic shock according to the Sepsis-2 criteria were enrolled in two different periods: from May 2011 to November 2011 (before-QIP cohort) and from August 2012 to June 2013 (after-QIP cohort). Measurements and main results The effect of QIP on bundle compliance and hospital mortality was evaluated in a before-after analysis. We enrolled 467 patients in the before-QIP group and 656 in the after-QIP group. At the time of enrollment, septic shock was diagnosed in 50% of patients, similarly between the two periods. In the after-QIP group, we observed increased compliance to the "simplified rapid (1 h) intervention bundle" (the Sepsis 6 bundle - S6) at three time-points evaluated (1 h, 13.7 to 18.7%, p = 0.018, 3 h, 37.1 to 48.0%, p = 0.013, overall study period, 46.2 to 57.9%, p < 0.001). We then analyzed compliance with S6 and hospital mortality in the before- and after-QIP periods, stratifying the two patients' cohorts by admission characteristics. Adherence to the S6 bundle was increased in patients with severe sepsis in the absence of shock, in patients with serum lactate <4.0 mmol/L, and in patients with hypotension at the time of enrollment, regardless of the type of admission (from EDs or MWs). Subsequently, in an observational analysis, we also investigated the relation between bundle compliance and hospital mortality by logistic regression. In the after-QIP cohort, we observed a lower in-hospital mortality than that observed in the before-QIP cohort. This finding was reported in subgroups where a higher adherence to the S6 bundle in the after-QIP period was found. After adjustment for confounders, the QIP appeared to be independently associated with a significant improvement in hospital mortality. Among the single S6 procedures applied within the first hour of sepsis diagnosis, compliance with blood culture and antibiotic therapy appeared significantly associated with reduced in-hospital mortality. Conclusion A multi-faceted QIP aimed at promoting an early simplified bundle of care for the management of septic patients out of the ICU was associated with improved compliance with sepsis bundles and lower in-hospital mortality.
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Affiliation(s)
- Gianpaola Monti
- Department of Anesthesia and Intensive Care, ASST GOM Niguarda Ca’ Granda, Milan, Italy
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Angelo Calini
- Department of Anesthesia and Intensive Care, ASST GOM Niguarda Ca’ Granda, Milan, Italy
| | - Alice Nova
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Silvia Marchesi
- Intensiv och perioperativ vard, Skane Universitetssjukhus, Malmo, Sweden
| | - Giovanni Nattino
- Istituto di ricerche farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
| | - Greta Carrara
- Istituto di ricerche farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
| | - Sergio Morra
- Department of Anesthesia and Intensive Care, ASST Ovest Milano, Legnano, Italy
| | | | - Monica Savioli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCSC Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Federico Capra Marzani
- Department of Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Moreno Tresoldi
- Unit of General Medicine and Advanced Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Villa
- Department of Emergency, ASST FBF - Sacco, Ospedale L. Sacco, Milan, Italy
| | - Stefano Greco
- Department of Anesthesia and Intensive Care, ASST Valle Olona, Ospedale Busto Arsitio, Busto Arsitio, Italy
| | - Paolo Bonfanti
- Infectious Diseases, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | - Sergio Vesconi
- Department of Anesthesia and Intensive Care, ASST GOM Niguarda Ca’ Granda, Milan, Italy
| | - Pietro Caironi
- Department of Anesthesia and Intensive Care, AOU S. Luigi Gonzaga, Università degli Studi di Torino, Orbassano, Italy
| | - Roberto Fumagalli
- Department of Anesthesia and Intensive Care, ASST GOM Niguarda Ca’ Granda, Milan, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
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DeShon B, Dummitt B, Allen J, Yount B. Prediction of sepsis onset in hospital admissions using survival analysis. J Clin Monit Comput 2022; 36:1611-1619. [PMID: 35076834 DOI: 10.1007/s10877-022-00804-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 01/03/2022] [Indexed: 11/25/2022]
Abstract
To determine the efficacy of modern survival analysis methods for predicting sepsis onset in ICU, emergency, medical/surgical, and TCU departments. We performed a retrospective analysis on ICU, med/surg, ED, and TCU cases from multiple Mercy Health hospitals from August 2018 to March 2020. Patients in these departments were monitored by the Mercy Virtual vSepsis team and sepsis cases were determined and documented in the Mercy EHR via a rule-based engine utilizing clinical data. We used survival-based modeling methods to predict sepsis onset in these cases. The three survival methods that were used to predict the onset of severe sepsis and septic shock produced AUC values > 0.85 and each provided a median lead time of > 20 h prior to disease onset. This methodology improves upon previous work by demonstrating excellent model performance when generalizing survival-based prediction methods to both severe sepsis and septic shock as well as non-ICU departments.IRB InformationTrial Registration ID: 1,532,327-1.Trial Effective Date: 12/02/2019.
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Affiliation(s)
- Brandon DeShon
- Mercy Health, 14528 S. Outer Forty, Chesterfield, MO, 63017, USA.
| | - Benjamin Dummitt
- Mercy Health, 14528 S. Outer Forty, Chesterfield, MO, 63017, USA
| | - Joshua Allen
- Mercy Health, 14528 S. Outer Forty, Chesterfield, MO, 63017, USA
| | - Byron Yount
- Mercy Health, 14528 S. Outer Forty, Chesterfield, MO, 63017, USA
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Suttapanit K, Satiracharoenkul S, Sanguanwit P, Prachanukool T. The Accuracy of Sepsis Screening Score for Mortality Prediction at Emergency Department Triage. West J Emerg Med 2022; 23:698-705. [PMID: 36205674 PMCID: PMC9541988 DOI: 10.5811/westjem.2022.6.56754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/20/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction Sepsis has a mortality rate of 10–40% worldwide. Many screening tools for sepsis prediction and for emergency department (ED) triage are controversial. This study compared the accuracy of the scores for predicting 28-day mortality in adult patients with sepsis in the triage area of the ED. Methods Adult patients who presented to the ED of a tertiary-care university hospital from January–December 2019 with an initial diagnosis of sepsis or other infection-related conditions were enrolled. We calculated predictive scores using information collected in the ED triage area. Prognostic accuracy was measured by the area under the receiver operating characteristic curve (AUROC) for predicting 28-day mortality as a primary outcome. The secondary outcomes included mechanical ventilation usage and vasopressor usage for 28 days. Results We analyzed a total of 550 patients. The 28-day mortality rate was 12.4% (n = 68). The 28-day mortality rate was best detected by the National Early Warning Score (NEWS) (AUROC = 0.770; 95% confidence interval [CI]: 0.705–0.835), followed by the quick Sequential Organ Failure Assessment (qSOFA) score (AUROC = 0.7473; 95% CI: 0.688–0.806), Search Out Severity (SOS) score (AUROC = 0.749; 95% CI: 0.685–0.815), Emergency Severity Index (ESI) triage (AUROC = 0.599; 95% CI: 0.542–0.656, and the Systemic Inflammatory Response System (SIRS) criteria (AUROC = 0.588; 95% CI: 0.522–0.654]). The NEWS also provided a higher AUROC and outperformed for 28-day mechanical ventilator usage and 28-day vasopressor usage. Conclusion The NEWS outperforms qSOFA, SOS, SIRS, and ESI triage in predicting 28-day mortality, mechanical ventilator, and vasopressor usage of a patient with sepsis who is seen at ED triage.
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Affiliation(s)
- Karn Suttapanit
- Mahidol University, Faculty of Medicine Ramathibodi Hospital, Department of Emergency Medicine, Bangkok, Thailand
| | - Sirasit Satiracharoenkul
- Mahidol University, Faculty of Medicine Ramathibodi Hospital, Department of Emergency Medicine, Bangkok, Thailand
| | - Pitsucha Sanguanwit
- Mahidol University, Faculty of Medicine Ramathibodi Hospital, Department of Emergency Medicine, Bangkok, Thailand
| | - Thidathit Prachanukool
- Mahidol University, Faculty of Medicine Ramathibodi Hospital, Department of Emergency Medicine, Bangkok, Thailand
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Four consecutive yearly point-prevalence studies in Wales indicate lack of improvement in sepsis care on the wards. Sci Rep 2021; 11:16222. [PMID: 34376757 PMCID: PMC8355110 DOI: 10.1038/s41598-021-95648-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/22/2021] [Indexed: 12/15/2022] Open
Abstract
The ‘Sepsis Six’ bundle was promoted as a deliverable tool outside of the critical care settings, but there is very little data available on the progress and change of sepsis care outside the critical care environment in the UK. Our aim was to compare the yearly prevalence, outcome and the Sepsis Six bundle compliance in patients at risk of mortality from sepsis in non-intensive care environments. Patients with a National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled into four yearly 24-h point prevalence studies, carried out in fourteen hospitals across Wales from 2016 to 2019. We followed up patients to 30 days between 2016–2019 and to 90 days between 2017 and 2019. Out of the 26,947 patients screened 1651 fulfilled inclusion criteria and were recruited. The full ‘Sepsis Six’ care bundle was completed on 223 (14.0%) occasions, with no significant difference between the years. On 190 (11.5%) occasions none of the bundle elements were completed. There was no significant correlation between bundle element compliance, NEWS or year of study. One hundred and seventy (10.7%) patients were seen by critical care outreach; the ‘Sepsis Six’ bundle was completed significantly more often in this group (54/170, 32.0%) than for patients who were not reviewed by critical care outreach (168/1385, 11.6%; p < 0.0001). Overall survival to 30 days was 81.7% (1349/1651), with a mean survival time of 26.5 days (95% CI 26.1–26.9) with no difference between each year of study. 90-day survival for years 2017–2019 was 74.7% (949/1271), with no difference between the years. In multivariate regression we identified older age, heart failure, recent chemotherapy, higher frailty score and do not attempt cardiopulmonary resuscitation orders as significantly associated with increased 30-day mortality. Our data suggests that despite efforts to increase sepsis awareness within the NHS, there is poor compliance with the sepsis care bundles and no change in the high mortality over the study period. Further research is needed to determine which time-sensitive ward-based interventions can reduce mortality in patients with sepsis and how can these results be embedded to routine clinical practice. Trial registration Defining Sepsis on the Wards ISRCTN 86502304 https://doi.org/10.1186/ISRCTN86502304 prospectively registered 09/05/2016.
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Tarquinio N, Viticchi G, Zaccone V, Martino M, Fioranelli A, Morciano P, Moroncini G, Di Pentima C, Martini A, Nitti C, Salvi A, Burattini M, Falsetti L. The value of admission Troponin I to predict outcomes in suspected infections in elderly patients admitted in Internal Medicine: results from the SOFA-T collaboration, a multi-center study. Intern Emerg Med 2021; 16:981-988. [PMID: 33428111 DOI: 10.1007/s11739-020-02610-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/16/2020] [Indexed: 01/24/2023]
Abstract
Elderly patients affected by suspected infection and declining clinical conditions can be admitted to stepdown units (SDU), but a risk stratification is necessary to optimize their management. Admission troponin I (aTnI) has a prognostic role, however, one of the most commonly used stratification tools, the Sequential Organ Failure Assessment score (SOFA), does not consider myocardial injury. With this paper, we aimed to evaluate the prognostic accuracy of a new score, named SOFA-T, considering both SOFA score and aTnI in a cohort of elderly patients admitted to the stepdown beds of two Internal Medicine departments. Patients aged > 65 years admitted in SDU of two different hospitals of the same region in a 12-months timeframe were retrospectively assessed obtaining age, sex, days of admission, in-hospital death, SOFA, aTnI and comorbidities. The best aTnI cutoff for in-hospital death was calculated with ROC curve analysis; dichotomous variables were compared with chi-squared test; continuous variables were compared with t test or Mann-Whitney test. We obtained a cohort of 390 patients. The best aTnI cutoff was 0.31 ng/ml: patients with increased aTnI had higher risk of in-hospital death (OR: 1.834; 95% CI 1.160-2.900; p = 0.009), and higher SOFA (6.81 ± 2.71 versus 5.97 ± 3.10; p = 0.010). Adding aTnI to SOFA increased significantly the area under the curve (AUCSOFA = 0.68; 95% CI 0.64-0.73; AUCSOFA-T = 0.71; 95% CI 0.65-0.76; p = 0.0001), with a slight improvement of the prognostic performance. In elderly patients admitted to SDU for suspected infection, sepsis or septic shock, aTnI slightly improves the accuracy of SOFA score of the in-hospital death prediction.
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Affiliation(s)
- N Tarquinio
- Internal Medicine Department, INRCA-IRCCS Hospital, Osimo, Ancona, Italy
| | - G Viticchi
- Clinica Di Neurologia, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" Di Ancona, Italy, Ancona, Italy
| | - V Zaccone
- Internal and Subintensive Medicine Department, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" Di Ancona, Via Conca 10, Ancona, Italy
| | - M Martino
- Internal Medicine Department, INRCA-IRCCS Hospital, Osimo, Ancona, Italy
| | - A Fioranelli
- Internal Medicine Department, INRCA-IRCCS Hospital, Osimo, Ancona, Italy
| | - P Morciano
- Emergency Medicine Residency Program, Marche Polytechnic University, Ancona, Italy
| | - G Moroncini
- Clinica Medica, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" Di Ancona, Italy, Ancona, Italy
| | - C Di Pentima
- Internal Medicine Department, INRCA-IRCCS Hospital, Osimo, Ancona, Italy
| | - A Martini
- Internal Medicine Department, INRCA-IRCCS Hospital, Osimo, Ancona, Italy
| | - C Nitti
- Internal and Subintensive Medicine Department, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" Di Ancona, Via Conca 10, Ancona, Italy
| | - A Salvi
- Internal and Subintensive Medicine Department, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" Di Ancona, Via Conca 10, Ancona, Italy
| | - M Burattini
- Internal Medicine Department, INRCA-IRCCS Hospital, Osimo, Ancona, Italy
| | - L Falsetti
- Internal and Subintensive Medicine Department, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" Di Ancona, Via Conca 10, Ancona, Italy.
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Luo J, Jiang W, Weng L, Peng J, Hu X, Wang C, Liu G, Huang H, Du B. Usefulness of qSOFA and SIRS scores for detection of incipient sepsis in general ward patients: A prospective cohort study. J Crit Care 2019; 51:13-18. [PMID: 30685579 DOI: 10.1016/j.jcrc.2019.01.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 01/10/2019] [Accepted: 01/14/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE To prospectively assess the diagnostic value of quick Sequential Organ Failure Assessment (qSOFA) and systemic inflammatory response syndrome (SIRS) scores for sepsis in ward patients with infections. MATERIALS AND METHODS Consecutive patients admitted with infection or developing infection during hospital stay were included. All variables for calculating qSOFA, SIRS, and SOFA scores were collected, and the maximum scores were determined until hospital discharge, death, or day 28, whichever occurred earlier. The primary outcome was sepsis at 28 days. Diagnostic and prognostic values were assessed using the area under the receiver operating characteristic curve (AUROC) with the conventional cutoff value of 2. RESULTS Of 409 general ward patients, 146 patients and 371 patients met qSOFA and SIRS criteria, 229 patients developed sepsis. Although qSOFA score had a better overall diagnostic performance of sepsis (AUROC 0.75 vs. 0.69), it had a much lower sensitivity (53% vs. 98%) and higher specificity (87% vs. 18%) than SIRS score. In addition, qSOFA score had a better prognostic value than SIRS score (AUROC 0.86 vs. 0.67). CONCLUSIONS Neither SIRS score nor qSOFA score could serve as an ideal screening tool for early identification sepsis, whereas qSOFA score might help to identify patients with higher risk of poor clinical outcome. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02930070.
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Affiliation(s)
- Jingchao Luo
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China; Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China
| | - Wei Jiang
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Li Weng
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Jinmin Peng
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Xiaoyun Hu
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Chunyao Wang
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Guangyun Liu
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Huibin Huang
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China.
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Derivation and Validation of a Biomarker-Based Clinical Algorithm to Rule Out Sepsis From Noninfectious Systemic Inflammatory Response Syndrome at Emergency Department Admission. Crit Care Med 2018; 46:1421-1429. [DOI: 10.1097/ccm.0000000000003206] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Lung ultrasound in diagnosing pneumonia in childhood: a systematic review and meta-analysis. J Ultrasound 2018; 21:183-195. [PMID: 29931473 DOI: 10.1007/s40477-018-0306-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 05/29/2018] [Indexed: 10/28/2022] Open
Abstract
PURPOSE Pneumonia is the third leading cause of death in children under 5 years of age worldwide. In pediatrics, both the accuracy and safety of diagnostic tools are important. Lung ultrasound (LUS) could be a safe diagnostic tool for this reason. We searched in the literature for diagnostic studies about LUS to predict pneumonia in pediatric patients using systematic review and meta-analysis. METHODS The Medline, CINAHL, Cochrane Library, Embase, SPORTDiscus, ScienceDirect, and Web of Science databases from inception to September 2017 were searched. All studies that evaluated the diagnostic accuracy of LUS in determining the presence of pneumonia in patients under 18 years of age were included. RESULTS 1042 articles were found by systematic search. 76 articles were assessed for eligibility. Seventeen studies were included in the systematic review. We included 2612 pooled cases. The age of the pooled sample population ranged from 0 to about 21 years old. Summary sensitivity, specificity, and AUC were 0.94 (IQR: 0.89-0.97), 0.93 (IQR: 0.86-0.98), and 0.98 (IQR: 0.94-0.99), respectively. No agreement on reference standard was detected: nine studies used chest X-rays, while four studies considered the clinical diagnosis. Only one study used computed tomography. CONCLUSIONS LUS seems to be a promise tool for diagnosing pneumonia in children. However, the high heterogeneity found across the individual studies, and the absence of a reliable reference standard, make the finding questionable. More methodologically rigorous studies are needed.
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9
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Larsen FF, Petersen JA. Novel biomarkers for sepsis: A narrative review. Eur J Intern Med 2017; 45:46-50. [PMID: 28965741 DOI: 10.1016/j.ejim.2017.09.030] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 09/12/2017] [Accepted: 09/23/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Sepsis is a prevalent condition among hospitalized patients that carries a high risk of morbidity and mortality. Rapid recognition of sepsis as the cause of deterioration is desirable, so effective treatment can be initiated rapidly. Traditionally, diagnosis was based on presence of two or more positive SIRS criteria due to infection. However, recently published sepsis-3 criteria put more emphasis on organ dysfunction caused by infection in the definition of sepsis. Regardless of this, no gold standard for diagnosis exist, and clinicians still rely on a number of traditional and novel biomarkers to discriminate between patients with and without infection, as the cause of deterioration. METHOD Narrative review of current literature. RESULTS A number of the most promising biomarkers for diagnoses and prognostication of sepsis are presented. CONCLUSION Procalcitonin, presepsin, CD64, suPAR, and sTREM-1 are the best evaluated biomarkers for diagnosis and prognostication of sepsis to date. All have limitations in differentiation between infected and non-infected patients with SIRS, and their future role in diagnosis needs to be evaluated. It is important to test utility, performance, and validity of future biomarkers before implementing them in routine clinical care.
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Affiliation(s)
| | - J Asger Petersen
- Department of Day Surgery, Hvidovre Hospital, Kettegaards Alle 30, 2650 Hvidovre, Denmark.
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10
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López-Mestanza C, Andaluz-Ojeda D, Gómez-López JR, Bermejo-Martín JF. Clinical factors influencing mortality risk in hospital-acquired sepsis. J Hosp Infect 2017; 98:194-201. [PMID: 28882641 DOI: 10.1016/j.jhin.2017.08.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 08/29/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Identification of factors that confer an increased risk of mortality in hospital-acquired sepsis (HAS) is necessary to help prevent, and improve the outcome of, this condition. AIM To evaluate the clinical characteristics and factors associated with mortality in patients with HAS. METHODS Retrospective study of patients with HAS in a major Spanish Hospital from 2011 to 2015. Data from adults receiving any of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes associated with sepsis were collected. Those fulfilling the SEPSIS-2 definition with no evidence of infection during the first 48 h following hospitalization were included (N = 196). Multivariate analysis was employed to identify the risk factors of mortality. FINDINGS HAS patients were found to have many of the risk factors associated with cardiovascular disease (male sex, ageing, antecedent of cardiac disease, arterial hypertension, dyslipidaemia, smoking habit) and cancer. Vascular disease or chronic kidney disease were associated with 28-day mortality. Time from hospital admission to sepsis diagnosis, and the presence of organ failure were risk factors for 28-day and hospital mortality. Experiencing more than one episode of sepsis increased the risk of hospital mortality. 'Sepsis code' for the early identification of sepsis was protective against hospital mortality. CONCLUSION This study identifies several major factors associated with mortality in patients suffering from HAS. Implementation of surveillance programmes for the early identification and treatment of sepsis translate into a clear benefit.
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Affiliation(s)
- C López-Mestanza
- BIO∙SEPSIS (Laboratory of Biomedical Research in Sepsis), Hospital Clínico Universitario de Valladolid, SACYL, Valladolid, Spain.
| | - D Andaluz-Ojeda
- Critical Care Medicine Service, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - J R Gómez-López
- General Surgery Service, Hospital de Medina del Campo, SACYL, Medina del Campo-Valladolid, Spain
| | - J F Bermejo-Martín
- BIO∙SEPSIS (Laboratory of Biomedical Research in Sepsis), Hospital Clínico Universitario de Valladolid, SACYL, Valladolid, Spain
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Meaudre E, Nguyen C, Contargyris C, Montcriol A, d'Aranda E, Esnault P, Bensalah M, Prunet B, Bordes J, Goutorbe P. Management of septic shock in intermediate care unit. Anaesth Crit Care Pain Med 2017; 37:121-127. [PMID: 28790011 DOI: 10.1016/j.accpm.2017.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 02/28/2017] [Accepted: 07/10/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND While guidelines advocate goal-directed resuscitation based on timed bundles, the management of septic shock (SS) outside an ICU setting has been poorly studied in intermediate care units (IMCU). PATIENTS AND METHOD We reviewed all cases of septic shock patients admitted to our IMCU between January 2013 and June 2014. The characteristics of sepsis, compliance of bundles, and outcomes were collected. The IMCU population was compared with the SS patients admitted to the ICU during the same period. The primary objective was to evaluate the feasibility of care in an IMCU. RESULTS We treated 59 patients in the IMCU. Forty-three patients (73%) were fully managed in the IMCU and 16 patients (27%) were secondarily transferred to the ICU. In the first 3hours, the compliance to bundles was: blood cultures (95%), plasma lactate concentration (90%), vascular filling volume (1500ml (1000-2000)) and antibiotics (100%). A central venous line and an arterial catheter were inserted in 85% and 98.3% of the cases. At 24h, patients who were transferred to the ICU had higher lactate concentrations than the other patients (1.4±0.7mmol versus 2.9±3.4mmol; P=0.03). A 24 hours-SOFA score>4 was correlated with a transfer in ICU (OR 7,75 (95% CI 2.08-28,81; P=0.002)). CONCLUSIONS Our work demonstrated the ability to manage SS patients solely in an IMCU. It showed that the SS resuscitation bundle can be successfully implemented outside the ICU. A lack of improvement at the 24th hour is associated with a transfer to the ICU.
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Affiliation(s)
- Eric Meaudre
- Department of intensive care, military teaching hospital, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, BP 20545, 83041 Toulon cedex 9, France.
| | - Cédric Nguyen
- Department of intensive care, military teaching hospital, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, BP 20545, 83041 Toulon cedex 9, France.
| | - Claire Contargyris
- Department of intensive care, military teaching hospital, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, BP 20545, 83041 Toulon cedex 9, France.
| | - Ambroise Montcriol
- Department of intensive care, military teaching hospital, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, BP 20545, 83041 Toulon cedex 9, France.
| | - Erwan d'Aranda
- Department of intensive care, military teaching hospital, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, BP 20545, 83041 Toulon cedex 9, France.
| | - Pierre Esnault
- Department of intensive care, military teaching hospital, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, BP 20545, 83041 Toulon cedex 9, France.
| | - Mourad Bensalah
- Department of intensive care, military teaching hospital, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, BP 20545, 83041 Toulon cedex 9, France.
| | - Bertrand Prunet
- Department of intensive care, military teaching hospital, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, BP 20545, 83041 Toulon cedex 9, France.
| | - Julien Bordes
- Department of intensive care, military teaching hospital, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, BP 20545, 83041 Toulon cedex 9, France.
| | - Philippe Goutorbe
- Department of intensive care, military teaching hospital, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, BP 20545, 83041 Toulon cedex 9, France.
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Screening for sepsis in general hospitalized patients: a systematic review. J Hosp Infect 2017; 96:305-315. [PMID: 28506711 DOI: 10.1016/j.jhin.2017.05.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 05/07/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Sepsis is a condition widely observed outside critical care areas. AIM To examine the application of sepsis screening tools for early recognition of sepsis in general hospitalized patients to: (i) identify the accuracy of these tools; (ii) determine the outcomes associated with their implementation; and (iii) describe the implementation process. METHODS A systematic review method was used. PubMed, CINAHL, Cochrane, Scopus, Web of Science, and Embase databases were systematically searched for primary articles, published from January 1990 to June 2016, that investigated screening tools or alert mechanisms for early identification of sepsis in adult general hospitalized patients. The review protocol was registered with PROSPERO (CRD42016042261). FINDINGS More than 8000 citations were screened for eligibility after duplicates had been removed. Six articles met the inclusion criteria testing two types of sepsis screening tools. Electronic tools can capture, recognize abnormal variables, and activate an alert in real time. However, accuracy of these tools was inconsistent across studies with only one demonstrating high specificity and sensitivity. Paper-based, nurse-led screening tools appear to be more sensitive in the identification of septic patients but were only studied in small samples and particular populations. The process of care measures appears to be enhanced; however, demonstrating improved outcomes is more challenging. Implementation details are rarely reported. Heterogeneity of studies prevented meta-analysis. CONCLUSION Clinicians, researchers and health decision-makers should consider these findings and limitations when implementing screening tools, research or policy on sepsis recognition in general hospitalized patients.
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Matthaeus-Kraemer CT, Thomas-Rueddel DO, Schwarzkopf D, Rueddel H, Poidinger B, Reinhart K, Bloos F. Crossing the handover chasm: Clinicians' perceptions of barriers to the early detection and timely management of severe sepsis and septic shock. J Crit Care 2016; 36:85-91. [PMID: 27546753 DOI: 10.1016/j.jcrc.2016.06.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 05/17/2016] [Accepted: 06/29/2016] [Indexed: 12/17/2022]
Abstract
PURPOSE The purpose was to identify barriers to the early detection and timely management of severe sepsis throughout the emergency department (ED), general ward (GW), intermediate care unit (IMC), and the intensive care unit (ICU). MATERIALS AND METHODS Five multicenter focus group discussions with 29 clinicians were conducted. Discussions were based on a moderation guide were recorded and transcribed. Qualitative analysis was performed according to the principles of the concept mapping method and the framework approach. RESULTS The major causes of the delayed detection and treatment could be summarized in a framework of communication errors and handover difficulties throughout patients' course of treatment, which can be divided into 5 core areas: inadequate histories before hospital admission; poorly coordinated handovers between the ambulance service and the ED; delayed patient transfer between the ED and the GW as well as delays in patient transfers between the GW and the ICU by, for example, a lack of bed capacity and a shortage of staff. Generally, participants from all wards mentioned that the urgency with which septic patients needed to be treated was not communicated. CONCLUSIONS Our study shows the need to improve intra- and interunit handover processes in hospital care, which would ensure a holistic treatment concept, thereby improving patient care.
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Affiliation(s)
- Claudia T Matthaeus-Kraemer
- The Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany.
| | - Daniel O Thomas-Rueddel
- The Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany; Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany.
| | - Daniel Schwarzkopf
- The Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany.
| | - Hendrik Rueddel
- The Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany; Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany.
| | - Bernhard Poidinger
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany.
| | - Konrad Reinhart
- The Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany; Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany.
| | - Frank Bloos
- The Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany; Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany.
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Ratzinger F, Eichbichler K, Schuardt M, Tsirkinidou I, Mitteregger D, Haslacher H, Perkmann T, Schmetterer KG, Doffner G, Burgmann H. Sepsis in standard care: patients' characteristics, effectiveness of antimicrobial therapy and patient outcome--a cohort study. Infection 2015; 43:345-52. [PMID: 25840554 DOI: 10.1007/s15010-015-0771-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 03/24/2015] [Indexed: 12/29/2022]
Abstract
PURPOSE Fast diagnosis and initiation of appropriate antibiotic therapy is pivotal for the survival of sepsis patients. However, most studies on suspected sepsis patients are conducted in the intensive care unit or in the emergency room setting, neglecting the standard care setting. This study evaluated sepsis risk factors, microbiological accurateness of the initial empiric antimicrobial therapy and its effect on hospital mortality in standard care patients. METHODS In this prospective observational cohort study, patients with clinically suspected sepsis meeting two or more SIRS criteria were screened on standard care wards. After hospital discharge, occurrence of an infection was assessed according to standardized criteria, and empirical antibiotic therapy was evaluated using antibiograms of recognized pathogens by expert review. RESULTS Of the 2384 screened patients, 298 fulfilled two or more SIRS criteria. Among these were 28.2 % SIRS patients without infection, 46.3 % non-bacteremic/fungemic sepsis patients and 25.5 % bacteremic/fungemic sepsis patients. Occurrence of a malignant disease and chills were associated with a higher risk of patients having bacteremic/fungemic sepsis, whereas other described risk factors remained insignificant. In total, 91.1 % of suspected sepsis patients received empirical antimicrobial therapy, but 41.1 % of bacteremic sepsis patients received inappropriate therapy. Non-surviving bacteremic sepsis patients received a higher proportion of inappropriate therapy than those who survived (p = 0.022). CONCLUSIONS A significant proportion of bacteremic sepsis patients receive inappropriate empiric antimicrobial therapy. Our results indicate that rapid availability of microbiological results is vital, since inappropriate antimicrobial therapy tended to increase the hospital mortality of sepsis patients.
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Affiliation(s)
- Franz Ratzinger
- Division of Medical and Chemical Laboratory Diagnostics, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
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