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Hawk KF, Weiner SG, Rothenberg C, Bernstein E, D'Onofrio G, Herring A, Hoppe J, Ketcham E, LaPietra A, Nelson L, Perrone J, Ranney M, Samuels EA, Strayer R, Sharma D, Goyal P, Schuur J, Venkatesh AK. Leveraging a Learning Collaborative Model to Develop and Pilot Quality Measures to Improve Opioid Prescribing in the Emergency Department. Ann Emerg Med 2024; 83:225-234. [PMID: 37831040 DOI: 10.1016/j.annemergmed.2023.08.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 10/14/2023]
Abstract
The American College of Emergency Physicians (ACEP) Emergency Medicine Quality Network (E-QUAL) Opioid Initiative was launched in 2018 to advance the dissemination of evidence-based resources to promote the care of emergency department (ED) patients with opioid use disorder. This virtual platform-based national learning collaborative includes a low-burden, structured quality improvement project, data benchmarking, tailored educational content, and resources designed to support a nationwide network of EDs with limited administrative and research infrastructure. As a part of this collaboration, we convened a group of experts to identify and design a set of measures to improve opioid prescribing practices to provide safe analgesia while reducing opioid-related harms. We present those measures here, alongside initial performance data on those measures from a sample of 370 nationwide community EDs participating in the 2019 E-QUAL collaborative. Measures include proportion of opioid administration in the ED, proportion of alternatives to opioids as first-line treatment, proportion of opioid prescription, opioid pill count per prescription, and patient medication safety education among ED visits for atraumatic back pain, dental pain, or headache. The proportion of benzodiazepine and opioid coprescribing for ED visits for atraumatic back pain was also evaluated. This project developed and effectively implemented a collection of 6 potential measures to evaluate opioid analgesic prescribing across a national sample of community EDs, representing the first feasibility assessment of opioid prescribing-related measures from rural and community EDs.
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Affiliation(s)
- Kathryn F Hawk
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
| | | | - Craig Rothenberg
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Edward Bernstein
- Boston Medical Center Department of Emergency Medicine, Boston, MA
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Andrew Herring
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, University of California, San Francisco
| | - Jason Hoppe
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver
| | - Eric Ketcham
- Presbyterian Healthcare, Espanola & Santa Fe, NM
| | - Alexis LaPietra
- Division of Emergency Medicine, RWJBarnabus Health, West Orange, NJ
| | - Lewis Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Megan Ranney
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
| | | | - Reuben Strayer
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Dhruv Sharma
- American College of Emergency Physicians, Dallas, TX
| | - Pawan Goyal
- American College of Emergency Physicians, Dallas, TX
| | - Jeremiah Schuur
- Department of Emergency Medicine, Brown School of Medicine, Providence, RI
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
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Lam RPK, Hung KKC, Lui CT, Kwok WS, Lam WWT, Lau EHY, Sridhar S, Ng PYT, Cheng CH, Tsang TC, Tsui MSH, Graham CA, Rainer TH. Early sepsis care with the National Early Warning Score 2-guided Sepsis Hour-1 Bundle in the emergency department: hybrid type 1 effectiveness-implementation pilot stepped wedge randomised controlled trial (NEWS-1 TRIPS) protocol. BMJ Open 2024; 14:e080676. [PMID: 38307529 PMCID: PMC10836386 DOI: 10.1136/bmjopen-2023-080676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 01/24/2024] [Indexed: 02/04/2024] Open
Abstract
INTRODUCTION Early sepsis treatment in the emergency department (ED) is crucial to improve patient survival. Despite international promulgation, the uptake of the Surviving Sepsis Campaign (SSC) Hour-1 Bundle (lactate measurement, blood culture, broad-spectrum antibiotics, 30 mL/kg crystalloid for hypotension/lactate ≥4 mmol/L and vasopressors for hypotension during/after fluid resuscitation within 1 hour of sepsis recognition) is low across healthcare settings. Delays in sepsis recognition and a lack of high-quality evidence hinder its implementation. We propose a novel sepsis care model (National Early Warning Score, NEWS-1 care), in which the SSC Hour-1 Bundle is triggered objectively by a high NEWS-2 (≥5). This study aims to determine the feasibility of a full-scale type 1 hybrid effectiveness-implementation trial on the NEWS-1 care in multiple EDs. METHODS AND ANALYSIS We will conduct a pilot type 1 hybrid trial and prospectively recruit 200 patients from 4 public EDs in Hong Kong cluster randomised in a stepped wedge design over 10 months. All study sites will start with an initial period of standard care and switch in random order at 2-month intervals to the NEWS-1 care unidirectionally. The implementation evaluation will employ mixed methods guided by the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, which includes qualitative and quantitative data from focus group interviews, staff survey and clinical record reviews. We will analyse the 14 feasibility outcomes as progression criteria to a full-scale trial, including trial acceptability to patients and staff, patient and staff recruitment rates, accuracy of sepsis screening, protocol adherence, accessibility to follow-up data, safety and preliminary clinical impacts of the NEWS1 care, using descriptive statistics. ETHICS AND DISSEMINATION The institutional review boards of all study sites approved this study. This study will establish the feasibility of a full-scale hybrid trial. We will disseminate the findings through peer-reviewed publications, conference presentations and educational activities. TRIAL REGISTRATION NUMBER NCT05731349.
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Affiliation(s)
- Rex Pui Kin Lam
- Department of Emergency Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- Accident and Emergency Department, Queen Mary Hospital, Hospital Authority, Hong Kong, China
| | - Kevin Kei Ching Hung
- Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Hong Kong, China
- Accident and Emergency Department, Prince of Wales Hospital, Hospital Authority, Hong Kong, China
| | - Chun Tat Lui
- Accident and Emergency Department, Tuen Mun Hospital, Hospital Authority, Hong Kong, China
| | - Wai Shing Kwok
- Accident and Emergency Department, Pamela Youde Nethersole Eastern Hospital, Hospital Authority, Hong Kong, China
| | - Wendy Wing Tak Lam
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Eric Ho Yin Lau
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Siddharth Sridhar
- Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Peter Yau Tak Ng
- Accident and Emergency Department, Tuen Mun Hospital, Hospital Authority, Hong Kong, China
| | - Chi Hung Cheng
- Accident and Emergency Department, Prince of Wales Hospital, Hospital Authority, Hong Kong, China
| | - Tat Chi Tsang
- Accident and Emergency Department, Queen Mary Hospital, Hospital Authority, Hong Kong, China
| | - Matthew Sik Hon Tsui
- Accident and Emergency Department, Queen Mary Hospital, Hospital Authority, Hong Kong, China
| | - Colin Alexander Graham
- Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Hong Kong, China
- Accident and Emergency Department, Prince of Wales Hospital, Hospital Authority, Hong Kong, China
| | - Timothy Hudson Rainer
- Department of Emergency Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- Accident and Emergency Department, Queen Mary Hospital, Hospital Authority, Hong Kong, China
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Patel MD, Williams JG, Bachman MW, Cyr JM, Cabañas JG, Miller NS, Gorstein LN, Hajjar MA, Turcios H, Malcolm JT, Brice JH. Effectiveness of a Novel Rapid Infusion Device and Clinician Education for Early Fluid Therapy by Emergency Medical Services in Sepsis Patients: A Pre-Post Observational Study. PREHOSP EMERG CARE 2023; 28:753-760. [PMID: 38015064 DOI: 10.1080/10903127.2023.2286292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE Emergency medical services (EMS) clinicians are tasked with early fluid resuscitation for patients with sepsis. Traditional methods for prehospital fluid delivery are limited in speed and ease-of-use. We conducted a comparative effectiveness study of a novel rapid infusion device for prehospital fluid delivery in suspected sepsis patients. METHODS This pre-post observational study evaluated a hand-operated, rapid infusion device in a single large EMS system from July 2021-July 2022. Prior to device deployment, EMS clinicians completed didactic and simulation-based device training. Data were extracted from the EMS electronic health record. Eligible patients included adults with suspected sepsis treated by EMS with intravenous fluids. The primary outcome was the proportion of patients receiving goal fluid volume (at least 500 mL) prior to hospital arrival. Secondary outcomes included in-hospital mortality, disposition, and length of stay. Multivariable logistic regression was used to compare outcomes between 6-month pre- and post-implementation periods (July-December 2021 and February-July 2022, respectively), adjusting for patient demographics, abnormal prehospital vital signs, and EMS transport interval. RESULTS Of 1,180 eligible patients (552 in the pre-implementation period; 628 in the post-implementation period), the mean age was 72 years old, 45% were female, and 25% were minority race-ethnicity. Median (interquartile range) fluid volume (in mL) increased between the pre- and post-implementation periods (600 [400,1,000] and 850 [500-1,000], respectively). Goal fluid volume was achieved in 70% of pre-implementation patients and 82% of post-implementation patients. In adjusted analysis, post-implementation patients were significantly more likely to receive goal fluid volume than pre-implementation patients (adjusted odds ratio (aOR) 2.00, 95% confidence interval (CI) 1.51-2.66). Pre-post in-hospital mortality was not significantly different (aOR 0.91, 95% CI 0.59-1.39). CONCLUSION In a single EMS system, sepsis education and introduction of a rapid infusion device was associated with achieving goal fluid volume for suspected sepsis. Further research is needed to assess the clinical effectiveness of infusion device implementation to improve sepsis patient outcomes.
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Affiliation(s)
- Mehul D Patel
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jefferson G Williams
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Wake County EMS, Raleigh, North Carolina
| | | | - Julianne M Cyr
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - José G Cabañas
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Wake County EMS, Raleigh, North Carolina
| | - Nathaniel S Miller
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lauren N Gorstein
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - M Abdul Hajjar
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Henry Turcios
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Jane H Brice
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Sterk E, Wassermann T, Lamonge R, Semenchuck N, Rech MA. Overcultured? Blood cultures on discharged ED patients were ordered more frequently after the SEP-1 bundle initiation. Am J Emerg Med 2023; 67:84-89. [PMID: 36821960 PMCID: PMC10121910 DOI: 10.1016/j.ajem.2023.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 01/17/2023] [Accepted: 01/17/2023] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION In 2015, the Severe Sepsis and Early Septic Shock Management Bundle (SEP-1) tied hospital reimbursement to performance on a series of time sensitive indicators, including ordering blood cultures on patients with severe sepsis or septic shock. This metric could have broadly shaped ordering practices in the Emergency Department (ED), including for patients who did not have severe sepsis or septic shock. In this study, we sought to evaluate whether the frequency of blood culture orders on adult patients discharged from the ED changed after the SEP-1 metric, whether the rates of positivity for pathogens or contaminants changed after the SEP-1 metric, and whether similar changes were seen in orders for other laboratory tests. METHODS This was a retrospective evaluation of blood culture orders from discharged adult ED patients from a suburban academic hospital between January 1, 2012 and June 30, 2019. We compared the number of blood cultures per discharged adult patient before and after the SEP-1 metric. We categorized each culture that grew an organism as a pathogen or a contaminant, and we compared rates of pathogen and contaminant growth before and after SEP-1. We compared rates of orders of blood cultures and lactates as labs related to SEP-1 with rates of orders of D-dimers, lipases, human chorionic gonadotropins (HCGs), and brain natriuretic peptides (BNPs) as labs unrelated to SEP-1 before and after the implementation of the SEP-1 metric. RESULTS There were 144,343 adult patients discharged from the ED during the study period. A total of 6754 blood cultures were drawn from 3827 of those patient visits. The rate increased from 43.1 cultures per 1000 discharged patients before the SEP-1 metric to 75.9 blood cultures per 1000 discharged patients, an increase of 76.2% (p < 0.001). The cultures had a decreased rate of positivity (from 3.93% before SEP-1 to 3.03% after SEP-1, p = 0.044) and an unchanged rate of blood cultures resulting in a contaminant (2.49% to 1.85%, p = 0.071). Overall, orders of the labs unrelated to SEP-1 increased by an average of 16.8% after the SEP-1 metric and orders of the labs related to SEP-1 increased by an average of 81.0%. CONCLUSION After the SEP-1 bundle, blood cultures were ordered more frequently on discharged ED patients. These cultures had a lower rate of positivity for pathogens and an unchanged rate of growth of contaminants. This increase was not matched by a similar increase in other labs. Taken together, these findings suggest that the SEP-1 metric had the unintended consequence of increasing orders of blood cultures on patients healthy enough to be discharged from the ED.
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Affiliation(s)
- Ethan Sterk
- Loyola University Medical Center, Department of Emergency Medicine, Maywood, IL, United States of America.
| | - Travis Wassermann
- Loyola University Medical Center, Department of Emergency Medicine, Maywood, IL, United States of America.
| | - Ralph Lamonge
- Michigan Medicine, Department of Anesthesiology, Ann Arbor, MI, United States of America
| | - Nicolas Semenchuck
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, IL, United States of America
| | - Megan A Rech
- Loyola University Medical Center, Department of Pharmacy, Maywood, IL, United States of America; Loyola University Chicago, Stritch School of Medicine, Department of Emergency Medicine, Maywood, IL, United States of America
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Tu KJ, Wymore C, Tchangalova N, Fuller BM, Mohr NM. The impact of telehealth in sepsis care: A systematic review. J Telemed Telecare 2023:1357633X231170038. [PMID: 37093782 PMCID: PMC11187410 DOI: 10.1177/1357633x231170038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
OBJECTIVES Sepsis is associated with significant mortality. Telehealth may improve the quality of early sepsis care, but the use and impact of telehealth applications for sepsis remain unclear. We aim to describe the telehealth interventions that have been used to facilitate sepsis care, and to summarize the reported effect of telehealth on sepsis outcomes. DATA SOURCES We identified articles reporting telehealth use for sepsis using an English-language search of PubMed, CINAHL Plus (EBSCO), Academic Search Ultimate (EBSCO), APA PsycINFO (EBSCO), Public Health (ProQuest), and Web of Science databases with no restrictions on publication date. STUDY SELECTION Included studies described the use of telehealth as an intervention for treating sepsis. Only comparative effectiveness analyses were included. DATA EXTRACTION AND SYNTHESIS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines, two investigators independently selected articles for inclusion and abstracted data. A random-effects subgroup analysis was conducted on patient survival treated with and without telehealth. RESULTS A total of 15 studies were included, involving 188,418 patients with sepsis. Thirteen studies used observational study designs, and the most common telehealth applications were provider-to-provider telehealth consultation and intensive care unit telehealth. Clinical and methodological heterogeneity was significantly high. Telehealth use was associated with higher survival, especially in settings with low control group survival. The effect of telehealth on other care processes and outcomes were more varied and likely dependent on hospital-level factors. CONCLUSIONS Telehealth has been used in diverse applications for sepsis care, and it may improve patient outcomes in certain contexts. Additional interventional trials and cost-based analyses would clarify the causal role of telehealth in improving sepsis outcomes.
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Affiliation(s)
- Kevin J. Tu
- Department of Cell Biology and Molecular Genetics, University of Maryland, College Park, Maryland
| | - Cole Wymore
- Department of Emergency Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Nedelina Tchangalova
- Research and Academic Services, University of Maryland Libraries, College Park, Maryland
| | - Brian M. Fuller
- Division of Critical Care, Department of Anesthesiology, Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Nicholas M. Mohr
- Departments of Emergency Medicine, Anesthesia Critical Care, and Epidemiology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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Kiser M. Improving Sepsis Compliance With Human Factors Interventions in a Community Hospital Emergency Room. PATIENT SAFETY 2023. [DOI: 10.33940/culture/2023.3.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Background: Adherence to best practices for sepsis management at a small community hospital was below system, state, and national benchmarks and affected vital indicators, including mortality. This study aimed to improve sepsis best practice compliance by implementing human factors–influenced interventions.
Methods: The Plan-Do-Study-Act quality improvement methodology was used for this project. Baseline metrics included sepsis bundle compliance following CMS (Centers for Medicare & Medicaid Services) core measure standards, hospital morality, sepsis triage screening, and physician order set use.
Interventions: Several human factors workflows and tools were used to boost early identification with screening opportunities and enhance staff awareness of sepsis indicators.
Results: With the interventions, the hospital’s compliance with sepsis best practice treatment improved by a 23 percentage-point increase from baseline. Sepsis triage screening also increased and remained consistent after project interventions.
Conclusions: With the project, using human factors tools enhanced staff engagement and increased sepsis awareness. Engagement increased sepsis identification and screening in a small community hospital setting.
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Davino T, Van Hoof TJ, Elwell J, DeLayo M. Educational needs assessment identifying opportunities to improve sepsis care. BMJ Open Qual 2022; 11:bmjoq-2022-001930. [PMID: 36588307 PMCID: PMC9723901 DOI: 10.1136/bmjoq-2022-001930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 11/08/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION In 2015, the Centers for Medicare and Medicaid Services developed a national quality bundle for the management of patients with severe sepsis and septic shock (SEP-1). Despite performance improvement measures, compliance remains low. This needs assessment is the first stage of a quality improvement initiative to improve SEP-1 compliance. Using a conceptual outcomes framework, this needs assessment analyses SEP-1 compliance data, knowledge, and competence to identify gaps in care and educational opportunities. METHODS The needs assessment began with a review of national and statewide SEP-1 compliance data to identify a need for improvement. The needs assessment proceeded with a retrospective chart review to evaluate process measures and identify which providers would most likely benefit from educational interventions. A focus group provided perspective on the chart review findings. RESULTS During the period of 1 April 2017-31 March 2018, national SEP-1 compliance was 51% and compliance at the studied institution was 19%. The chart review included 51 patients (66.7% severe sepsis, 33.3% septic shock). Frequently missed SEP-1 measures included administration of intravenous fluids (0% severe sepsis, 58.8% septic shock), repeat lactate levels (52.6% severe sepsis, 60% septic shock), documentation of volume and tissue perfusion assessment (58.8%), vasopressor administration (73.3%) and administration of broad-spectrum antibiotics (76.5%, severe sepsis). Focus group perceptions identified themes related to gaps in declarative and dispositional knowledge. CONCLUSIONS This educational needs assessment highlights gaps in SEP-1 clinician performance, competence and knowledge. A multifaceted education programme is the next step for this performance improvement project. Education should include a series of meetings, activities, and workshops that include declarative knowledge, procedural knowledge and dispositional knowledge. Simulation activities can provide an opportunity for providers to demonstrate competence. Point-of-care prompts and performance measurement and feedback of patient care data can support clinician performance. This needs assessment underscores the need for a multifaceted approach to clinician education and performance to improve SEP-1 compliance.
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Affiliation(s)
- Tammy Davino
- Intensive Care Unit, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Thomas J Van Hoof
- School of Nursing, University of Connecticut, Storrs, Connecticut, USA
| | - Joy Elwell
- School of Nursing, University of Connecticut, Storrs, Connecticut, USA
| | - Michelle DeLayo
- Intensive Care Unit, University of Connecticut Health Center, Farmington, Connecticut, USA
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Rodos A, Aaronson E, Rothenberg C, Goyal P, Sharma D, Slesinger T, Schuur J, Venkatesh A. Improving Sepsis Management Through the Emergency Quality Network Sepsis Initiative. Jt Comm J Qual Patient Saf 2022; 48:572-580. [PMID: 36137885 DOI: 10.1016/j.jcjq.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Public reporting of the Centers for Medicare & Medicaid (CMS) SEP-1 sepsis quality measure is often too late and without the data granularity to inform real-time quality improvement (QI). In response, the American College of Emergency Physicians (ACEP) Emergency Quality Network (E-QUAL) Sepsis Initiative sought to support QI efforts through benchmarking of preliminary draft SEP-1 scores for emergency department (ED) patients. This study sought to determine the anticipatory value of these preliminary SEP-1 benchmarking scores and publicly reported performance. METHODS Cross-sectional analysis was performed on QI data collected from hospital-based ED sites participating in the E-QUAL Sepsis Collaborative in 2017 and 2018. Participating EDs submitted SEP-1 benchmarking scores semiannually, which were compared to publicly reported CMS SEP-1 data. EDs also reported implementation data on a variety of sepsis-related QI activities for comparison based on SEP-1 performance. RESULTS Among 220 EDs participating in E-QUAL, SEP-1 benchmarking scores showed weak but statistically significant correlation with CMS SEP-1 scores (r = 0.189, p = 0.01). Mean E-QUAL SEP-1 benchmarking scores were higher than mean CMS SEP-1 scores (74.1% vs. 57.2%), with 83.2% of sites reporting a benchmarking score higher than the CMS SEP-1 score. EDs with SEP-1 scores in the bottom 20% reported completion of more sepsis-related QI activities than EDs with average or top 20% SEP-1 scores. CONCLUSION Preliminary benchmarking results demonstrate a weak, statistically significant correlation with subsequent publicly reported CMS SEP-1 scores and suggest that ED performance in sepsis care may exceed overall hospital performance inclusive of all inpatients. Sepsis quality measurement and sepsis QI efforts may be best guided by separating ED sepsis cases from in-hospital sepsis cases as is done for other acute time-sensitive conditions.
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Spiegel R, Hockstein M, Waters J, Goyal M. The Survival of the Surviving Sepsis Campaign. Med Clin North Am 2022; 106:1109-1117. [PMID: 36280336 DOI: 10.1016/j.mcna.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Even well-intentioned policies have great potential to cause harm. This statement is vividly illustrated by the influential, yet controversial, Surviving Sepsis Campaign guidelines and subsequent CMS benchmarks. Despite low-quality evidence, tendentious industry ties, and rebuke from the Infectious Disease Society of America (IDSA), these benchmarks continue to eschew therapy driven by clinician expertise and individual patient needs in favor of mandating an arbitrary, one-size-fits-all approach that suspends clinical judgment and promotes indiscriminate use of treatments that have the potential to cause great harm.
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Affiliation(s)
- Rory Spiegel
- Department of Emergency Medicine, Medstar Washington Hospital Center, 110 Irving St, Washington, DC 20010, USA; Department of Critical Care Medicine, Medstar Washington Hospital Center, Washington, DC 20010, USA.
| | - Max Hockstein
- Department of Emergency Medicine, Medstar Washington Hospital Center, 110 Irving St, Washington, DC 20010, USA; Department of Critical Care Medicine, Medstar Washington Hospital Center, Washington, DC 20010, USA
| | - Jessica Waters
- Department of Emergency Medicine, Medstar Washington Hospital Center, 110 Irving St, Washington, DC 20010, USA
| | - Munish Goyal
- Department of Emergency Medicine, Medstar Washington Hospital Center, 110 Irving St, Washington, DC 20010, USA
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Can an End-to-End Telesepsis Solution Improve the Severe Sepsis and Septic Shock Management Bundle-1 Metrics for Sepsis Patients Admitted From the Emergency Department to the Hospital? Crit Care Explor 2022; 4:e0767. [PMID: 36248316 PMCID: PMC9553400 DOI: 10.1097/cce.0000000000000767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
UNLABELLED Early detection and treatment for sepsis patients are key components to improving sepsis care delivery and increased The Severe Sepsis and Septic Shock Management Bundle (SEP-1) compliance may correlate with improved outcomes. OBJECTIVES We assessed the impact of implementing a partially automated end-to-end sepsis solution including electronic medical record-linked automated monitoring, early detection, around-the-clock nurse navigators, and teleconsultation, on SEP-1 compliance in patients with primary sepsis, present at admission, admitted through the emergency department (ER). DESIGN SETTING AND PARTICIPANTS After a "surveillance only" training period between September 3, 2020, and October 5, 2020, the automated end-to-end sepsis solution intervention period occurred from October 6, 2020, to January 1, 2021 in five ERs in an academic health system. Patients who screened positive for greater than or equal to 3 sepsis screening criteria (systemic inflammatory response syndrome, quick Sequential Organ Failure Assessment, pulse oximetry), had evidence of infection and acute organ dysfunction, and were receiving treatment consistent with infection or sepsis were included. MAIN OUTCOMES AND MEASURES SEP-1 compliance during the "surveillance only" period compared to the intervention period. RESULTS During the intervention period, 56,713 patients presented to the five ERs; 20,213 (35.6%) met electronic screening criteria for potential sepsis; 1,233 patients had a primary diagnosis of sepsis, present at admission, and were captured by the nurse navigators. Median age of the cohort was 68 years (interquartile range, 57-79 yr); 55.3% were male; 63.5% were White/Caucasian, 26.3% Black/African-American; was 16.7%, and 879 patients (71.3%) were presumed bacterial sepsis, nonviral etiology, and SEP-1 bundle eligible. Nurse navigator real-time classification of this group increased from 51.7% during the "surveillance only" period to 71.8% during the intervention period (p = 0.0002). Five hospital SEP-1 compliance for the period leading into the study period (July 1, 2020-August 31, 2020) was 62% (p < 0.0001), during the "surveillance only" period, it was 68.4% and during the intervention period it was 78.3% (p = 0.002). CONCLUSIONS AND RELEVANCE During an 11-week period of sepsis screening, monitoring, and teleconsultation in 5 EDs, SEP-1 compliance improved significantly compared with institutional SEP-1 reporting metrics and to a "surveillance only" training period.
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Sloan SN, Rodriguez N, Seward T, Sare L, Moore L, Stahl G, Johnson K, Goade S, Arnce R. Compliance with SEP-1 guidelines is associated with improved outcomes for septic shock but not for severe sepsis. JOURNAL OF INTENSIVE MEDICINE 2022; 2:167-172. [PMID: 36789014 PMCID: PMC9924005 DOI: 10.1016/j.jointm.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/11/2022] [Accepted: 03/13/2022] [Indexed: 06/18/2023]
Abstract
BACKGROUND In 2018, the Centers for Medicaid and Medicare Services (CMS) issued a protocol for the treatment of sepsis. This bundle protocol, titled SEP-1 is a multicomponent 3 h and 6 h resuscitation treatment for patients with the diagnosis of either severe sepsis or septic shock. The SEP-1 bundle includes antibiotic administration, fluid bolus, blood cultures, lactate measurement, vasopressors for fluid-refractory hypotension, and a reevaluation of volume status. We performed a retrospective analysis of patients diagnosed with either severe sepsis or septic shock comparing mortality outcomes based on compliance with the updated SEP-1 bundle at a rural community hospital. METHODS Mortality outcome and readmission data were extracted from an electronic medical records database from January 1, 2019, to June 30, 2020. International Classification of Diseases (ICD)-10 codes were used to identify patients with either severe sepsis or septic shock. Once identified, patients were separated into four populations: patients with severe sepsis who met SEP-1, patients with severe sepsis who failed SEP-1, patients with septic shock who met SEP-1, and patients with septic shock who failed SEP-1. A patient who met bundle criteria (SEP-1 criteria) received each component of the bundle in the time allotted. Using chi-squared test of homogeneity, mortality outcomes for population proportions were investigated. Two sample proportion summary hypothesis test and 95% confidence intervals (CI) determined significance in mortality outcomes. RESULTS Out of our 1122 patient population, 437 patients qualified to be measured by CMS criteria. Of the 437 patients, 195 met the treatment bundle and 242 failed the treatment bundle. Upon comparing the two groups, we found the probable difference in mortality rate between the met(14.87%) and failed bundle(27.69%) groups to be significant(95% CI: 5.28-20.34, P=0.0013). However, the driving force of this result lies in the subgroup of patients with severe sepsis with septic shock, which show a higher mortality rate compared to the subgroup with just severe sepsis. The difference was within the range of 3.31% to 29.71%. CONCLUSION This study shows that with septic shock obtained a benefit, decreased mortality, when the SEP-1 bundle was met. However, meeting the SEP-1 bundle had no benefit for patients who had the diagnosis of severe sepsis alone. The significant difference in mortality, found between the met and failed bundle groups, is primarily due to the number of patients with septic shock, and whether or not those patients with septic shock met or failed the bundle.
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Affiliation(s)
- Shelly N.B. Sloan
- Department of Primary Care, College of Medicine, Kansas City University, 2901St. Johns Blvd., Joplin, MO 64804, USA
| | - Nate Rodriguez
- Department of Primary Care, College of Medicine, Kansas City University, 2901St. Johns Blvd., Joplin, MO 64804, USA
| | - Thomas Seward
- Department of Primary Care, College of Medicine, Kansas City University, 2901St. Johns Blvd., Joplin, MO 64804, USA
| | - Lucy Sare
- Department of Primary Care, College of Medicine, Kansas City University, 2901St. Johns Blvd., Joplin, MO 64804, USA
| | - Lukas Moore
- Department of Primary Care, College of Medicine, Kansas City University, 2901St. Johns Blvd., Joplin, MO 64804, USA
| | - Greg Stahl
- Department of Quality Improvement, Freeman Health System, Joplin, MO 64804, USA
| | - Kerry Johnson
- Department of Mathematics, Missouri Southern State University, Joplin, MO 64801, USA
| | - Scott Goade
- Department of Pharmacy, Freeman Health System, Joplin, MO 64804, USA
| | - Robert Arnce
- Department of Primary Care, College of Medicine, Kansas City University, 2901St. Johns Blvd., Joplin, MO 64804, USA
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Naar L, Hechi MWE, Gallastegi AD, Renne BC, Fawley J, Parks JJ, Mendoza AE, Saillant NN, Velmahos GC, Kaafarani HMA, Lee J. Intensive Care Unit Volume of Sepsis Patients Does Not Affect Mortality: Results of a Nationwide Retrospective Analysis. J Intensive Care Med 2022; 37:728-735. [PMID: 34231406 DOI: 10.1177/08850666211024184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is little research evaluating outcomes from sepsis in intensive care units (ICUs) with lower sepsis patient volumes as compared to ICUs with higher sepsis patient volumes. Our objective was to compare the outcomes of septic patients admitted to ICUs with different sepsis patient volumes. MATERIALS AND METHODS We included all patients from the eICU-CRD database admitted for the management of sepsis with blood lactate ≥ 2mmol/L within 24 hours of admission. Our primary outcome was ICU mortality. Secondary outcomes included hospital mortality, 30-day ventilator free days, and initiation of renal replacement therapy (RRT). ICUs were grouped in quartiles based on the number of septic patients treated at each unit. RESULTS 10,716 patients were included in our analysis; 272 (2.5%) in low sepsis volume ICUs, 1,078 (10.1%) in medium-low sepsis volume ICUs, 2,608 (24.3%) in medium-high sepsis volume ICUs, and 6,758 (63.1%) in high sepsis volume ICUs. On multivariable analyses, no significant differences were documented regarding ICU and hospital mortality, and ventilator days in patients treated in lower versus higher sepsis volume ICUs. Patients treated at lower sepsis volume ICUs had lower rates of RRT initiation as compared to high volume units (medium-high vs. high: OR = 0.78, 95%CI = 0.66-0.91, P-value = 0.002 and medium-low vs. high: OR = 0.57, 95%CI = 0.44-0.73, P-value < 0.001). CONCLUSION The previously described volume-outcome association in septic patients was not identified in an intensive care setting.
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Affiliation(s)
- Leon Naar
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Majed W El Hechi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ander Dorken Gallastegi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - B Christian Renne
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jason Fawley
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan J Parks
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jarone Lee
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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13
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Gettel CJ, Tinloy B, Nedza SM, Granovsky MA, Goyal P, Terry AT, Venkatesh AK. The future of value-based emergency care: Development of an emergency medicine MIPS value pathway framework. J Am Coll Emerg Physicians Open 2022; 3:e12672. [PMID: 35310403 PMCID: PMC8918116 DOI: 10.1002/emp2.12672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 11/10/2022] Open
Abstract
The Centers for Medicare & Medicaid Services (CMS) implemented the Merit-based Incentive Payment System (MIPS) to accelerate the transition of physician payment toward value-based care models and away from traditional fee-for-service payment programs. In recent years, CMS has sought to modify the program by developing a MIPS Value Pathway (MVP) framework intended to use existing and future physician quality and cost measures to reward value-based care delivery. This article describes the multi-step process of the MVP Task Force, convened by the American College of Emergency Physicians (ACEP) to develop an emergency medicine-specific MVP proposal informed by diverse stakeholder perceptions regarding: (1) which existing quality measures reflect high quality emergency care, and (2) the degree to which emergency clinicians can impact clinical outcomes and cost for the care domains captured by existing quality measures. The MVP Task Force synthesized stakeholder feedback and underwent a consensus-building approach to develop the "Adopting Best Practices and Promoting Patient Safety within Emergency Medicine" MVP, recently reviewed and approved by CMS for national implementation starting in 2023. Our process and findings have broad implications for clinicians, administrators, and policymakers navigating the continued transition to value-based care in conjunction with CMS's implementation of the MVP framework.
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Affiliation(s)
- Cameron J. Gettel
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
- National Clinician Scholars ProgramDepartment of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
| | | | | | | | - Pawan Goyal
- American College of Emergency PhysiciansIrvingTexasUSA
| | - Aisha T. Terry
- Department of Emergency MedicineGeorge Washington University School of MedicineWashingtonDistrict of ColumbiaUSA
| | - Arjun K. Venkatesh
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
- Center for Outcomes Research and EvaluationYale School of MedicineNew HavenConnecticutUSA
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14
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Warstadt NM, Caldwell JR, Tang N, Mandola S, Jamin C, Dahn C. Quality initiative to improve emergency department sepsis bundle compliance through utilisation of an electronic health record tool. BMJ Open Qual 2022; 11:bmjoq-2021-001624. [PMID: 34992053 PMCID: PMC8739442 DOI: 10.1136/bmjoq-2021-001624] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 12/10/2021] [Indexed: 12/23/2022] Open
Abstract
Introduction Sepsis is a common cause of emergency department (ED) presentation and hospital admission, accounting for a disproportionate number of deaths each year relative to its incidence. Sepsis outcomes have improved with increased recognition and treatment standards promoted by the Surviving Sepsis Campaign. Due to delay in recognition and other barriers, sepsis bundle compliance remains low nationally. We hypothesised that a targeted education intervention regarding use of an electronic health record (EHR) tool for identification and management of sepsis would lead to increased EHR tool utilisation and increased sepsis bundle compliance. Methods We created a multidisciplinary quality improvement team to provide training and feedback on EHR tool utilisation within our ED. A prospective evaluation of the rate of EHR tool utilisation was monitored from June through December 2020. Simultaneously, we conducted two retrospective cohort studies comparing overall sepsis bundle compliance for patients when EHR tool was used versus not used. The first cohort was all patients with intention-to-treat for any sepsis severity. The second cohort of patients included adult patients with time of recognition of sepsis in the ED admitted with a diagnosis of severe sepsis or septic shock. Results EHR tool utilisation increased from 23.3% baseline prior to intervention to 87.2% during the study. In the intention-to-treat cohort, there was a statistically significant difference in compliance between EHR tool utilisation versus no utilisation in overall bundle compliance (p<0.001) and for several individual components: initial lactate (p=0.009), repeat lactate (p=0.001), timely antibiotics (p=0.031), blood cultures before antibiotics (p=0.001), initial fluid bolus (p<0.001) and fluid reassessment (p<0.001). In the severe sepsis and septic shock cohort, EHR tool use increased from 71.2% pre-intervention to 85.0% post-intervention (p=0.008). Conclusion With training, feedback and EHR optimisation, an EHR tool can be successfully integrated into current workflows and appears to increase sepsis bundle compliance.
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Affiliation(s)
- Nicholus Michael Warstadt
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - J Reed Caldwell
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Nicole Tang
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Staci Mandola
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Catherine Jamin
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA.,Divison of Critical Care Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Cassidy Dahn
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA .,Divison of Critical Care Medicine, New York University Grossman School of Medicine, New York, New York, USA
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15
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Boccio E, Haimovich AD, Jacob V, Maciejewski KR, Wira CR, Belsky J. Sepsis Fluid Metric Compliance and its Impact on Outcomes of Patients with Congestive Heart Failure, End-Stage Renal Disease or Obesity. J Emerg Med 2021; 61:466-480. [PMID: 34088547 DOI: 10.1016/j.jemermed.2021.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/13/2021] [Accepted: 03/01/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Emergency physicians express concern administering a 30-cc/kg fluid bolus to septic shock patients with pre-existing congestive heart failure (CHF), end-stage renal disease (ESRD), or obesity, due to the perceived risk of precipitating a fluid overload state. OBJECTIVE Our aim was to determine whether there is a difference in fluid administration to septic shock patients with these pre-existing conditions in the emergency department (ED). Secondary objectives focused on whether compliance impacts mortality, need for intubation, and length of stay. METHODS We conducted a retrospective chart review of 470,558 ED patient encounters at a single urban academic center during a 5-year period. RESULTS Of 847 patients with septic shock, 308 (36.36%) had no pre-existing condition and 199 (23.49%), 17 (2.01%), and 154 (18.18%) had the single pre-existing condition of CHF, ESRD, and obesity, respectively, and 169 (19.95%) had multiple pre-existing conditions. Weight-based fluid compliance was achieved in 460 patients (54.31%). There was a lower likelihood of compliance among patients with CHF (adjusted odds ratio [aOR] 0.35; 95% confidence interval [CI] 0.24-0.52; p < 0.001), ESRD (aOR 0.11, 95% CI 0.04-0.32; p < 0.001), and obesity (aOR 0.29, 95% CI 0.19-0.44; p < 0.001) compared with patients with no pre-existing conditions. Compliance decreased further in patients with multiple pre-existing conditions (aOR 0.49, 95% CI 0.33-0.72; p < 0.001). Compliance was not associated with mortality in patients with CHF and ESRD, but was protective in patients with obesity and those with no pre-existing conditions. CONCLUSIONS Septic shock patients with pre-existing CHF, ESRD, or obesity are less likely to achieve compliance with a 30-cc/kg weight-based fluid goal compared with those without these pre-existing conditions.
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Affiliation(s)
- Eric Boccio
- Department of Emergency Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - Adrian D Haimovich
- Department of Emergency Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - Vinitha Jacob
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Charles R Wira
- Department of Emergency Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - Justin Belsky
- Department of Emergency Medicine, Yale New Haven Hospital, New Haven, Connecticut
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16
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Faust JS. Moving Beyond the Centers for Medicare and Medicaid Services' "Severe Sepsis and Septic Shock Early Management Bundle" Core Quality Measure. Ann Emerg Med 2021; 78:20-26. [PMID: 33962816 DOI: 10.1016/j.annemergmed.2021.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Indexed: 12/28/2022]
Affiliation(s)
- Jeremy S Faust
- Brigham & Women's Hospital Department of Emergency Medicine, Division of Health Policy and Public Health, Harvard Medical School, Boston, MA.
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17
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Yealy DM, Mohr NM, Shapiro NI, Venkatesh A, Jones AE, Self WH. Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report. Ann Emerg Med 2021; 78:1-19. [PMID: 33840511 DOI: 10.1016/j.annemergmed.2021.02.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Indexed: 12/12/2022]
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18
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Sepsis Bundles That Focus on Clinician Judgment and Proven Interventions Are Needed to Increase Bundle Compliance and Effectiveness. Crit Care Med 2021; 48:602-605. [PMID: 32205611 DOI: 10.1097/ccm.0000000000004263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Loza-Gomez A, Hofmann E, NokLam C, Menchine M. Severe sepsis and septic shock in patients transported by prehospital services versus walk in patients to the emergency department. Am J Emerg Med 2020; 45:173-178. [PMID: 33041138 DOI: 10.1016/j.ajem.2020.08.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/04/2020] [Accepted: 08/07/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Sepsis is a leading cause of death in the hospital for which aggressive treatment is recommended to improve patient outcomes. It is possible that sepsis patients brought in by emergency medical services (EMS) have a unique advantage in the emergency department (ED) which could improve sepsis bundle compliance. OBJECTIVE To evaluate patient care processes and outcome differences between severe sepsis and septic shock patients in the emergency department who were brought in by EMS compared to non-EMS patients. METHODS We performed a retrospective chart review of all severe sepsis and septic shock patients who declared in the ED during January 2012 thru December 2014. We compared differences in patient characteristics, patient care processes, sepsis bundle compliance metrics, and outcomes between both groups. RESULTS Of the 1066 patients included in the study, 387 (36.6%) were brought in by EMS and 679 (63.7%) patients arrived via non-EMS transport. In the multivariate regression model, time of triage to sepsis declaration (coeff = -0.406; 95% CI = -0.809, -0.003; p = 0.048) and time of triage to physician (coeff = -0.543; 95% CI = -0.864, -0.221; p = 0.001) was significantly shorter for EMS patients. We found no statistical difference in adjusted individual sepsis compliance metrics, overall bundle compliance, or mortality between both groups. CONCLUSION EMS transported patients have quicker sepsis declaration times and are seen sooner by ED providers. However, we found no statistical difference in bundle compliance or patient outcomes between walk in patients and EMS transported patients.
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Affiliation(s)
- Angelica Loza-Gomez
- Department of Emergency Medicine, Keck School of Medicine of USC, 1200 North State, Rm 1011, Los Angeles, California, 90033, United States of America.
| | - Erik Hofmann
- Department of Emergency Medicine, Keck School of Medicine of USC, 1200 North State, Rm 1011, Los Angeles, California, 90033, United States of America
| | - Chun NokLam
- Department of Emergency Medicine, Keck School of Medicine of USC, 1200 North State, Rm 1011, Los Angeles, California, 90033, United States of America
| | - Michael Menchine
- Department of Emergency Medicine, Keck School of Medicine of USC, 1200 North State, Rm 1011, Los Angeles, California, 90033, United States of America
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20
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Berdahl CT, Schuur JD, Rothenberg C, Samadian K, Sharma D, Tarrant N, Goyal P, Venkatesh AK. Practice structure and quality improvement activities among emergency departments in the Emergency Quality (E-QUAL) Network. J Am Coll Emerg Physicians Open 2020; 1:839-844. [PMID: 33145529 PMCID: PMC7593479 DOI: 10.1002/emp2.12078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/31/2020] [Accepted: 04/03/2020] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES Little academic investigation has been done to describe emergency department (ED) practice structure and quality improvement activities. Our objective was to describe staffing, payment mechanisms, and quality improvement activities among EDs in a nationwide quality improvement network and also stratify results to descriptively compare (1) single- versus multi-site EDs and (2) small-group versus large-group EDs. METHODS Observational study examining EDs that completed activities for the 2018 wave of the Emergency Quality Network (E-QUAL), a voluntary network of EDs nationwide that self-report quality improvement activities. EDs were defined as single-site or multi-site based on self-reported billing practices; additionally, EDs were defined as large-group if they and a majority of other sites with the same group name also identified as multi-site. All other sites were deemed small-group. RESULTS Data from 377 EDs were included. For staffing, the median number of clinicians was 17 overall (16 single-site; 19 multi-site). For payment, 376 of 377 EDs (99.7%) participated in the Merit-Based Incentive Payment System. Thirty-five EDs (9.2%) participated in a federal alternative payment model, and 19 (5.0%) participated in a commercial alternative payment model. For quality improvement, single- and multi-site EDs reported similar progress on quality improvement strategies; however, small-group EDs reported more advanced quality improvement strategies compared to large-group EDs for 8/10 quality improvement strategies included in a survey (eg, "achieved a formal plan to eliminate waste"). CONCLUSION Among EDs in E-QUAL, staffing, payment, and quality improvement activities are similar between single- and multi-site EDs. Group-level analysis suggests that practice structure may influence adoption of quality improvement strategies. Future work is needed to further evaluate practice structure and its influence on quality improvement activities and quality.
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Affiliation(s)
- Carl T. Berdahl
- Departments of Medicine and Emergency MedicineCedars‐Sinai Medical CenterWest HollywoodCalifornia
| | - Jeremiah D. Schuur
- Department of Emergency MedicineThe Warren Alpert Medical School of Brown UniversityProvidenceRhode Island
| | - Craig Rothenberg
- Department of Emergency MedicineYale University School of MedicineNew HavenConnecticut
| | - Kian Samadian
- University of Massachusetts School of MedicineWorcesterMassachusetts
| | - Dhruv Sharma
- American College of Emergency PhysiciansIrvingTexas
| | | | - Pawan Goyal
- American College of Emergency PhysiciansIrvingTexas
| | - Arjun K. Venkatesh
- Department of Emergency MedicineYale University School of MedicineNew HavenConnecticut
- Center for Outcomes Research and EvaluationYale New Haven Hospital New HavenConnecticut
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21
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Comparison of an ED triage sepsis screening tool and qSOFA in identifying CMS SEP-1 patients. Am J Emerg Med 2020; 38:1995-1999. [DOI: 10.1016/j.ajem.2020.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/30/2020] [Accepted: 06/08/2020] [Indexed: 11/19/2022] Open
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22
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Winslow R. Failing the metric but saving lives: The protocolization of sepsis treatment through quality measurement. Soc Sci Med 2020; 253:112982. [PMID: 32298917 DOI: 10.1016/j.socscimed.2020.112982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 11/18/2022]
Abstract
Quality metrics in the healthcare sector have become a key component of ensuring improved health outcomes and care equity. Alongside the emergence of information technology in healthcare (eg. electronic health records), the primary method utilized to infer "quality" has been the development of measures for healthcare processes and outcomes. Engaging with the specific case of sepsis treatment and sepsis quality metrics, this paper traces how quality is defined, measured, and codified in a 600-bed acute-care hospital in New York City. Sepsis is a severe health condition, primarily managed in the emergency department, that is caused by infection and can result in multi-organ shutdown and mortality. Multiple government agencies have established metrics that regulate New York hospitals based on their compliance with specific sepsis treatment procedures. I draw on data from a 15-month ethnography and in-depth interviews with clinicians and administrators, to show how quality measurement is reshaping the ways healthcare is delivered and organized. I reveal how, at Borough Hospital, efforts to treat sepsis based on quality metrics have constrained clinician expertise, prioritized compliance, and reoriented workflow towards standardized treatment protocols. This reorientation leads to, what I term abstracted surveillance protocols, that increasingly regulate definitions of healthcare quality. I demonstrate that abstracted surveillance protocols enable highly complex clinical processes to be measured based on metric compliance rather than clinical pathways, therefore moving definitions of quality away from the bedside.
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Affiliation(s)
- Rosalie Winslow
- Doctoral Candidate in Sociology, Social & Behavioral Sciences, University of California, San Francisco, 3333 California St., Suite 455, San Francisco, CA, 94118, USA.
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Baghdadi JD, Wong MD, Uslan DZ, Bell D, Cunningham WE, Needleman J, Kerbel R, Brook R. Adherence to the SEP-1 Sepsis Bundle in Hospital-Onset v. Community-Onset Sepsis: a Multicenter Retrospective Cohort Study. J Gen Intern Med 2020; 35:1153-1160. [PMID: 32040837 PMCID: PMC7174506 DOI: 10.1007/s11606-020-05653-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 09/26/2019] [Accepted: 12/10/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Sepsis is the leading cause of in-hospital death. The SEP-1 sepsis bundle is a protocol for early sepsis care that requires providers to diagnose and treat sepsis quickly. Limited evidence suggests that adherence to the sepsis bundle is lower in cases of hospital-onset sepsis. OBJECTIVE To compare sepsis bundle adherence in hospital-onset vs. community-onset sepsis. DESIGN Retrospective cohort study using multivariable analysis of clinical data. PARTICIPANTS A total of 4658 inpatients age 18 or older were identified by diagnosis codes consistent with sepsis or disseminated infection. SETTING Four university hospitals in California between 2014 and 2016. MAIN OUTCOMES AND MEASURES The primary outcome was adherence to key components of the sepsis bundle defined by the Centers for Medicare and Medicaid Services in their core measure, SEP-1. Covariates included clinical characteristics related to the patient, infection, and pathogen. KEY RESULTS Compared with community-onset, cases of hospital-onset sepsis were less likely to receive SEP-1 adherent care (relative risk 0.33, 95% confidence interval 0.29-0.38, p < 0.001). With the exception of vasopressors (RR 1.11, p = 0.002), each component of SEP-1 evaluated-blood cultures (RR 0.76, p < 0.001), serum lactate (RR 0.51, p < 0001), broad-spectrum antibiotics (RR 0.62, p < 0.001), intravenous fluids (0.47, p < 0.001), and follow-up lactate (RR 0.71, p < 0.001)-was less likely to be performed within the recommended time frame in hospital-onset sepsis. Within the hospital, cases of hospital-onset sepsis arising on the ward were less likely to receive SEP-1-adherent care than were cases arising in the intensive care unit (RR 0.68, p = 0.004). CONCLUSIONS Inpatients with hospital-onset sepsis receive different management than individuals with community-onset sepsis. It remains to be determined whether system-level factors, provider-level factors, or factors related to measurement explain the observed variation in care or whether variation in care affects outcomes.
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Affiliation(s)
- Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Mitchell D Wong
- UCLA Division of General Internal Medicine, Los Angeles, CA, USA
| | - Daniel Z Uslan
- UCLA Division of Infectious Diseases, Los Angeles, CA, USA
| | - Douglas Bell
- UCLA Division of General Internal Medicine, Los Angeles, CA, USA
| | - William E Cunningham
- UCLA Fielding School of Public Health, Department of Health Policy and Management, Los Angeles, CA, USA
| | - Jack Needleman
- UCLA Fielding School of Public Health, Department of Health Policy and Management, Los Angeles, CA, USA
| | | | - Robert Brook
- UCLA Department of Medicine, Los Angeles, CA, USA
- RAND Corporation, Santa Monica, CA, USA
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, USA
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24
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Wang J, Strich JR, Applefeld WN, Sun J, Cui X, Natanson C, Eichacker PQ. Driving blind: instituting SEP-1 without high quality outcomes data. J Thorac Dis 2020; 12:S22-S36. [PMID: 32148923 DOI: 10.21037/jtd.2019.12.100] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In 2015, the Centers for Medicare and Medicaid Services (CMS) instituted an all-or-none sepsis performance measure bundle (SEP-1) to promote high-quality, cost-effective care. Systematic reviews demonstrated only low-quality evidence supporting most of SEP-1's interventions. CMS has removed some but not all of these unproven components. The current SEP-1 version requires patients with suspected sepsis have a lactate level, blood cultures, broad-spectrum antibiotics and, if hypotensive, a fixed 30 mL/kg fluid infusion within 3 hours, and a repeat lactate if initially elevated within 6 hours. Experts have continued to raise concerns that SEP-1 remains overly prescriptive, lacks a sound scientific basis and presents risks (overuse of antibiotics and inappropriate fluids not titrated to need). To incentivize compliance with SEP-1, CMS now publicly publishes how often hospitals complete all interventions in individual patients. However, compliance measured across hospitals (5 studies, 48-2,851 hospitals) or patients (three studies, 110-851 patients) has been low (approximately 50%) which is not surprising given SEP-1's lack of scientific basis. The largest observational study (1,738 patients) reporting survival rates employing SEP-1 found they were not significantly improved with the measure (P=0.53) as did the next largest study (851 patients, adjusted survival odds ratio 1.36, 95% CI, 0.85 to 2.18). Two smaller observational studies (158 and 450 patients) reported SEP-1 improved unadjusted survival (P≤0.05) but were confounded either by baseline imbalances or by simultaneous introduction of a code sepsis protocol to improve compliance. Regardless, retrospective studies have well known biases related to non-randomized designs, uncontrolled data collection and failure to adjust for unrecognized influential variables. Such low-quality science should not be the basis for a national mandate compelling care for a rapidly lethal disease with a high mortality rate. Instead, SEP-1 should be based on high quality reproducible evidence from randomized controlled trials (RCT) demonstrating its benefit and thereby safety. Otherwise we risk not only doing harm but standardizing it.
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Affiliation(s)
- Jeffrey Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Jeffrey R Strich
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Willard N Applefeld
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Xizhong Cui
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Peter Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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25
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Janke AT, Danagoulian S, Venkatesh AK, Levy PD. Medicaid expansion and resource utilization in the emergency department. Am J Emerg Med 2020; 38:2586-2590. [PMID: 31982222 DOI: 10.1016/j.ajem.2019.12.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 11/25/2019] [Accepted: 12/24/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND The Affordable Care Act (ACA) has impacted the insurance mix of emergency department (ED) visits, yet the degree to which this has influenced provider behavior is not clear. METHODS This was a difference-in-differences (DID) analysis of ED-visit data from five states in 2013 and 2014. Sample states included 3 expanding Medicaid under the ACA, 1 rejecting ACA funding and delaying an eligibility expansion, and 1 with no eligibility change. We included self-pay and Medicaid patients aged 27 to 64 years. A subsample analysis was done for chest pain visits. DID logistic models were estimated for likelihood of admission for given Medicaid-paid ED visits in expansion states as compared to non-expansion states. Among chest pain visits we assessed likelihood given visits resulted in admission or advanced cardiac imaging, where clinician discretion may be more significant. RESULTS A total of 8,157,748 ED visits with primary payer Medicaid and self-pay were included, of which 331,422 were for chest pain. The proportion of visits paid for by Medicaid rose in expansion states by between 15.8% and 38.9%. Medicaid eligibility expansion was associated with increased odds of admission (OR 1.070 [95% CI 1.051-1.089]). Among chest pain visits, expansion was associated with increased odds of admission (OR 1.294 [95% CI 1.144-1.464]), but not advanced cardiac imaging (OR 1.099 [95% CI 0.983-1.229]). CONCLUSION Medicaid expansion was associated with small increases in ED visit admissions across the board and among the subgroup of patients presenting with chest pain.
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Affiliation(s)
- Alexander T Janke
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress, New Haven, CT 06510, USA.
| | - Shooshan Danagoulian
- Department of Economics, Wayne State University, 656 W Kirby St 2074, FAB, Detroit, MI 48202, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress, New Haven, CT 06510, USA
| | - Phillip D Levy
- Department of Emergency Medicine, Wayne State University School of Medicine, 6135 Woodward Ave, Detroit, MI 48202, USA
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26
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Kim JH, Ku NS, Kim YJ, Kim HB, Seok H, Lee DG, Lee JS, Jeong SJ, Choi JH, Sohn JW, Kim MJ, Park DW. Korean Registry for Improving Sepsis Survival (KISS): Protocol for a Multicenter Cohort of Adult Patients with Sepsis or Septic Shock. Infect Chemother 2020; 52:31-38. [PMID: 32239810 PMCID: PMC7113452 DOI: 10.3947/ic.2020.52.1.31] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Indexed: 12/29/2022] Open
Abstract
Sepsis is one of the significant causes of morbidity and mortality. The burden caused by sepsis has continued to increase in recent years in the Korea, highlighting the urgent need for the implementation of strategies to improve sepsis treatment outcomes. We therefore designed a web-based sepsis registry system (“Korean Registry for Improving Sepsis Survival” [KISS]) protocol to be used in hospitals in the Korea for evaluation of the epidemiology and clinical characteristics of patients with sepsis, via an analysis of outcome predictors. The inclusion criteria of this registry are as follows: adult patients ≥18 years admitted to the participating hospitals who are diagnosed with sepsis or septic shock. Demographic and clinical information data of the patients will be collected from hospital medical records and will be recorded in a case report form, which will be entered into a web-based data management system. The analysis of the collected data will be performed as follows: (1) epidemiological and clinical characteristics of sepsis and septic shock, (2) application of sepsis bundles and antibiotic stewardship, and (3) audit and feedback. In conclusion, we aim to build the comprehensive web-based sepsis registry in the Korea through a nation-wide network of participating hospitals. Information collected and analyzed through the KISS can be used for further improvements in the clinical management of sepsis. Furthermore, the KISS will facilitate research leading to the formulation of public health policies regarding sepsis bundle and antibiotic stewardship strategies in the Korea.
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Affiliation(s)
- Jong Hun Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Nam Su Ku
- Department of Internal Medicine and AIDS research institute, Yonsei University College of Medicine, Seoul, Korea
| | - Youn Jeong Kim
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeri Seok
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Dong Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Seo Lee
- Division of Infectious Diseases, Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Su Jin Jeong
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Hyun Choi
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jang Wook Sohn
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Min Ja Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Dae Won Park
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.
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27
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Burke LG, Epstein SK, Burke RC, Orav EJ, Jha AK. Trends in Mortality for Medicare Beneficiaries Treated in the Emergency Department From 2009 to 2016. JAMA Intern Med 2020; 180:80-88. [PMID: 31682713 PMCID: PMC6830439 DOI: 10.1001/jamainternmed.2019.4866] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
IMPORTANCE Emergency department (ED) visits are common and increasing. Whether outcomes associated with care in the ED are improving over time is largely unknown to date. OBJECTIVE To examine trends in 30-day mortality rates associated with ED care among Medicare beneficiaries aged 65 years or older. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used a random 5% sample in 2009 and 2010 and a 20% sample from 2011 to 2016, for a total of 15 416 385 ED visits from 2009 to 2016 among Medicare beneficiaries aged 65 years or older. EXPOSURES Time (year) as a continuous variable. MAIN OUTCOMES AND MEASURES The primary outcome was 30-day mortality, overall and stratified by illness severity and hospital characteristics. Secondary outcomes included mortality rates on the day of the ED visit (day 0) as well as at 7 and 14 days. Changes in disposition from the ED (admission, observation, transfer, died in the ED, and discharged) over time were also examined. RESULTS The sample included 15 416 385 ED visits (60.8% women and 39.2% men; mean [SD] age, 78.6 [8.5] years) at 4828 acute care hospitals. The percentage of patients discharged from the ED increased from 53.6% in 2009 to 56.7% in 2016. Unadjusted 30-day mortality declined from 5.1% in 2009 to 4.6% in 2016 (-0.068% per year; 95% CI, -0.074% to -0.063% per year; P < .001). After adjusting for hospital random effects, patient demographics, and chronic conditions, the adjusted 30-day mortality trend was -0.198% per year (95% CI, -0.204% to -0.193% per year; P < .001). The magnitude of this trend was greatest for patients with a high severity of illness (-0.662%; 95% CI, -0.681% to -0.644%; P < .001), followed by those with a medium severity of illness (-0.103% per year; 95% CI, -0.108% to -0.097% per year; P < .001) and those with a low severity of illness (-0.009% per year; 95% CI, -0.006% to -0.011% per year; P < .001). Declines in mortality were seen in each category of ED disposition, including visits resulting in admission (-0.356% per year; 95% CI, -0.368% to -0.343% per year; P < .001) as well as those resulting in discharge (-0.059% per year; 95% CI, -0.064% to -0.055% per year; P < .001). The decline was greater for major teaching hospitals (compared with nonteaching hospitals), nonprofit hospitals (compared with for-profit hospitals), and urban hospitals (compared with rural hospitals). CONCLUSIONS AND RELEVANCE Among Medicare beneficiaries receiving ED care in the United States, mortality within 30 days of an ED visit appears to have declined in recent years, particularly for patients with the highest severity of illness, even as fewer patients are being admitted from an ED visit. This study's findings suggest that further study is needed to understand the reasons for this decline and why certain types of hospitals are seeing greater improvements in outcomes.
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Affiliation(s)
- Laura G Burke
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts.,Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Stephen K Epstein
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts.,Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ryan C Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - E John Orav
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ashish K Jha
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Harvard Global Health Institute, Cambridge, Massachusetts
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Marik PE, Farkas JD, Spiegel R, Weingart S. POINT: Should the Surviving Sepsis Campaign Guidelines Be Retired? Yes. Chest 2019; 155:12-14. [PMID: 30616719 DOI: 10.1016/j.chest.2018.10.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 10/02/2018] [Indexed: 01/29/2023] Open
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA.
| | - Joshua D Farkas
- Division of Pulmonary and Critical Care Medicine, Larner College of Medicine at the University of Vermont, Burlington VT
| | - Rory Spiegel
- Department Emergency Medicine, Critical Care Fellow Division of Pulmonary Critical Care University of Maryland Medical Center, Baltimore, MD
| | - Scott Weingart
- Department Emergency Medicine, Stony Brook School of Medicine, Stony Brook, NY
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29
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Rhee C, Wang R, Song Y, Zhang Z, Kadri SS, Septimus EJ, Fram D, Jin R, Poland RE, Hickok J, Sands K, Klompas M. Risk Adjustment for Sepsis Mortality to Facilitate Hospital Comparisons Using Centers for Disease Control and Prevention's Adult Sepsis Event Criteria and Routine Electronic Clinical Data. Crit Care Explor 2019; 1:e0049. [PMID: 32166230 PMCID: PMC7063887 DOI: 10.1097/cce.0000000000000049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Variability in hospital-level sepsis mortality rates may be due to differences in case mix, quality of care, or diagnosis and coding practices. Centers for Disease Control and Prevention's Adult Sepsis Event definition could facilitate objective comparisons of sepsis mortality rates between hospitals but requires rigorous risk-adjustment tools. We developed risk-adjustment models for Adult Sepsis Events using administrative and electronic health record data. DESIGN Retrospective cohort study. SETTING One hundred thirty-six U.S. hospitals in Cerner HealthFacts (derivation dataset) and 137 HCA Healthcare hospitals (validation dataset). PATIENTS A total of 95,154 hospitalized adult patients (derivation) and 201,997 patients (validation) meeting Centers for Disease Control and Prevention Adult Sepsis Event criteria. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We created logistic regression models of increasing complexity using administrative and electronic health record data to predict in-hospital mortality. An administrative model using demographics, comorbidities, and coded markers of severity of illness at admission achieved an area under the receiver operating curve of 0.776 (95% CI, 0.770-0.783) in the Cerner cohort, with diminishing calibration at higher baseline risk deciles. An electronic health record-based model that integrated administrative data with laboratory results, vasopressors, and mechanical ventilation achieved an area under the receiver operating curve of 0.826 (95% CI, 0.820-0.831) in the derivation cohort and 0.827 (95% CI, 0.824-0.829) in the validation cohort, with better calibration than the administrative model. Adding vital signs and Glasgow Coma Score minimally improved performance. CONCLUSIONS Models incorporating electronic health record data accurately predict hospital mortality for patients with Adult Sepsis Events and outperform models using administrative data alone. Utilizing laboratory test results, vasopressors, and mechanical ventilation without vital signs may achieve a good balance between data collection needs and model performance, but electronic health record-based models must be attentive to potential variability in data quality and availability. With ongoing testing and refinement of these risk-adjustment models, Adult Sepsis Event surveillance may enable more meaningful comparisons of hospital sepsis outcomes and provide an important window into quality of care.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Rui Wang
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Yue Song
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Zilu Zhang
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medical Oncology, Harvard Medical School/Dana Farber Cancer Institute, Boston, MA
| | - Sameer S Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Edward J Septimus
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Internal Medicine, Texas A&M College of Medicine, Houston, TX
| | | | - Robert Jin
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
| | - Russell E Poland
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Clinical Services Group, HCA Healthcare, Nashville, TN
| | | | - Kenneth Sands
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Clinical Services Group, HCA Healthcare, Nashville, TN
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
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30
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Rhee C, Wang R, Zhang Z, Fram D, Kadri SS, Klompas M. Epidemiology of Hospital-Onset Versus Community-Onset Sepsis in U.S. Hospitals and Association With Mortality: A Retrospective Analysis Using Electronic Clinical Data. Crit Care Med 2019; 47:1169-1176. [PMID: 31135503 PMCID: PMC6697188 DOI: 10.1097/ccm.0000000000003817] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Prior studies have reported that hospital-onset sepsis is associated with higher mortality rates than community-onset sepsis. Most studies, however, have used inconsistent case-finding methods and applied limited risk-adjustment for potential confounders. We used consistent sepsis criteria and detailed electronic clinical data to elucidate the epidemiology and mortality associated with hospital-onset sepsis. DESIGN Retrospective cohort study. SETTING 136 U.S. hospitals in the Cerner HealthFacts dataset. PATIENTS Adults hospitalized in 2009-2015. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified sepsis using Centers for Disease Control and Prevention Adult Sepsis Event criteria and estimated the risk of in-hospital death for hospital-onset sepsis versus community-onset sepsis using logistic regression models. In patients admitted without community-onset sepsis, we estimated risk of death associated with hospital-onset sepsis using Cox regression models with sepsis as a time-varying covariate. Models were adjusted for baseline characteristics and severity of illness. Among 2.2 million hospitalizations, there were 95,154 sepsis cases: 83,620 (87.9%) community-onset sepsis and 11,534 (12.1%) hospital-onset sepsis (0.5% of hospitalized cohort). Compared to community-onset sepsis, hospital-onset sepsis patients were younger (median 66 vs 68 yr) but had more comorbidities (median Elixhauser score 14 vs 11), higher Sequential Organ Failure Assessment scores (median 4 vs 3), higher ICU admission rates (61% vs 44%), longer hospital length of stay (median 19 vs 8 d), and higher in-hospital mortality (33% vs 17%) (p < 0.001 for all comparisons). On multivariate analysis, hospital-onset sepsis was associated with higher mortality versus community-onset sepsis (odds ratio, 2.1; 95% CI, 2.0-2.2) and patients admitted without sepsis (hazard ratio, 3.0; 95% CI, 2.9-3.2). CONCLUSIONS Hospital-onset sepsis complicated one in 200 hospitalizations and accounted for one in eight sepsis cases, with one in three patients dying in-hospital. Hospital-onset sepsis preferentially afflicted ill patients but even after risk-adjustment, they were twice as likely to die as community-onset sepsis patients; in patients admitted without sepsis, hospital-onset sepsis tripled the risk of death. Hospital-onset sepsis is an important target for surveillance, prevention, and quality improvement initiatives.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Rui Wang
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
| | - Zilu Zhang
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
| | | | - Sameer S. Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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Yurso M, Box B, Burgon T, Hauck L, Tagg K, Clem K, Paculdo D, Acelajado MC, Tamondong-Lachica D, Peabody JW, PhD MD. Reducing Unneeded Clinical Variation in Sepsis and Heart Failure Care to Improve Outcomes and Reduce Cost: A Collaborative Engagement with Hospitalists in a MultiState System. J Hosp Med 2019; 14:541-546. [PMID: 31251162 PMCID: PMC6715052 DOI: 10.12788/jhm.3220] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/25/2019] [Accepted: 04/02/2019] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To (1) measure hospitalist care for sepsis and heart failure patients using online simulated patients, (2) improve quality and reduce cost through customized feedback, and (3) compare patient-level outcomes between project participants and nonparticipants. METHODS We conducted a prospective, quasi-controlled cohort study of hospitalists in eight hospitals matched with comparator hospitalists in six nonparticipating hospitals across the AdventHealth system. We provided measurement and feedback to participants using Clinical Performance and Value (CPV) vignettes to measure and track quality improvement. We then compared length of stay (LOS) and cost results between the two groups. RESULTS 107 providers participated in the study. Over two years, participants improved CPV scores by nearly 8% (P < .001), with improvements in utilization of the three-hour sepsis bundle (46.0% vs 57.7%; P = .034) and ordering essential medical treatment elements for heart failure (58.2% vs 72.1%; P = .038). In study year one, average LOS observed/expected (O/E) rates dropped by 8% for participants, compared to 2.5% in the comparator group, equating to an additional 570 hospital days saved among project participants. In study year two, cost O/E rates improved from 1.16 to 0.98 for participants versus 1.14 to 1.01 in the comparator group. Based on these improvements, we calculated total cost savings of $6.2 million among study participants, with $3.8 million linked to system-wide improvements and an additional $2.4 million in savings attributable to this project. CONCLUSIONS CPV case simulation-based measurement and feedback helped drive improvements in evidence-based care that translated into lower costs and LOS, above-and-beyond other improvements at AdventHealth.
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Affiliation(s)
- Michael Yurso
- AdventHealth, Office of Clinical Excellence, Altamonte Springs, Florida
| | - Brent Box
- AdventHealth, Office of Clinical Excellence, Altamonte Springs, Florida
| | | | - Loran Hauck
- AdventHealth, Office of Clinical Excellence, Altamonte Springs, Florida
| | - Krystyna Tagg
- AdventHealth, Office of Clinical Excellence, Altamonte Springs, Florida
| | - Kathleen Clem
- AdventHealth, Office of Clinical Excellence, Altamonte Springs, Florida
| | | | | | | | | | - MD PhD
- QURE Healthcare, San Francisco, California
- University of California, San Francisco, College of Medicine, San Francisco, California
- University of California, Los Angeles, Fielding School of Public Health, Los Angeles, California
- Corresponding Author: John Peabody, MD PhD; E-mail: ; Telephone: 415-321-3388
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32
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First, Most, and Best: The Implications of Delays in Implementing Surviving Sepsis Campaign Guidelines. Crit Care Med 2019. [PMID: 29538114 DOI: 10.1097/ccm.0000000000002972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Deb P, Murtaugh CM, Bowles KH, Mikkelsen ME, Khajavi HN, Moore S, Barrón Y, Feldman PH. Does Early Follow-Up Improve the Outcomes of Sepsis Survivors Discharged to Home Health Care? Med Care 2019; 57:633-640. [PMID: 31295191 DOI: 10.1097/mlr.0000000000001152] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is little evidence to guide the care of over a million sepsis survivors following hospital discharge despite high rates of hospital readmission. OBJECTIVE We examined whether early home health nursing (first visit within 2 days of hospital discharge and at least 1 additional visit in the first posthospital week) and early physician follow-up (an outpatient visit in the first posthospital week) reduce 30-day readmissions among Medicare sepsis survivors. DESIGN A pragmatic, comparative effectiveness analysis of Medicare data from 2013 to 2014 using nonlinear instrumental variable analysis. SUBJECTS Medicare beneficiaries in the 50 states and District of Columbia discharged alive after a sepsis hospitalization and received home health care. MEASURES The outcomes, protocol parameters, and control variables were from Medicare administrative and claim files and the home health Outcome and Assessment Information Set (OASIS). The primary outcome was 30-day all-cause hospital readmission. RESULTS Our sample consisted of 170,571 mostly non-Hispanic white (82.3%), female (57.5%), older adults (mean age, 76 y) with severe sepsis (86.9%) and a multitude of comorbid conditions and functional limitations. Among them, 44.7% received only the nursing protocol, 11.0% only the medical doctor protocol, 28.1% both protocols, and 16.2% neither. Although neither protocol by itself had a statistically significant effect on readmission, both together reduced the probability of 30-day all-cause readmission by 7 percentage points (P=0.006; 95% confidence interval=2, 12). CONCLUSIONS Our findings suggest that, together, early postdischarge care by home health and medical providers can reduce hospital readmissions for sepsis survivors.
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Affiliation(s)
- Partha Deb
- Hunter College, City University of New York (CUNY) and National Bureau of Economic Research (NBER)
| | - Christopher M Murtaugh
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY
| | - Kathryn H Bowles
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY
- University of Pennsylvania School of Nursing
| | - Mark E Mikkelsen
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Hoda Nouri Khajavi
- Hunter College and the Graduate Center, City University of New York (CUNY), New York, NY
| | | | - Yolanda Barrón
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY
| | - Penny H Feldman
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY
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Trent SA, Jarou ZJ, Havranek EP, Ginde AA, Haukoos JS. Variation in Emergency Department Adherence to Treatment Guidelines for Inpatient Pneumonia and Sepsis: A Retrospective Cohort Study. Acad Emerg Med 2019; 26:908-920. [PMID: 30343515 DOI: 10.1111/acem.13639] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/12/2018] [Accepted: 10/17/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Evidence-based clinical practice guidelines (CPGs) for the treatment of pneumonia and sepsis have existed for many years with multiple studies suggesting improved patient outcomes. Despite their importance, little is known about variation in emergency department (ED) adherence to these CPGs. Our objectives were to estimate variation in ED adherence across CPGs for pneumonia and sepsis and identify patient, provider, and environmental factors associated with adherence. METHODS This was a multicenter retrospective study using standard medical record review methods. The population consisted of consecutive adults hospitalized for pneumonia or sepsis (identified by discharge ICD-9 codes) at five Colorado hospitals (two academic, three community) who were admitted to the hospital from the ED and for whom the ED diagnosed or initiated treatment. The outcome measured was ED adherence to the CPG (primary) and in-hospital mortality (secondary). Hierarchical generalized linear models were used for analysis. RESULTS Among 827 patients, ED care was 57% adherence to CPGs with significant variation in adherence across CPGs (sepsis 50%, pneumonia 64%, p < 0.001). Patients were less likely to receive adherent care if they presented with chief complaints that were associated but not typical of the diagnosis (odds ratio [OR] = 0.6, 95% confidence interval [CI] = 0.4-0.8), received an ED diagnosis that was not specific to the CPG (associated diagnosis OR = 0.3 [95% CI = 0.2-0.5]; unrelated diagnosis OR = 0.4 [95% CI = 0.2-0.6]) or presented to a community hospital (OR = 0.6, 95% CI = 0.4-0.9). ED CPG nonadherence was associated with higher in-hospital mortality (OR = 2.4, 95% CI = 1.2-4.8). CONCLUSION Adherence to ED infectious CPGs for pneumonia and sepsis varies significantly across diseases and types of institutions with significant room for improvement, especially in light of a significant association with in-hospital mortality.
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Affiliation(s)
- Stacy A. Trent
- Department of Emergency Medicine Denver Health Medical Center Denver CO
- Department of Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Zachary J. Jarou
- Department of Emergency Medicine Denver Health Medical Center Denver CO
- Department of Emergency Medicine University of Chicago School of Medicine Chicago IL
| | - Edward P. Havranek
- Department of Medicine Denver Health Medical Center Denver CO
- Division of Cardiology University of Colorado School of Medicine Aurora CO
| | - Adit A. Ginde
- Department of Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Jason S. Haukoos
- Department of Emergency Medicine Denver Health Medical Center Denver CO
- Department of Emergency Medicine University of Colorado School of Medicine Aurora CO
- Department of Epidemiology Colorado School of Public Health Aurora CO
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Lactate-Guided Resuscitation Strategies in Septic Shock: Differentiating the Bad From the Unexceptional. Ann Emerg Med 2019; 73:688-690. [DOI: 10.1016/j.annemergmed.2019.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Affiliation(s)
- Susan G Bryant
- Susan G. Bryant is a nursing faculty member at Davidson County Community College in Lexington, N.C
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Greenwood-Ericksen MB, Rothenberg C, Mohr N, Andrea SD, Slesinger T, Osborn T, Whittle J, Goyal P, Tarrant N, Schuur JD, Yealy DM, Venkatesh A. Urban and Rural Emergency Department Performance on National Quality Metrics for Sepsis Care in the United States. J Rural Health 2018; 35:490-497. [PMID: 30488590 DOI: 10.1111/jrh.12339] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE The Centers for Medicare and Medicaid Services (CMS) and the American College of Emergency Physicians (ACEP) developed national quality measures for emergency department (ED) sepsis care. Like care for many conditions, meeting sepsis quality metrics can vary between settings. We sought to examine and compare sepsis care quality in rural vs urban hospital-based EDs. METHODS We analyzed data from EDs participating in the national Emergency Quality Network (E-QUAL). We collected preliminary performance data on both the CMS measure (SEP-1) and the ACEP measures via manual chart review. We analyzed SEP-1 data at the hospital level based on existing CMS definitions and analyzed ACEP measure data at the patient level. We report descriptive statistics of performance variation in rural and urban EDs. FINDINGS Rural EDs comprised 58 of the EDs reporting SEP-1 results and 405 rural patient charts in the manual review. Of sites reporting SEP-1 results, 44% were rural and demonstrated better aggregate SEP-1 bundle adherence than urban EDs (79% vs 71%; P = .049). Both urban and rural hospitals reported high levels of compliance with the ACEP recommended initial actions of obtaining lactate and blood cultures, with urban EDs outperforming rural EDs on metrics of IV fluid administration and antibiotics (74% urban vs 60% rural; P ≤ .001; 91% urban vs 84% rural; P ≤ .001, respectively). CONCLUSIONS Sepsis care at both rural and urban EDs often achieves success with national metrics. However, performance on individual components of ED sepsis care demonstrates opportunities for improved processes of care at rural EDs.
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Affiliation(s)
| | - Craig Rothenberg
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut.,Yale New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut
| | - Nicholas Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | - Todd Slesinger
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Tiffany Osborn
- Department of Surgery, Acute and Critical Care Surgery and Department of Medicine, Emergency Medicine, Washington University, St. Louis, Missouri
| | - Jessica Whittle
- Department of Emergency Medicine, UT Chattanooga/Erlanger Health Systems, Chattanooga, Tennessee
| | - Pawan Goyal
- American College of Emergency Physicians, Washington, DC
| | - Nalani Tarrant
- American College of Emergency Physicians, Washington, DC
| | - Jeremiah D Schuur
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Arjun Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut.,Yale New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut
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Rhee C, Filbin M, Massaro AF, Bulger A, McEachern D, Tobin KA, Kitch B, Thurlo-Walsh B, Kadar A, Koffman A, Pande A, Hamad Y, Warren DK, Jones T, O’Brien C, Anderson DJ, Wang R, Klompas M. Compliance With the National SEP-1 Quality Measure and Association With Sepsis Outcomes: A Multicenter Retrospective Cohort Study. Crit Care Med 2018; 46:1585-1591. [PMID: 30015667 PMCID: PMC6138564 DOI: 10.1097/ccm.0000000000003261] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Many septic patients receive care that fails the Centers for Medicare and Medicaid Services' SEP-1 measure, but it is unclear whether this reflects meaningful lapses in care, differences in clinical characteristics, or excessive rigidity of the "all-or-nothing" measure. We compared outcomes in cases that passed versus failed SEP-1 during the first 2 years after the measure was implemented. DESIGN Retrospective cohort study. SETTING Seven U.S. hospitals. PATIENTS Adult patients included in SEP-1 reporting between October 2015 and September 2017. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 851 sepsis cases in the cohort, 281 (33%) passed SEP-1 and 570 (67%) failed. SEP-1 failures had higher rates of septic shock (20% vs 9%; p < 0.001), hospital-onset sepsis (11% vs 4%; p = 0.001), and vague presenting symptoms (46% vs 30%; p < 0.001). The most common reasons for failure were omission of 3- and 6-hour lactate measurements (228/570 failures, 40%). Only 86 of 570 failures (15.1%) had greater than 3-hour delays until broad-spectrum antibiotics. Cases that failed SEP-1 had higher in-hospital mortality rates (18.4% vs 11.0%; odds ratio, 1.82; 95% CI, 1.19-2.80; p = 0.006), but this association was no longer significant after adjusting for differences in clinical characteristics and severity of illness (adjusted odds ratio, 1.36; 95% CI, 0.85-2.18; p = 0.205). Delays of greater than 3 hours until antibiotics were significantly associated with death (adjusted odds ratio, 1.94; 95% CI, 1.04-3.62; p = 0.038), whereas failing SEP-1 for any other reason was not (adjusted odds ratio, 1.10; 95% CI, 0.70-1.72; p = 0.674). CONCLUSIONS Crude mortality rates were higher in sepsis cases that failed versus passed SEP-1, but there was no difference after adjusting for clinical characteristics and severity of illness. Delays in antibiotic administration were associated with higher mortality but only accounted for a small fraction of SEP-1 failures. SEP-1 may not clearly differentiate between high- and low-quality care, and detailed risk adjustment is necessary to properly interpret associations between SEP-1 compliance and mortality.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston MA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Michael Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Amy Bulger
- Department of Quality and Safety, Brigham and Women’s Hospital, Boston, MA
| | - Donna McEachern
- Department of Quality and Safety, Brigham and Women’s Hospital, Boston, MA
| | - Kathleen A. Tobin
- Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, MA
| | - Barrett Kitch
- Department of Medicine, North Shore Medical Center, Salem, MA
| | - Bert Thurlo-Walsh
- Office of Quality, Patient Safety & Experience, Newton-Wellesley Hospital, Newton, MA
| | - Aran Kadar
- Department of Medicine, Newton-Wellesley Hospital, Newton, MA
| | - Alexandra Koffman
- Department of Quality, Brigham and Women’s Faulkner Hospital, Boston, MA
| | - Anupam Pande
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Yasir Hamad
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - David K. Warren
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Travis Jones
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Cara O’Brien
- Department of Medicine, Duke University Medical Center, Durham, NC
| | | | - Rui Wang
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston MA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston MA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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Spiegel R, Farkas JD, Rola P, Kenny JE, Olusanya S, Marik PE, Weingart SD. The 2018 Surviving Sepsis Campaign's Treatment Bundle: When Guidelines Outpace the Evidence Supporting Their Use. Ann Emerg Med 2018; 73:356-358. [PMID: 30193754 DOI: 10.1016/j.annemergmed.2018.06.046] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Indexed: 12/29/2022]
Affiliation(s)
- Rory Spiegel
- Department of Emergency Medicine and Division of Pulmonary and Critical Care, University of Maryland Medical Center, Baltimore, MD.
| | - Joshua D Farkas
- Division of Pulmonary and Critical Care Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, Montreal, Quebec, Canada
| | | | - Segun Olusanya
- Department of Perioperative Medicine, St Bartholomew's Hospital, London, UK
| | - Paul E Marik
- Department of Internal Medicine and Pulmonary and Critical Care Medicine, Eastern Virginia Medical School
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Variability in determining sepsis time zero and bundle compliance rates for the centers for medicare and medicaid services SEP-1 measure. Infect Control Hosp Epidemiol 2018; 39:994-996. [PMID: 29932042 DOI: 10.1017/ice.2018.134] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We compared sepsis "time zero" and Centers for Medicare and Medicaid Services (CMS) SEP-1 pass rates among 3 abstractors in 3 hospitals. Abstractors agreed on time zero in 29 of 80 (36%) cases. Perceived pass rates ranged from 9 of 80 cases (11%) to 19 of 80 cases (23%). Variability in time zero and perceived pass rates limits the utility of SEP-1 for measuring quality.
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Han X, Edelson DP, Snyder A, Pettit N, Sokol S, Barc C, Howell MD, Churpek MM. Implications of Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock Early Management Bundle and Initial Lactate Measurement on the Management of Sepsis. Chest 2018; 154:302-308. [PMID: 29804795 DOI: 10.1016/j.chest.2018.03.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/09/2018] [Accepted: 03/19/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Sepsis remains a significant cause of morbidity and mortality in the United States, leading to the implementation of the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). SEP-1 identifies patients with "severe sepsis" via clinical and laboratory criteria and mandates interventions, including lactate draws and antibiotics, within a specific time window. We sought to characterize the patients affected and to study the implications of SEP-1 on patient care and outcomes. METHODS All adults admitted to the University of Chicago from November 2008 to January 2016 were eligible. Modified SEP-1 criteria were used to identify appropriate patients. Time to lactate draw and antibiotic and IV fluid administration were calculated. In-hospital mortality was examined. RESULTS Lactates were measured within the mandated window 32% of the time on the ward (n = 505) compared with 55% (n = 818) in the ICU and 79% (n = 2,144) in the ED. Patients with delayed lactate measurements demonstrated the highest in-hospital mortality at 29%, with increased time to antibiotic administration (median time, 3.9 vs 2.0 h). Patients with initial lactates > 2.0 mmol/L demonstrated an increase in the odds of death with hourly delay in lactate measurement (OR, 1.02; 95% CI, 1.0003-1.05; P = .04). CONCLUSIONS Delays in lactate measurement are associated with delayed antibiotics and increased mortality in patients with initial intermediate or elevated lactate levels. Systematic early lactate measurement for all patients with sepsis will lead to a significant increase in lactate draws that may prompt more rapid physician intervention for patients with abnormal initial values.
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Affiliation(s)
- Xuan Han
- Department of Medicine, University of Chicago, Chicago, IL
| | - Dana P Edelson
- Department of Medicine, University of Chicago, Chicago, IL; Center for Healthcare Delivery Science and Innovation, Chicago, IL
| | - Ashley Snyder
- Department of Medicine, University of Michigan Hospital, Ann Arbor, MI
| | - Natasha Pettit
- Department of Pharmacy, University of Chicago, Chicago, IL
| | - Sarah Sokol
- Department of Pharmacy, University of Chicago, Chicago, IL
| | - Carmen Barc
- Center for Quality, University of Chicago, Chicago, IL
| | | | - Matthew M Churpek
- Department of Medicine, University of Chicago, Chicago, IL; Center for Healthcare Delivery Science and Innovation, Chicago, IL.
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