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Lawrence JR, Lee BS, Fadahunsi AI, Mowery BD. Evaluating Sepsis Bundle Compliance as a Predictor for Patient Outcomes at a Community Hospital: A Retrospective Study. J Nurs Care Qual 2024; 39:252-258. [PMID: 38470467 PMCID: PMC11116060 DOI: 10.1097/ncq.0000000000000767] [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: 03/13/2024]
Abstract
BACKGROUND Clinicians are encouraged to use the Centers for Medicare & Medicaid Services early management bundle for severe sepsis and septic shock (SEP-1); however, it is unclear whether this process measure improves patient outcomes. PURPOSE The purpose of this study was to evaluate whether compliance with the SEP-1 bundle is a predictor of hospital mortality, length of stay (LOS), and intensive care unit LOS at a suburban community hospital. METHODS A retrospective observational study was conducted. RESULTS A total of 577 patients were included in the analysis. Compliance with the SEP-1 bundle was not a significant predictor for patient outcomes. CONCLUSIONS SEP-1 compliance may not equate with quality of health care. Efforts to comply with SEP-1 may help organizations develop systems and structures that improve patient outcomes. Health care leaders should evaluate strategies beyond SEP-1 compliance to ensure continuous improvement of outcomes for patients experiencing sepsis.
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Affiliation(s)
- John R Lawrence
- Author Affiliations: Inova Mount Vernon Hospital, Alexandria, Virginia (Mr Lawrence); George Mason University, Fairfax, Virginia (Drs Lee and Fadahunsi); and Inova Health System, Fairfax, Virginia (Dr Mowery)
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2
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Ginestra JC, Coz Yataco AO, Dugar SP, Dettmer MR. Hospital-Onset Sepsis Warrants Expanded Investigation and Consideration as a Unique Clinical Entity. Chest 2024; 165:1421-1430. [PMID: 38246522 PMCID: PMC11177099 DOI: 10.1016/j.chest.2024.01.028] [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: 08/01/2023] [Revised: 12/27/2023] [Accepted: 01/15/2024] [Indexed: 01/23/2024] Open
Abstract
Sepsis causes more than a quarter million deaths among hospitalized adults in the United States each year. Although most cases of sepsis are present on admission, up to one-quarter of patients with sepsis develop this highly morbid and mortal condition while hospitalized. Compared with patients with community-onset sepsis (COS), patients with hospital-onset sepsis (HOS) are twice as likely to require mechanical ventilation and ICU admission, have more than two times longer ICU and hospital length of stay, accrue five times higher hospital costs, and are twice as likely to die. Patients with HOS differ from those with COS with respect to underlying comorbidities, admitting diagnosis, clinical manifestations of infection, and severity of illness. Despite the differences between these patient populations, patients with HOS sepsis are understudied and warrant expanded investigation. Here, we outline important knowledge gaps in the recognition and management of HOS in adults and propose associated research priorities for investigators. Of particular importance are questions regarding standardization of research and clinical case identification, understanding of clinical heterogeneity among patients with HOS, development of tailored management recommendations, identification of impactful prevention strategies, optimization of care delivery and quality metrics, identification and correction of disparities in care and outcomes, and how to ensure goal-concordant care for patients with HOS.
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Affiliation(s)
- Jennifer C Ginestra
- Palliative and Advanced Illness Research (PAIR) Center, Division of Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA
| | - Angel O Coz Yataco
- Division of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Siddharth P Dugar
- Division of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Matthew R Dettmer
- Division of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Center for Emergency Medicine, Emergency Services Institute, Cleveland Clinic, Cleveland, OH.
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3
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Barbash IJ, Davis BS, Saul M, Hwa R, Brant EB, Seymour CW, Kahn JM. Association Between Medicare's Sepsis Reporting Policy (SEP-1) and the Documentation of a Sepsis Diagnosis in the Clinical Record. Med Care 2024; 62:388-395. [PMID: 38620117 DOI: 10.1097/mlr.0000000000001997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
STUDY DESIGN Interrupted time series analysis of a retrospective, electronic health record cohort. OBJECTIVE To determine the association between the implementation of Medicare's sepsis reporting measure (SEP-1) and sepsis diagnosis rates as assessed in clinical documentation. BACKGROUND The role of health policy in the effort to improve sepsis diagnosis remains unclear. PATIENTS AND METHODS Adult patients hospitalized with suspected infection and organ dysfunction within 6 hours of presentation to the emergency department, admitted to one of 11 hospitals in a multi-hospital health system from January 2013 to December 2017. Clinician-diagnosed sepsis, as reflected by the inclusion of the terms "sepsis" or "septic" in the text of clinical notes in the first two calendar days following presentation. RESULTS Among 44,074 adult patients with sepsis admitted to 11 hospitals over 5 years, the proportion with sepsis documentation was 32.2% just before the implementation of SEP-1 in the third quarter of 2015 and increased to 37.3% by the fourth quarter of 2017. Of the 9 post-SEP-1 quarters, 8 had odds ratios for a sepsis diagnosis >1 (overall range: 0.98-1.26; P value for a joint test of statistical significance = 0.005). The effects were clinically modest, with a maximum effect of an absolute increase of 4.2% (95% CI: 0.9-7.8) at the end of the study period. The effect was greater in patients who did not require vasopressors compared with patients who required vasopressors ( P value for test of interaction = 0.02). CONCLUSIONS SEP-1 implementation was associated with modest increases in sepsis diagnosis rates, primarily among patients who did not require vasoactive medications.
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Affiliation(s)
- Ian J Barbash
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, School of Medicine, Pittsburgh, PA
- Department of Critical Care Medicine, CRISMA Center, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- UPMC, Pittsburgh PA
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Billie S Davis
- Department of Critical Care Medicine, CRISMA Center, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Melissa Saul
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rebecca Hwa
- Department of Computer Science, School of Computing and Information, University of Pittsburgh, Pittsburgh, PA
| | - Emily B Brant
- Department of Critical Care Medicine, CRISMA Center, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- UPMC, Pittsburgh PA
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Christopher W Seymour
- Department of Critical Care Medicine, CRISMA Center, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- UPMC, Pittsburgh PA
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Jeremy M Kahn
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, School of Medicine, Pittsburgh, PA
- UPMC, Pittsburgh PA
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
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4
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Law AC, Bosch NA, Song Y, Tale A, Lasser KE, Walkey AJ. In-Hospital vs 30-Day Sepsis Mortality at US Safety-Net and Non-Safety-Net Hospitals. JAMA Netw Open 2024; 7:e2412873. [PMID: 38819826 PMCID: PMC11143462 DOI: 10.1001/jamanetworkopen.2024.12873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/11/2024] [Indexed: 06/01/2024] Open
Abstract
Importance In-hospital mortality of patients with sepsis is frequently measured for benchmarking, both by researchers and policymakers. Prior studies have reported higher in-hospital mortality among patients with sepsis at safety-net hospitals compared with non-safety-net hospitals; however, in critically ill patients, in-hospital mortality rates are known to be associated with hospital discharge practices, which may differ between safety-net hospitals and non-safety-net hospitals. Objective To assess how admission to safety-net hospitals is associated with 2 metrics of short-term mortality (in-hospital mortality and 30-day mortality) and discharge practices among patients with sepsis. Design, Setting, and Participants Retrospective, national cohort study of Medicare fee-for-service beneficiaries aged 66 years and older, admitted with sepsis to an intensive care unit from January 2011 to December 2019 based on information from the Medicare Provider Analysis and Review File. Data were analyzed from October 2022 to September 2023. Exposure Admission to a safety-net hospital (hospitals with a Medicare disproportionate share index in the top quartile per US region). Main Outcomes and Measures Coprimary outcomes: in-hospital mortality and 30-day mortality. Secondary outcomes: (1) in-hospital do-not-resuscitate orders, (2) in-hospital palliative care delivery, (3) discharge to a postacute facility (skilled nursing facility, inpatient rehabilitation facility, or long-term acute care hospital), and (4) discharge to hospice. Results Between 2011 and 2019, 2 551 743 patients with sepsis (mean [SD] age, 78.8 [8.2] years; 1 324 109 [51.9%] female; 262 496 [10.3%] Black, 2 137 493 [83.8%] White, and 151 754 [5.9%] other) were admitted to 666 safety-net hospitals and 1924 non-safety-net hospitals. Admission to safety-net hospitals was associated with higher in-hospital mortality (odds ratio [OR], 1.09; 95% CI, 1.06-1.13) but not 30-day mortality (OR, 1.01; 95% CI, 0.99-1.04). Admission to safety-net hospitals was associated with lower do-not-resuscitate rates (OR, 0.86; 95% CI, 0.81-0.91), palliative care delivery rates (OR, 0.66; 95% CI, 0.60-0.73), and hospice discharge (OR, 0.82; 95% CI, 0.78-0.87) but not with discharge to postacute facilities (OR, 0.98; 95% CI, 0.95-1.01). Conclusions and Relevance In this cohort study, among patients with sepsis, admission to safety-net hospitals was associated with higher in-hospital mortality but not with 30-day mortality. Differences in in-hospital mortality may partially be explained by greater use of hospice at non-safety-net hospitals, which shifts attribution of death from the index hospitalization to hospice. Future investigations and publicly reported quality measures should consider time-delimited rather than hospital-delimited measures of short-term mortality to avoid undue penalty to safety-net hospitals with similar short-term mortality.
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Affiliation(s)
- Anica C. Law
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nicholas A. Bosch
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Yang Song
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Archana Tale
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Karen E. Lasser
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - Allan J. Walkey
- Division of Health Systems Science, Department of Medicine, University of Massachusetts Chan Medical School, Worcester
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5
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Vandervelde R, Mlynarek ME, Ramesh M, Patel N, Veve MP, August BA. Impact of time to treatment in first occurrence, non-severe Clostridioides difficile infection for elderly patients: are we waiting too long to treat? ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e59. [PMID: 38698948 PMCID: PMC11062792 DOI: 10.1017/ash.2024.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/03/2024] [Accepted: 03/07/2024] [Indexed: 05/05/2024]
Abstract
Objective Data evaluating timeliness of antibiotic therapy in Clostridioides difficile infections (CDI) are not well established. The study's purpose was to evaluate the impact of time-to-CDI treatment on disease progression. Methods A case-control study was performed among hospitalized patients with CDI from 1/2018 to 2/2022. Inclusion criteria were age ≥65 years, first occurrence, non-severe CDI at symptom onset, and CDI treatment for ≥72 hours. Cases included patients who progressed to severe or fulminant CDI; controls were patients without CDI progression. Time to CDI treatment was evaluated in three ways: a classification and regression tree (CART)-defined threshold, time as a continuous variable, and time as a categorical variable. Results 272 patients were included; 136 with CDI progression, 136 patients without. The median (IQR) age was 74 (69-81) years, 167 (61%) were women, and 108 (40%) were immunosuppressed. CDI progression patients more commonly were toxin positive (66 [49%] vs 52 [38%], P = .087) with hospital-acquired disease (57 [42%] vs 29 [21%], P < 0.001). A CART-derived breakpoint for optimal time-to-CDI treatment of 64 hours established early (184, 68%) and delayed treatment (88, 32%). When accounting for confounding variables, delayed CDI treatment was associated with disease progression (adjOR, 4.6; 95%CI, 2.6-8.2); this was observed regardless of how time-to-CDI-active therapy was evaluated (continuous adjOR, 1.02; categorical adjOR, 2.11). Conclusion Delayed CDI treatment was associated with disease progression and could represent an important antimicrobial stewardship measure with future evaluation.
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Affiliation(s)
| | | | - Mayur Ramesh
- Department of Infectious Diseases, Henry Ford Hospital, Detroit, MI, USA
| | - Nimish Patel
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Michael P. Veve
- Department of Pharmacy, Henry Ford Hospital, Detroit, MI, USA
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
| | - Benjamin A. August
- Department of Pharmacy, Henry Ford Hospital, Detroit, MI, USA
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
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Rhee C, Strich JR, Chiotos K, Classen DC, Cosgrove SE, Greeno R, Heil EL, Kadri SS, Kalil AC, Gilbert DN, Masur H, Septimus EJ, Sweeney DA, Terry A, Winslow DL, Yealy DM, Klompas M. Improving Sepsis Outcomes in the Era of Pay-for-Performance and Electronic Quality Measures: A Joint IDSA/ACEP/PIDS/SHEA/SHM/SIDP Position Paper. Clin Infect Dis 2024; 78:505-513. [PMID: 37831591 DOI: 10.1093/cid/ciad447] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Indexed: 10/15/2023] Open
Abstract
The Centers for Medicare & Medicaid Services (CMS) introduced the Severe Sepsis/Septic Shock Management Bundle (SEP-1) as a pay-for-reporting measure in 2015 and is now planning to make it a pay-for-performance measure by incorporating it into the Hospital Value-Based Purchasing Program. This joint IDSA/ACEP/PIDS/SHEA/SHM/SIPD position paper highlights concerns with this change. Multiple studies indicate that SEP-1 implementation was associated with increased broad-spectrum antibiotic use, lactate measurements, and aggressive fluid resuscitation for patients with suspected sepsis but not with decreased mortality rates. Increased focus on SEP-1 risks further diverting attention and resources from more effective measures and comprehensive sepsis care. We recommend retiring SEP-1 rather than using it in a payment model and shifting instead to new sepsis metrics that focus on patient outcomes. CMS is developing a community-onset sepsis 30-day mortality electronic clinical quality measure (eCQM) that is an important step in this direction. The eCQM preliminarily identifies sepsis using systemic inflammatory response syndrome (SIRS) criteria, antibiotic administrations or diagnosis codes for infection or sepsis, and clinical indicators of acute organ dysfunction. We support the eCQM but recommend removing SIRS criteria and diagnosis codes to streamline implementation, decrease variability between hospitals, maintain vigilance for patients with sepsis but without SIRS, and avoid promoting antibiotic use in uninfected patients with SIRS. We further advocate for CMS to harmonize the eCQM with the Centers for Disease Control and Prevention's (CDC) Adult Sepsis Event surveillance metric to promote unity in federal measures, decrease reporting burden for hospitals, and facilitate shared prevention initiatives. These steps will result in a more robust measure that will encourage hospitals to pay more attention to the full breadth of sepsis care, stimulate new innovations in diagnosis and treatment, and ultimately bring us closer to our shared goal of improving outcomes for patients.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeffrey R Strich
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Kathleen Chiotos
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David C Classen
- Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ron Greeno
- Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Emily L Heil
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sameer S Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska School of Medicine, Omaha, Nebraska, USA
| | - David N Gilbert
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Henry Masur
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Edward J Septimus
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
- Department of Internal Medicine, Texas A&M College of Medicine, Houston, Texas, USA
| | - Daniel A Sweeney
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Diego School of Medicine, San Diego, California, USA
| | - Aisha Terry
- Department of Emergency Medicine, George Washington University School of Medicine, Washington D.C., USA
| | - Dean L Winslow
- Division of Infectious Diseases, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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7
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Cranston T, Thompson K, Bowles KH. The Role and Initiatives Led by the Sepsis Coordinator to Improve Sepsis Bundle Compliance and Care Across the Continuum. Crit Care Nurs Clin North Am 2023; 35:413-424. [PMID: 37838416 DOI: 10.1016/j.cnc.2023.05.006] [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: 10/16/2023]
Abstract
A dedicated sepsis coordinator role at Penn Medicine Lancaster General Hospital led initiatives to improve sepsis core measure compliance by 40% during the course of 4 years with submission of all sepsis cases. Chart abstraction and analysis of noncompliant cases identified areas for improvement: early recognition education, order set revisions, documentation support, and the implementation of a nurse-driven 24/7 sepsis monitoring process. The cooperative work with Penn Medicine affiliates, sharing best practices, improves overall sepsis bundle compliance and transitions of care. Ongoing achievements acknowledge the value of building relationships and leading improvements through the collaborative efforts of interprofessional teams.
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Affiliation(s)
- Teresa Cranston
- Penn Medicine Lancaster General Hospital, 555 North Duke Street, Lancaster, PA 17602, USA
| | - Katharine Thompson
- Penn Medicine Lancaster General Hospital, 555 North Duke Street, Lancaster, PA 17602, USA.
| | - Kathryn H Bowles
- University of Pennsylvania, University of Pennsylvania School of Nursing, 418 Curie Boulevard, Claire M. Fagin Hall, Room 340, Philadelphia, PA 19104, USA
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Pak TR, Young J, McKenna CS, Agan A, DelloStritto L, Filbin MR, Dutta S, Kadri SS, Septimus EJ, Rhee C, Klompas M. Risk of Misleading Conclusions in Observational Studies of Time-to-Antibiotics and Mortality in Suspected Sepsis. Clin Infect Dis 2023; 77:1534-1543. [PMID: 37531612 PMCID: PMC10686960 DOI: 10.1093/cid/ciad450] [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: 04/05/2023] [Revised: 06/20/2023] [Accepted: 07/31/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Influential studies conclude that each hour until antibiotics increases mortality in sepsis. However, these analyses often (1) adjusted for limited covariates, (2) included patients with long delays until antibiotics, (3) combined sepsis and septic shock, and (4) used linear models presuming each hour delay has equal impact. We evaluated the effect of these analytic choices on associations between time-to-antibiotics and mortality. METHODS We retrospectively identified 104 248 adults admitted to 5 hospitals from 2015-2022 with suspected infection (blood culture collection and intravenous antibiotics ≤24 h of arrival), including 25 990 with suspected septic shock and 23 619 with sepsis without shock. We used multivariable regression to calculate associations between time-to-antibiotics and in-hospital mortality under successively broader confounding-adjustment, shorter maximum time-to-antibiotic intervals, stratification by illness severity, and removing assumptions of linear hourly associations. RESULTS Changing covariates, maximum time-to-antibiotics, and severity stratification altered the magnitude, direction, and significance of observed associations between time-to-antibiotics and mortality. In a fully adjusted model of patients treated ≤6 hours, each hour was associated with higher mortality for septic shock (adjusted odds ratio [aOR]: 1.07; 95% CI: 1.04-1.11) but not sepsis without shock (aOR: 1.03; .98-1.09) or suspected infection alone (aOR: .99; .94-1.05). Modeling each hour separately confirmed that every hour of delay was associated with increased mortality for septic shock, but only delays >6 hours were associated with higher mortality for sepsis without shock. CONCLUSIONS Associations between time-to-antibiotics and mortality in sepsis are highly sensitive to analytic choices. Failure to adequately address these issues can generate misleading conclusions.
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Affiliation(s)
- Theodore R Pak
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jessica Young
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Caroline S McKenna
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Anna Agan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Laura DelloStritto
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sayon Dutta
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sameer S Kadri
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Edward J Septimus
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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9
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Monti G, Rezoagli E, Calini A, Nova A, Marchesi S, Nattino G, Carrara G, Morra S, Cortellaro F, Savioli M, Capra Marzani F, Tresoldi M, Villa P, Greco S, Bonfanti P, Spitoni MG, Vesconi S, Caironi P, Fumagalli R. Effect of a quality improvement program on compliance to the sepsis bundle in non-ICU patients: a multicenter prospective before and after cohort study. Front Med (Lausanne) 2023; 10:1215341. [PMID: 38020128 PMCID: PMC10680451 DOI: 10.3389/fmed.2023.1215341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Objective Sepsis and septic shock are major challenges and economic burdens to healthcare, impacting millions of people globally and representing significant causes of mortality. Recently, a large number of quality improvement programs focused on sepsis resuscitation bundles have been instituted worldwide. These educational initiatives have been shown to be associated with improvements in clinical outcomes. We aimed to evaluate the impact of a multi-faceted quality implementing program (QIP) on the compliance of a "simplified 1-h bundle" (Sepsis 6) and hospital mortality of severe sepsis and septic shock patients out of the intensive care unit (ICU). Methods Emergency departments (EDs) and medical wards (MWs) of 12 academic and non-academic hospitals in the Lombardy region (Northern Italy) were involved in a multi-faceted QIP, which included educational and organizational interventions. Patients with a clinical diagnosis of severe sepsis or septic shock according to the Sepsis-2 criteria were enrolled in two different periods: from May 2011 to November 2011 (before-QIP cohort) and from August 2012 to June 2013 (after-QIP cohort). Measurements and main results The effect of QIP on bundle compliance and hospital mortality was evaluated in a before-after analysis. We enrolled 467 patients in the before-QIP group and 656 in the after-QIP group. At the time of enrollment, septic shock was diagnosed in 50% of patients, similarly between the two periods. In the after-QIP group, we observed increased compliance to the "simplified rapid (1 h) intervention bundle" (the Sepsis 6 bundle - S6) at three time-points evaluated (1 h, 13.7 to 18.7%, p = 0.018, 3 h, 37.1 to 48.0%, p = 0.013, overall study period, 46.2 to 57.9%, p < 0.001). We then analyzed compliance with S6 and hospital mortality in the before- and after-QIP periods, stratifying the two patients' cohorts by admission characteristics. Adherence to the S6 bundle was increased in patients with severe sepsis in the absence of shock, in patients with serum lactate <4.0 mmol/L, and in patients with hypotension at the time of enrollment, regardless of the type of admission (from EDs or MWs). Subsequently, in an observational analysis, we also investigated the relation between bundle compliance and hospital mortality by logistic regression. In the after-QIP cohort, we observed a lower in-hospital mortality than that observed in the before-QIP cohort. This finding was reported in subgroups where a higher adherence to the S6 bundle in the after-QIP period was found. After adjustment for confounders, the QIP appeared to be independently associated with a significant improvement in hospital mortality. Among the single S6 procedures applied within the first hour of sepsis diagnosis, compliance with blood culture and antibiotic therapy appeared significantly associated with reduced in-hospital mortality. Conclusion A multi-faceted QIP aimed at promoting an early simplified bundle of care for the management of septic patients out of the ICU was associated with improved compliance with sepsis bundles and lower in-hospital mortality.
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Affiliation(s)
- Gianpaola Monti
- Department of Anesthesia and Intensive Care, ASST GOM Niguarda Ca’ Granda, Milan, Italy
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Angelo Calini
- Department of Anesthesia and Intensive Care, ASST GOM Niguarda Ca’ Granda, Milan, Italy
| | - Alice Nova
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Silvia Marchesi
- Intensiv och perioperativ vard, Skane Universitetssjukhus, Malmo, Sweden
| | - Giovanni Nattino
- Istituto di ricerche farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
| | - Greta Carrara
- Istituto di ricerche farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
| | - Sergio Morra
- Department of Anesthesia and Intensive Care, ASST Ovest Milano, Legnano, Italy
| | | | - Monica Savioli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCSC Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Federico Capra Marzani
- Department of Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Moreno Tresoldi
- Unit of General Medicine and Advanced Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Villa
- Department of Emergency, ASST FBF - Sacco, Ospedale L. Sacco, Milan, Italy
| | - Stefano Greco
- Department of Anesthesia and Intensive Care, ASST Valle Olona, Ospedale Busto Arsitio, Busto Arsitio, Italy
| | - Paolo Bonfanti
- Infectious Diseases, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | - Sergio Vesconi
- Department of Anesthesia and Intensive Care, ASST GOM Niguarda Ca’ Granda, Milan, Italy
| | - Pietro Caironi
- Department of Anesthesia and Intensive Care, AOU S. Luigi Gonzaga, Università degli Studi di Torino, Orbassano, Italy
| | - Roberto Fumagalli
- Department of Anesthesia and Intensive Care, ASST GOM Niguarda Ca’ Granda, Milan, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
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10
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Schlapbach LJ, Zimmermann EA, Meylan S, Stocker M, Suter PM, Jakob SM, National Action Plan Working Group OBOTSS. Swiss Sepsis National Action Plan: A coordinated national action plan to stop sepsis-related preventable deaths and to improve the support of people affected by sepsis in Switzerland. Front Med (Lausanne) 2023; 10:1114546. [PMID: 36891186 PMCID: PMC9986258 DOI: 10.3389/fmed.2023.1114546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/20/2023] [Indexed: 02/22/2023] Open
Abstract
Background Sepsis is a devastating disease which causes yearly over 10 million deaths worldwide. In 2017, the World Health Organization (WHO) issued a resolution prompting member states to improve the prevention, recognition, and management of sepsis. The 2021 European Sepsis Report revealed that-contrary to other European countries-Switzerland had not yet actioned the sepsis resolution. Methods A panel of experts convened at a policy workshop to address how to improve awareness, prevention, and treatment of sepsis in Switzerland. Goal of the workshop was to formulate a set of consensus recommendations toward creating a Swiss Sepsis National Action Plan (SSNAP). In a first part, stakeholders presented existing international sepsis quality improvement programs and national health programs relevant for sepsis. Thereafter, the participants were allocated into three working groups to identify opportunities, barriers, and solutions on (i) prevention and awareness, (ii) early detection and treatment, and (iii) support for sepsis survivors. Finally, the entire panel summarized the findings from the working groups and identified priorities and strategies for the SSNAP. All discussions during the workshop were transcribed into the present document. All workshop participants and key experts reviewed the document. Results The panel formulated 14 recommendations to address sepsis in Switzerland. These focused on four domains, including (i) raising awareness in the community, (ii) improving healthcare workforce training on sepsis recognition and sepsis management; (iii) establishing standards for rapid detection, treatment and follow-up in sepsis patients across all age groups; and (iv) promoting sepsis research with particular focus on diagnostic and interventional trials. Conclusion There is urgency to tackle sepsis. Switzerland has a unique opportunity to leverage from lessons learnt during the COVID-19 pandemic to address sepsis as the major infection-related threat to society. This report details consensus recommendations, the rationale thereof, and key discussion points made by the stakeholders on the workshop day. The report presents a coordinated national action plan to prevent, measure, and sustainably reduce the personal, financial and societal burden, death and disability arising from sepsis in Switzerland.
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Affiliation(s)
- Luregn J Schlapbach
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.,Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QL, Australia
| | - Elisa A Zimmermann
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Sylvain Meylan
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Martin Stocker
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland
| | | | - Stephan M Jakob
- Department of Intensive Care Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - On Behalf Of The Swiss Sepsis National Action Plan Working Group
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.,Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QL, Australia.,Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,University of Geneva, Geneva, Switzerland.,Department of Intensive Care Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
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11
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Miller H, Tseng A, Lowerre T, Schefft M, Muñoz J, Pedigo S, Silverman J. Improving Time to Stat Intravenous Antibiotic Administration: An 8-Year Quality Initiative. Hosp Pediatr 2023; 13:88-94. [PMID: 36545766 DOI: 10.1542/hpeds.2021-006422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Prompt antibiotics have been shown to improve outcomes in pediatric sepsis, which continues to be a leading cause of death in children. We describe the quality improvement (QI) efforts of a single academic children's hospital to improve antibiotic timeliness. METHODS Using the electronic health record, we report time from order to the administration of stat intravenous (IV) antibiotics from 2012 to 2020 using statistical process control charts. We describe QI interventions initiated over the study period. These include the formation of a Pediatric Sepsis Committee, routine use of automated dispensing machines for stat IV antibiotics, creation of sepsis order sets, manual and automated sepsis screening implementation, participation in national sepsis QI collaboratives, creation of difficult intravenous access guidelines, and an automated notification system for charge nurses. As a balancing measure, we assessed stat IV antibiotic use normalized to total emergency department visits and inpatient days. RESULTS Multiple quality improvement interventions were initiated and sustained under the direction of the hospital Pediatric Sepsis Committee. We improved our stat IV antibiotics given within 1 hour of order from 33% in 2012 to 77% in 2019 and maintained this through the end of the study period in July 2020. CONCLUSIONS By using a multipronged quality improvement approach, we demonstrated consistent and sustained improvement in the timely administration of stat IV antibiotics over an 8-year period at our institution. Further study is needed to assess whether this is associated with reduced length of stay or improved survival in children with sepsis.
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Affiliation(s)
- Hannah Miller
- Division of Hospital Medicine.,Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Ashlie Tseng
- Division of Hospital Medicine.,Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Tracy Lowerre
- Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Matthew Schefft
- Division of Hospital Medicine.,Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Jose Muñoz
- Division of Hospital Medicine.,Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | | | - Jonathan Silverman
- Division of Pediatric Emergency Medicine.,Department of Emergency Medicine, Virginia Commonwealth University Health Systems, Richmond, Virginia
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12
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Boccio E, Haimovich A, Jacob V, Zhao X, Wira CR, Venkatesh A, Belsky J. Establishment of SEP-1 national practice guidelines does not impact fluid administration for septic shock patients. Am J Emerg Med 2022; 62:19-24. [DOI: 10.1016/j.ajem.2022.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/11/2022] [Accepted: 09/25/2022] [Indexed: 10/07/2022] Open
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13
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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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14
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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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15
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Klompas M, Rhee C. Antibiotics: it is all about timing, isn't it? Curr Opin Crit Care 2022; 28:513-521. [PMID: 35942689 DOI: 10.1097/mcc.0000000000000969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Sepsis guidelines and quality measures set aggressive deadlines for administering antibiotics to patients with possible sepsis or septic shock. However, the diagnosis of sepsis is often uncertain, particularly upon initial presentation, and pressure to treat more rapidly may harm some patients by exposing them to unnecessary or inappropriate broad-spectrum antibiotics. RECENT FINDINGS Observational studies that report that each hour until antibiotics increases mortality often fail to adequately adjust for comorbidities and severity of illness, fail to account for antibiotics given to uninfected patients, and inappropriately blend the effects of long delays with short delays. Accounting for these factors weakens or eliminates the association between time-to-antibiotics and mortality, especially for patients without shock. These findings are underscored by analyses of the Centers for Medicaid and Medicare Services SEP-1 measure: it has increased sepsis diagnoses and broad-spectrum antibiotic use but has not improved outcomes. SUMMARY Clinicians are advised to tailor the urgency of antibiotics to their certainty of infection and patients' severity of illness. Immediate antibiotics are warranted for patients with possible septic shock or high likelihood of infection. Antibiotics can safely be withheld to allow for more investigation, however, in most patients with less severe illnesses if the diagnosis of infection is uncertain.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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16
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Schootman M, Wiskow C, Loux T, Meyer L, Powell S, Gandhi A, Lacasse A. Evaluation of the effectiveness of an automated sepsis predictive tool on patient outcomes. J Crit Care 2022; 71:154061. [DOI: 10.1016/j.jcrc.2022.154061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/02/2022] [Accepted: 05/02/2022] [Indexed: 10/18/2022]
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17
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Ginestra JC, Kohn R, Hubbard RA, Crane-Droesch A, Halpern SD, Kerlin MP, Weissman GE. Association of Unit Census with Delays in Antimicrobial Initiation among Ward Patients with Hospital-acquired Sepsis. Ann Am Thorac Soc 2022; 19:1525-1533. [PMID: 35312462 PMCID: PMC9447380 DOI: 10.1513/annalsats.202112-1360oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/18/2022] [Indexed: 11/20/2022] Open
Abstract
Rationale: Patients with hospital-acquired sepsis (HAS) experience higher mortality and delayed care compared with those with community-acquired sepsis. Capacity strain, the extent to which demand for hospital resources exceeds availability, thus impacting patient care, is a possible mechanism underlying antimicrobial delays for HAS but has not been studied. Objectives: Assess the association of ward census with the timing of antimicrobial initiation among ward patients with HAS. Methods: This retrospective cohort study included adult patients hospitalized at five acute care hospitals between July 2017 and December 2019 who developed ward-onset HAS, distinguished from community-acquired sepsis by onset after 48 hours of hospitalization. The primary exposure was ward census, measured as the number of patients present in each ward at each hour, standardized by quarter and year. The primary outcome was time from sepsis onset to antimicrobial initiation. We used quantile regression to assess the association between ward census at sepsis onset and time to antimicrobial initiation among patients with HAS defined by Centers for Disease Control and Prevention Adult Sepsis Event criteria. We adjusted for hospital, year, quarter, age, sex, race, ethnicity, severity of illness, admission diagnosis, and service type. Results: A total of 1,672 hospitalizations included at least one ward-onset HAS episode. Median time to antimicrobial initiation after HAS onset was 4.1 hours (interquartile range, 0.4-22.3). Marginal adjusted time to antimicrobial initiation ranged from 3.6 hours (95% confidence interval [CI], 2.4-4.8 h) to 6.8 hours (95% CI, 5.3-8.4 h) at census levels 2 standard deviations (SDs) below and above the ward-specific mean, respectively. Each 1-SD increase in ward census at sepsis onset, representing a median of 2.4 patients, was associated with an increase in time to antimicrobial initiation of 0.80 hours (95% CI, 0.32-1.29 h). In sensitivity analyses, results were consistent across severity of illness and electronic health record-based sepsis definitions. Conclusions: Time to antimicrobial initiation increased with increasing census among ward patients with HAS. These findings suggest that delays in care for HAS may be related to ward capacity strain as measured by census. Additional work is needed to validate these findings and identify potential mechanisms operating through clinician behavior and care delivery processes.
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Affiliation(s)
- Jennifer C. Ginestra
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
| | - Rachel Kohn
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
| | - Rebecca A. Hubbard
- Palliative and Advanced Illness Research (PAIR) Center
- Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew Crane-Droesch
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
| | - Meeta Prasad Kerlin
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
| | - Gary E. Weissman
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
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18
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Sato R, Dugar S, Han X, Siuba MT, Mucha S, Dettmer M, Wang X, Yataco AC, Choudhary C, Khanna AK, Duggal A. TIME FROM HOSPITAL ADMISSION TO ONSET OF SEPTIC SHOCK IS ASSOCIATED WITH HIGHER IN-HOSPITAL MORTALITY. Shock 2022; 58:211-216. [PMID: 35959788 DOI: 10.1097/shk.0000000000001973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Objective: Several studies have shown septic shock developing later during the hospital stay is associated with higher mortality. However, the precise point at which time from hospital admission to the onset of septic shock (admission-shock-onset-time) becomes an independent prognostic marker of mortality remains unknown. This study evaluated the association between admission-shock-onset-time and in-hospital mortality among patients with septic shock and the optimal cutoff period to categorize early- and late-onset septic shock. Method: We conducted a single-center retrospective, observational cohort study at a quaternary academic hospital comprising adult patients with septic shock admitted to a medical intensive care unit (ICU) from January 2011 to December 2020. A multivariable additive logistic regression model was developed to assess if log-transformed admission-shock-onset-time was associated with in-hospital mortality. The thin plate spline function was used to describe the nonlinear relationship between the log-transformed admission-shock-onset-time and in-hospital mortality. The primary outcome was in-hospital mortality, and the secondary outcome was ICU mortality. Results: Two thousand five hundred twenty patients met the inclusion criteria with an overall in-hospital mortality of 37.3%. The log-transformed admission-shock-onset-time was associated with higher in-hospital and ICU mortality even after adjusting for clinical variables. The odds ratio for in-hospital mortality continued to increase throughout the observation period. The adjusted odds ratio exceeded 2 in between 20.1 and 54.6 h, and it surpassed 3 in between 54.6 and 148.4 h of the time from the hospital admission to shock onset. Conclusion: In-hospital mortality continued to rise as admission-shock-onset-time increased in patients with septic shock. No clear dichotomization between early and late septic shock could be ascertained, and this categorization may limit our understanding of the temporal relationship of shock onset to mortality.
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Affiliation(s)
- Ryota Sato
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Xiaozhen Han
- Department of Quantitative Health Sciences, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | | | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
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19
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Chan HK, Khose S, Chavez S, Patel B, Wang HE. Updated estimates of sepsis hospitalizations at United States academic medical centers. J Am Coll Emerg Physicians Open 2022; 3:e12782. [PMID: 35859855 PMCID: PMC9288236 DOI: 10.1002/emp2.12782] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/19/2022] [Accepted: 06/01/2022] [Indexed: 11/10/2022] Open
Abstract
Objective Sepsis is a major public health problem. Understanding the epidemiology of sepsis subtypes is important to quantify the magnitude of the problem and identify targets for system wide treatment strategies. We sought to describe the current national epidemiology of community‐acquired (CAS), hospital‐acquired (HAS) and healthcare‐associated sepsis (HCAS) hospitalizations among academic medical centers in the United States using current discharge diagnosis taxonomies. Methods Retrospective analysis of patient discharge data from the Vizient Clinical Data Base/Resource Manager. We identified sepsis hospitalizations using four ICD‐10 coding strategies: (1) “Martin” sepsis codes (21 ICD‐10 codes), (2) “Angus” sepsis codes (ICD‐10 infection + ICD‐10 organ dysfunction), (3) Medicare “SEP‐1” codes (28 ICD‐10 codes), and (4) “explicit sepsis” codes (ICD‐10 R65.20 and R65.21). Using present‐on‐admission flags for each diagnosis, we also distinguished: (1) community‐acquired sepsis (CAS), (2) hospital‐acquired sepsis (HAS), and (3) healthcare associated sepsis (HCAS). Results Among 22,655,240 hospitalizations, the number and incidence of sepsis hospitalizations were: (1) Martin (n = 1,718,257, 75.8 per 1000 hospitalizations), (2) Angus (n = 2,749,163, 121.3 per 1000), (3) SEP‐1 (n = 1,624,909, 71.7 per 1000), and (4) explicit sepsis (n = 655,853, 28.9 per 1000). CAS was the most common sepsis subtype. HAS exhibited higher adjusted mortality than CAS. ICU admission was highest for HAS (Martin, 1.5%; Angus, 1.5%; SEP‐1, 1.6%; Explicit, 1.9%). Conclusions These results illustrate the prevalence of sepsis at US academic medical centers using the most current sepsis classification taxonomies and discharge diagnosis codes. These results highlight important considerations when using hospital discharge data to characterize the epidemiology of sepsis.
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Affiliation(s)
- Hei Kit Chan
- Department of Emergency Medicine, Department of Biostatistics The University of Texas Health Science Center at Houston Houston Texas USA
| | - Swapnil Khose
- Department of Epidemiology, Human Genetics & Environmental Sciences, School of Public Health The University of Texas Health Science Center at Houston Houston Texas USA
- Department of Emergency Medicine, McGovern Medical School The University of Texas Health Science Center at Houston Houston Texas USA
| | - Summer Chavez
- Department of Emergency Medicine, Department of Biostatistics The University of Texas Health Science Center at Houston Houston Texas USA
| | - Bela Patel
- Department of Medicine, Division of Critical Care Medicine The University of Texas Health Science Center at Houston Houston Texas USA
| | - Henry E. Wang
- Department of Emergency Medicine The Ohio State University Columbus Ohio USA
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August BA, Griebe KM, Stine JJ, Hauser CD, Hunsaker T, Jones MC, Martz C, Peters MA, To L, Belanger R, Schlacht S, Swiderek J, Davis SL, Mlynarek ME, Smith ZR. Evaluating the impact of severe sepsis
3‐hour
bundle compliance on
28‐day in‐hospital
mortality: A propensity adjusted, nested case–control study. Pharmacotherapy 2022; 42:651-658. [DOI: 10.1002/phar.2715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 05/20/2022] [Accepted: 05/21/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Benjamin A. August
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | - Kristin M. Griebe
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | - John J. Stine
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | | | - Todd Hunsaker
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | - Mathew C. Jones
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | - Carolyn Martz
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | - Michael A. Peters
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | - Long To
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | | | | | - Jennifer Swiderek
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine Henry Ford Hospital Detroit Michigan USA
| | - Susan L. Davis
- Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences Detroit Michigan USA
| | - Mark E. Mlynarek
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | - Zachary R. Smith
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
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21
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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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22
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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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23
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Schwarzkopf D, Rüddel H, Brinkmann A, Fleischmann-Struzek C, Friedrich ME, Glas M, Gogoll C, Gründling M, Meybohm P, Pletz MW, Schreiber T, Thomas-Rüddel DO, Reinhart K. The German Quality Network Sepsis: Evaluation of a Quality Collaborative on Decreasing Sepsis-Related Mortality in a Controlled Interrupted Time Series Analysis. Front Med (Lausanne) 2022; 9:882340. [PMID: 35573007 PMCID: PMC9094049 DOI: 10.3389/fmed.2022.882340] [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] [Received: 02/23/2022] [Accepted: 03/31/2022] [Indexed: 11/13/2022] Open
Abstract
Background Sepsis is one of the leading causes of preventable deaths in hospitals. This study presents the evaluation of a quality collaborative, which aimed to decrease sepsis-related hospital mortality. Methods The German Quality Network Sepsis (GQNS) offers quality reporting based on claims data, peer reviews, and support for establishing continuous quality management and staff education. This study evaluates the effects of participating in the GQNS during the intervention period (April 2016–June 2018) in comparison to a retrospective baseline (January 2014–March 2016). The primary outcome was all-cause risk-adjusted hospital mortality among cases with sepsis. Sepsis was identified by International Classification of Diseases (ICD) codes in claims data. A controlled time series analysis was conducted to analyze changes from the baseline to the intervention period comparing GQNS hospitals with the population of all German hospitals assessed via the national diagnosis-related groups (DRGs)-statistics. Tests were conducted using piecewise hierarchical models. Implementation processes and barriers were assessed by surveys of local leaders of quality improvement teams. Results Seventy-four hospitals participated, of which 17 were university hospitals and 18 were tertiary care facilities. Observed mortality was 43.5% during baseline period and 42.7% during intervention period. Interrupted time-series analyses did not show effects on course or level of risk-adjusted mortality of cases with sepsis compared to the national DRG-statistics after the beginning of the intervention period (p = 0.632 and p = 0.512, respectively). There was no significant mortality decrease in the subgroups of patients with septic shock or ventilation >24 h or predefined subgroups of hospitals. A standardized survey among 49 local quality improvement leaders in autumn of 2018 revealed that most hospitals did not succeed in implementing a continuous quality management program or relevant measures to improve early recognition and treatment of sepsis. Barriers perceived most commonly were lack of time (77.6%), staff shortage (59.2%), and lack of participation of relevant departments (38.8%). Conclusion As long as hospital-wide sepsis quality improvement efforts will not become a high priority for the hospital leadership by assuring adequate resources and involvement of all pertinent stakeholders, voluntary initiatives to improve the quality of sepsis care will remain prone to failure.
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Affiliation(s)
- Daniel Schwarzkopf
- Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany.,Department for Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.,Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Hendrik Rüddel
- Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany.,Department for Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Alexander Brinkmann
- Department of Anesthesiology and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Carolin Fleischmann-Struzek
- Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany.,Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | | | - Michael Glas
- Department for Infectious Diseases and Infection Control, KH Labor GmbH, AMEOS Group, Bernburg, Germany
| | - Christian Gogoll
- Outpatient Services, Evangelische Lungenklinik Berlin-Buch, Berlin, Germany
| | - Matthias Gründling
- Department of Anesthesiology, University Hospital of Greifswald, Greifswald, Germany
| | - Patrick Meybohm
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Mathias W Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Torsten Schreiber
- Department of Anesthesia and Intensive Care, Zentralklinik Bad Berka, Bad Berka, Germany
| | | | - Konrad Reinhart
- Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany.,Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany.,Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
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24
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Abstract
The definition of sepsis has evolved significantly over the past three decades. Today, sepsis is defined as a dysregulated host immune response to microbial invasion leading to end organ dysfunction. Septic shock is characterized by hypotension requiring vasopressors after adequate fluid resuscitation with elevated lactate. Early recognition and intervention remain hallmarks for sepsis management. We addressed the current literature and assimilated thought regarding optimum initial resuscitation of the patient with sepsis. A nuanced understanding of the physiology of lactate is provided in our review. Physiologic and practical knowledge of steroid and vasopressor therapy for sepsis is crucial and addressed. As blood purification may interest the nephrologist treating sepsis, we have also added a brief discussion of its status.
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Affiliation(s)
- Sharad Patel
- Department of Critical Care, Rowan University Cooper Medical School, Camden, New Jersey
| | - Nitin Puri
- Department of Critical Care, Cooper Hospital University Medical Center, Camden, New Jersey
| | - R Phillip Dellinger
- Department of Critical Care, Cooper Hospital University Medical Center, Camden, New Jersey
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25
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Chang JL, Pearson JC, Rhee C. Early Empirical Use of Broad-Spectrum Antibiotics in Sepsis. Curr Infect Dis Rep 2022. [DOI: 10.1007/s11908-022-00777-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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26
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Murphy CV, Reed EE, Herman DD, Magrum B, Beatty JJ, Stevenson KB. Antimicrobial Stewardship in the ICU. Semin Respir Crit Care Med 2022; 43:131-140. [PMID: 35172363 DOI: 10.1055/s-0041-1740977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Increasing rates of infection and multidrug-resistant pathogens, along with a high use of antimicrobial therapy, make the intensive care unit (ICU) an ideal setting for implementing and supporting antimicrobial stewardship efforts. Overuse of antimicrobial agents is common in the ICU, as practitioners are challenged daily with achieving early, appropriate empiric antimicrobial therapy to improve patient outcomes. While early antimicrobial stewardship programs focused on the financial implications of antimicrobial overuse, current goals of stewardship programs align closely with those of critical care providers-to optimize patient outcomes, reduce development of resistance, and minimize adverse outcomes associated with antibiotic overuse and misuse such as acute kidney injury and Clostridioides difficile-associated disease. Significant opportunities exist in the ICU for critical care clinicians to support stewardship practices at the bedside, including thoughtful and restrained initiation of antimicrobial therapy, use of biomarkers in addition to rapid diagnostics, Staphylococcus aureus screening, and traditional microbiologic culture and susceptibilities to guide antibiotic de-escalation, and use of the shortest duration of therapy that is clinically appropriate. Integration of critical care practitioners into the initiatives of antimicrobial stewardship programs is key to their success. This review summarizes key components of antimicrobial stewardship programs and mechanisms for critical care practitioners to share the responsibility for antimicrobial stewardship.
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Affiliation(s)
- Claire V Murphy
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Erica E Reed
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Derrick D Herman
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - BrookeAnne Magrum
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Julia J Beatty
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kurt B Stevenson
- Division of Infectious Diseases, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio.,Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio
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27
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Walton NT, Mohr NM. Concept review of regionalized systems of acute care: Is regionalization the next frontier in sepsis care? J Am Coll Emerg Physicians Open 2022; 3:e12631. [PMID: 35024689 PMCID: PMC8733842 DOI: 10.1002/emp2.12631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
Regionalization has become a buzzword in US health care policy. Regionalization, however, has varied meanings, and definitions have lacked contextual information important to understanding its role in improving care. This concept review is a comprehensive primer and summation of 8 common core components of the national models of regionalization informed by text-based analysis of the writing of involved organizations (professional, regulatory, and research) guided by semistructured interviews with organizational leaders. Further, this generalized model of regionalized care is applied to sepsis care, a novel discussion, drawing on existing small-scale applications. This discussion highlights the fit of regionalization principles to the sepsis care model and the actualized and perceived potential benefits. The principal aim of this concept review is to outline regionalization in the United States and provide a roadmap and novel discussion of regionalized care integration for sepsis care.
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Affiliation(s)
| | - Nicholas M. Mohr
- Departments of Emergency Medicine, Anesthesia‐Critical Care Medicine, and EpidemiologyUniversity of Iowa–Carver College of MedicineIowa CityIowaUSA
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28
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Impact of 1-hour and 3-hour sepsis time bundles on patient outcomes and antimicrobial use: A before and after cohort study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 18:100305. [PMID: 35024649 PMCID: PMC8654968 DOI: 10.1016/j.lanwpc.2021.100305] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/03/2021] [Accepted: 09/28/2021] [Indexed: 12/24/2022]
Abstract
Background Sepsis bundles, promulgated by Surviving Sepsis Campaign have not been widely adopted because of variability in sepsis identification strategies, implementation challenges, concerns about excess antimicrobial use, and limited evidence of benefit. Methods A 1-hour septic shock and a 3-hour sepsis bundle were implemented using a Breakthrough Series Collaborative in 14 public hospitals in Queensland, Australia. A before (baseline) and after (post-intervention) study evaluated its impact on outcomes and antimicrobial prescription in patients with confirmed bacteremia and sepsis. Findings Between 01 July 2017 to 31 March 2020, of 6976 adults presenting to the Emergency Departments and had a blood culture taken, 1802 patients (732 baseline, 1070 post-intervention) met inclusion criteria. Time to antibiotics in 1-hour 73.7% vs 85.1% (OR 1.9 [95%CI 1.1-3.6]) and the 3-hour bundle compliance (48.2% to 63.3%, OR 1.7, [95%CI 1.4 to 2.1]) improved post-intervention, accompanied by a significant reduction in Intensive Care Unit (ICU) admission rates (26.5% vs 17.5% (OR 0.5, [95%CI 0.4 to 0.7]). There were no significant differences in-hospital and 30-day post discharge mortality between the two phases. In a post-hoc analysis of the post-intervention phase, sepsis pathway compliance was associated with lower in-hospital mortality (9.7% vs 14.9%, OR 0.6, 95%CI 0.4 to 0.8). The proportions of appropriate antimicrobial prescription at baseline and post-intervention respectively were 55.4% vs 64.1%, (OR 1.4 [95%CI 0.9 to 2.1]). Interpretation Implementing 1-hour and 3-hour sepsis bundles for patients presenting with bacteremia resulted in improved bundle compliance and a reduced need for ICU admission without adversely influencing antimicrobial prescription.
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29
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Patient Heterogeneity and the J-Curve Relationship Between Time-to-Antibiotics and the Outcomes of Patients Admitted With Bacterial Infection. Crit Care Med 2021; 50:799-809. [PMID: 34974496 DOI: 10.1097/ccm.0000000000005429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Sepsis remains a leading and preventable cause of hospital utilization and mortality in the United States. Despite updated guidelines, the optimal definition of sepsis as well as optimal timing of bundled treatment remain uncertain. Identifying patients with infection who benefit from early treatment is a necessary step for tailored interventions. In this study, we aimed to illustrate clinical predictors of time-to-antibiotics among patients with severe bacterial infection and model the effect of delay on risk-adjusted outcomes across different sepsis definitions. DESIGN A multicenter retrospective observational study. SETTING A seven-hospital network including academic tertiary care center. PATIENTS Eighteen-thousand three-hundred fifteen patients admitted with severe bacterial illness with or without sepsis by either acute organ dysfunction (AOD) or systemic inflammatory response syndrome positivity. MEASUREMENTS AND MAIN RESULTS The primary exposure was time to antibiotics. We identified patient predictors of time-to-antibiotics including demographics, chronic diagnoses, vitals, and laboratory results and determined the impact of delay on a composite of inhospital death or length of stay over 10 days. Distribution of time-to-antibiotics was similar across patients with and without sepsis. For all patients, a J-curve relationship between time-to-antibiotics and outcomes was observed, primarily driven by length of stay among patients without AOD. Patient characteristics provided good to excellent prediction of time-to-antibiotics irrespective of the presence of sepsis. Reduced time-to-antibiotics was associated with improved outcomes for all time points beyond 2.5 hours from presentation across sepsis definitions. CONCLUSIONS Antibiotic timing is a function of patient factors regardless of sepsis criteria. Similarly, we show that early administration of antibiotics is associated with improved outcomes in all patients with severe bacterial illness. Our findings suggest identifying infection is a rate-limiting and actionable step that can improve outcomes in septic and nonseptic patients.
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30
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Sepsis Among Medicare Beneficiaries: 4. Precoronavirus Disease 2019 Update January 2012-February 2020. Crit Care Med 2021; 49:2058-2069. [PMID: 34582410 PMCID: PMC8594514 DOI: 10.1097/ccm.0000000000005332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVES To provide updated information on the burdens of sepsis during acute inpatient admissions for Medicare beneficiaries. DESIGN Analysis of paid Medicare claims via the Centers for Medicare and Medicaid Services DataLink Project. SETTING All U.S. acute-care hospitals, excluding federally operated hospitals (Veterans Administration and Defense Health Agency). PATIENTS All Medicare beneficiaries, January 2012-February 2020, with an explicit sepsis diagnostic code assigned during an inpatient admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The count of Medicare Part A/B (fee-for-service) plus Medicare Advantage inpatient sepsis admissions rose from 981,027 (CY2012) to 1,700,433 (CY 2019). The proportion of total admissions with sepsis in the Medicare Advantage population rose from 21.43% to 35.39%, reflecting the increasing beneficiary proportion enrolled in Medicare Advantage. In CY2019, 6-month mortality rates in Medicare fee-for-service beneficiaries for sepsis continued to decline, but remained high: 59.9% for septic shock, 35.5% for severe sepsis, 30.8% for sepsis attributed to a specific organism, and 26.5% for unspecified sepsis. Total fee-for-service-only inpatient hospital costs rose from $17.79B (CY2012) to $22.98B (CY2019). We estimated that the aggregate cost of sepsis hospital care for the entire U.S. population was at least $57.47B in 2019. Inclusion of 14 months' (January 2019-February 2020) newer data exposed new trends: the cost per patient, number of admissions, and fraction of patients with sepsis labeled as present on admission inflected around November 2015, coincident with the change to International Classification of Diseases, 10th Edition, and introduction of the Severe Sepsis and Septic Shock Management Bundle (SEP-1) metric. CONCLUSIONS Sepsis among Medicare beneficiaries precoronavirus disease 2019 imposed immense burdens upon patients, their families, and the taxpayers.
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31
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Rhee C, Yu T, Wang R, Kadri SS, Fram D, Chen HC, Klompas M. Association Between Implementation of the Severe Sepsis and Septic Shock Early Management Bundle Performance Measure and Outcomes in Patients With Suspected Sepsis in US Hospitals. JAMA Netw Open 2021; 4:e2138596. [PMID: 34928358 PMCID: PMC8689388 DOI: 10.1001/jamanetworkopen.2021.38596] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE In October 2015, the Centers for Medicare & Medicaid Services began requiring US hospitals to report adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). OBJECTIVE To evaluate the association of SEP-1 implementation with sepsis treatment patterns and outcomes in diverse hospitals. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study with interrupted time-series analysis and logistic regression models was conducted among adults admitted to 114 hospitals from October 2013 to December 2017 with suspected sepsis (blood culture orders, ≥2 systemic inflammatory response syndrome criteria, and acute organ dysfunction) within 24 hours of hospital arrival. Data analysis was conducted from September 2020 to September 2021. EXPOSURES SEP-1 implementation in the fourth quarter (Q4) of 2015. MAIN OUTCOMES AND MEASURES The primary outcome was quarterly rates of risk-adjusted short-term mortality (in-hospital death or discharge to hospice). Secondary outcomes included lactate testing and administration of anti-methicillin-resistant Staphylococcus aureus (MRSA) or antipseudomonal β-lactam antibiotics within 24 hours of hospital arrival. Generalized estimating equations with robust sandwich variances were used to fit logistic regression models to assess for changes in level or trends in these outcomes, adjusting for baseline characteristics and severity of illness. RESULTS The cohort included 117 510 patients (median [IQR] age, 67 years [55-78] years; 60 530 [51.5%] men and 56 980 [48.5%] women) with suspected sepsis. Lactate testing rates increased from 55.1% (95% CI, 53.9%-56.2%) in Q4 of 2013 to 76.7% (95% CI, 75.4%-78.0%) in Q4 of 2017, with a significant level change following SEP-1 implementation (odds ratio [OR], 1.34; 95% CI, 1.04-1.74). There were increases in use of anti-MRSA antibiotics (19.8% [95% CI, 18.9%-20.7%] in Q4 of 2013 to 26.3% [95% CI, 24.9%-27.7%] in Q4 of 2017) and antipseudomonal antibiotics (27.7% [95% CI, 26.7%-28.8%] in Q4 of 2013 to 40.5% [95% CI, 38.9%-42.0%] in Q4 of 2017), but these trends preceded SEP-1 and did not change with SEP-1 implementation. Unadjusted short-term mortality rates were similar in the pre-SEP-1 period (Q4 of 2013 through Q3 of 2015) vs the post-SEP-1 period (Q1 of 2016 through Q4 of 2017) (20.3% [95% CI, 20.0%-20.6%] vs 20.4% [95% CI, 20.1%-20.7%]), and SEP-1 implementation was not associated with changes in level (OR, 0.94; 95% CI, 0.68-1.29) or trend (OR, 1.00; 95% CI, 0.97-1.04) for risk-adjusted short-term mortality rates. CONCLUSIONS AND RELEVANCE In this cohort study, SEP-1 implementation was associated with an immediate increase in lactate testing rates, no change in already-increasing rates of broad-spectrum antibiotic use, and no change in short-term mortality rates for patients with suspected sepsis. Other approaches to decrease sepsis mortality may be warranted.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Tingting Yu
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Rui Wang
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Sameer S. Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - David Fram
- Commonwealth Informatics, Waltham, Massachusetts
| | | | - Michael Klompas
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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32
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Alrawashdeh M, Klompas M, Kimmel S, Larochelle MR, Gokhale RH, Dantes RB, Hoots B, Hatfield KM, Reddy SC, Fiore AE, Septimus EJ, Kadri SS, Poland R, Sands K, Rhee C. Epidemiology, Outcomes, and Trends of Patients With Sepsis and Opioid-Related Hospitalizations in U.S. Hospitals. Crit Care Med 2021; 49:2102-2111. [PMID: 34314131 PMCID: PMC8602712 DOI: 10.1097/ccm.0000000000005141] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Widespread use and misuse of prescription and illicit opioids have exposed millions to health risks including serious infectious complications. Little is known, however, about the association between opioid use and sepsis. DESIGN Retrospective cohort study. SETTING About 373 U.S. hospitals. PATIENTS Adults hospitalized between January 2009 and September 2015. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Sepsis was identified by clinical indicators of concurrent infection and organ dysfunction. Opioid-related hospitalizations were identified by the International Classification of Diseases, 9th Revision, Clinical Modification codes and/or inpatient orders for buprenorphine. Clinical characteristics and outcomes were compared by sepsis and opioid-related hospitalization status. The association between opioid-related hospitalization and all-cause, in-hospital mortality in patients with sepsis was assessed using mixed-effects logistic models to adjust for baseline characteristics and severity of illness.The cohort included 6,715,286 hospitalizations; 375,479 (5.6%) had sepsis, 130,399 (1.9%) had opioid-related hospitalizations, and 8,764 (0.1%) had both. Compared with sepsis patients without opioid-related hospitalizations (n = 366,715), sepsis patients with opioid-related hospitalizations (n = 8,764) were younger (mean 52.3 vs 66.9 yr) and healthier (mean Elixhauser score 5.4 vs 10.5), had more bloodstream infections from Gram-positive and fungal pathogens (68.9% vs 47.0% and 10.6% vs 6.4%, respectively), and had lower in-hospital mortality rates (10.6% vs 16.2%; adjusted odds ratio, 0.73; 95% CI, 0.60-0.79; p < 0.001 for all comparisons). Of 1,803 patients with opioid-related hospitalizations who died in-hospital, 928 (51.5%) had sepsis. Opioid-related hospitalizations accounted for 1.5% of all sepsis-associated deaths, including 5.7% of sepsis deaths among patients less than 50 years old. From 2009 to 2015, the proportion of sepsis hospitalizations that were opioid-related increased by 77% (95% CI, 40.7-123.5%). CONCLUSIONS Sepsis is an important cause of morbidity and mortality in patients with opioid-related hospitalizations, and opioid-related hospitalizations contribute disproportionately to sepsis-associated deaths among younger patients. In addition to ongoing efforts to combat the opioid crisis, public health agencies should focus on raising awareness about sepsis among patients who use opioids and their providers.
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Affiliation(s)
- Mohammad Alrawashdeh
- Department of Population Medicine, Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston, MA
- Jordan University of Science and Technology, Jordan
| | - 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
| | - Simeon Kimmel
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Marc R Larochelle
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Runa H. Gokhale
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Raymund B Dantes
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Brooke Hoots
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
- Division of Overdose Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kelly M Hatfield
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Sujan C Reddy
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Anthony E. Fiore
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Edward J Septimus
- Department of Population Medicine, Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston, MA
- Texas A&M College of Medicine, Houston, TX
| | - Sameer S Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Russell Poland
- Clinical Operations Group, HCA Healthcare, Nashville, TN
| | - Kenneth Sands
- Department of Population Medicine, Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston, MA
- Clinical Operations Group, HCA Healthcare, Nashville, TN
| | - 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
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Rodriguez-Homs LG, Masoud SJ, Mosca MJ, Jawitz OK, O'Brien C, Mosca PJ. Greater Compliance With Early Sepsis Management is Associated With Safer Care and Shorter Hospital Stay. J Healthc Qual 2021; 43:347-354. [PMID: 34734919 DOI: 10.1097/jhq.0000000000000295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
ABSTRACT This retrospective, cross-sectional study of U.S. hospitals in Medicare's Inpatient Quality Reporting Program aimed to determine whether variation in Sepsis/Septic Shock (Bundle SEP-1) compliance is linked to hospital size and measures of safety and operational efficiency. Two thousand six hundred and fifty-three acute care hospitals in Medicare's Hospital Compare online database were included in the study. Relationships between SEP-1 bundle compliance, hospital size, and indices of operational excellence (including Patient Safety Index [PSI-90], average length of stay [ALOS] and readmission rate) were analyzed. SEP-1 compliance score was inversely associated with staffed bed number (r = -.14, p < .001), PSI-90 (r = -.01, p < .001), and ALOS (r = -.13, p < .001) in a multivariate analysis. Hospitals in the lowest versus highest quartile by bed number had SEP-1 compliance score of 49.8 ± 20.2% versus 46.9 ± 16.8%, p < .001. Hospitals in the lowest versus highest quartile for SEP-1 score had an ALOS of 5.0 ± 1.2 days versus 4.7 ± 1.1 days and PSI-90 rate of 1.03 ± 0.22 versus 0.98 ± 0.16, p < .001 for both. Although this does not establish a causal relationship, it supports the hypothesis that the ability of hospitals to successfully implement SEP-1 is associated with superior performance in key measures of operational excellence.
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Dellinger RP, Levy MM, Schorr CA, Townsend SR. 50 Years of Sepsis Investigation/Enlightenment Among Adults-The Long and Winding Road. Crit Care Med 2021; 49:1606-1625. [PMID: 34342304 DOI: 10.1097/ccm.0000000000005203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- R Phillip Dellinger
- Cooper Medical School of Rowan University and Cooper University Health, Camden, NJ
| | | | - Christa A Schorr
- Cooper Medical School of Rowan University and Cooper University Health, Camden, NJ
| | - Sean R Townsend
- University of California Pacific Medical Center, (Sutter Health), San Francisco, CA
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Weinberger J, Klompas M, Rhee C. What Is the Utility of Measuring Lactate Levels in Patients with Sepsis and Septic Shock? Semin Respir Crit Care Med 2021; 42:650-661. [PMID: 34544182 DOI: 10.1055/s-0041-1733915] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Elevations in blood lactate concentrations have been studied in sepsis and other disease states for decades and are well known to be associated with increased mortality. Many studies have also demonstrated the prognostic accuracy of serial lactate levels, and some have suggested that lactate clearance may be a useful therapeutic target for resuscitation. Lactate measurements have therefore gained an increasingly prominent role in sepsis definitions, screening protocols, management guidelines, and quality measures over the past two decades. The heavy emphasis on lactate monitoring, however, has also generated controversy and concerns. Lactate is not specific to infection and its frequent use for sepsis screening and diagnosis may therefore trigger unnecessary broad-spectrum antibiotic use in some patients. Because hyperlactatemia does not always reflect fluid-responsive hypoperfusion, titrating resuscitation to lactate clearance can also lead to unnecessary fluid and volume overload. More broadly, there is a lack of high-quality evidence demonstrating that initial and serial lactate monitoring leads to better patient-centered outcomes. Indeed, a recent randomized controlled trial comparing resuscitation strategies based on lactate clearance versus normalizing capillary refill time showed no benefit and potential harm with lactate-guided therapy. In this article, we review the basic pathobiology of lactate metabolism and delineate why the traditional paradigm that hyperlactatemia reflects tissue hypoxia is overly simplistic and incomplete. We then review the evidence behind the diagnostic, prognostic, and therapeutic uses of lactate monitoring and place this in the context of evolving sepsis diagnosis and management guidelines.
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Affiliation(s)
- Jeremy Weinberger
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.,Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Choi S, Son J, Oh DK, Huh JW, Lim CM, Hong SB. Rapid Response System Improves Sepsis Bundle Compliances and Survival in Hospital Wards for 10 Years. J Clin Med 2021; 10:jcm10184244. [PMID: 34575357 PMCID: PMC8466148 DOI: 10.3390/jcm10184244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Hospitalized patients can develop septic shock at any time. Therefore, it is important to identify septic patients in hospital wards and rapidly perform the optimal treatment. Although the sepsis bundle has already been reported to improve survival rates, the controversy over evidence of the effect of in-hospital sepsis continues to exist. We aimed to estimate the outcomes and bundle compliance of patients with septic shock in hospital wards managed through the rapid response system (RRS). METHODS A retrospective cohort study of 976 patients with septic shock managed through the RRS at an academic, tertiary care hospital in Korea from 2008 to 2017. RESULTS Of the 976 enrolled patients, the compliance of each sepsis bundle was high (80.8-100.0%), but the overall success rate of the bundle was low (58.3%). The compliance rate for achieving the overall sepsis bundle increased from 26.5% to 70.0%, and the 28-day mortality continuously decreased from 50% to 32.1% over 10 years. We analyzed the two groups according to whether they completed the overall sepsis bundle or not. Of the 976 enrolled patients, 569 (58.3%) sepsis bundles were completed, whereas 407 (41.7%) were incomplete. The complete bundle group showed lower 28-day mortality than the incomplete bundle group (37.1% vs. 53.6%, p < 0.001). In the multivariate multiple logistic regression model, the 28-day mortality was significantly associated with the complete bundle (adjusted odds ratio (OR), 0.61; 95% confidence intervals (CI), 0.40-0.91; p = 0.017). The obtaining of blood cultures (adjusted OR, 0.45; 95% CI, 0.33-0.63; p < 0.001) and lactate re-measurement (adjusted OR, 0.69; 95% CI, 0.50-0.95; p = 0.024) in each component of the sepsis bundle were associated with the 28-day mortality. CONCLUSIONS The rapid response system provides improving sepsis bundle compliances and survival in patients with septic shock in hospital wards.
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Affiliation(s)
- Sunhui Choi
- Medical Emergency Team, Asan Medical Center, Seoul 05505, Korea; (S.C.); (J.S.)
| | - Jeongsuk Son
- Medical Emergency Team, Asan Medical Center, Seoul 05505, Korea; (S.C.); (J.S.)
| | - Dong Kyu Oh
- Asan Medical Center, Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Seoul 05505, Korea; (D.K.O.); (J.W.H.); (C.-M.L.)
| | - Jin Won Huh
- Asan Medical Center, Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Seoul 05505, Korea; (D.K.O.); (J.W.H.); (C.-M.L.)
| | - Chae-Man Lim
- Asan Medical Center, Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Seoul 05505, Korea; (D.K.O.); (J.W.H.); (C.-M.L.)
| | - Sang-Bum Hong
- Asan Medical Center, Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Seoul 05505, Korea; (D.K.O.); (J.W.H.); (C.-M.L.)
- Correspondence: ; Tel.: +82-2-20454039
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Bauer SR, Han X, Wang XF, Reddy AJ. Response. Chest 2021; 159:878-879. [PMID: 33563439 DOI: 10.1016/j.chest.2020.09.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Seth R Bauer
- Department of Pharmacy, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Xiaozhen Han
- Department of Quantitative Health Sciences, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Xiao-Feng Wang
- Department of Quantitative Health Sciences, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Anita J Reddy
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH.
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Schlapbach LJ, Reinhart K, Kissoon N. A pediatric perspective on World Sepsis Day in 2021: leveraging lessons from the pandemic to reduce the global pediatric sepsis burden? Am J Physiol Lung Cell Mol Physiol 2021; 321:L608-L613. [PMID: 34405733 PMCID: PMC8461799 DOI: 10.1152/ajplung.00331.2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 12/29/2022] Open
Affiliation(s)
- Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland and Queensland Children's Hospital, Brisbane, Queensland, Australia
- Department of Intensive Care Medicine and Neonatology, and Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Konrad Reinhart
- Intensive Care Unit, Charité Universitätsmedizin, Berlin, Germany
| | - Niranjan Kissoon
- Intensive Care Unit, Charité Universitätsmedizin, Berlin, Germany
- The Centre for International Child Health, University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia, Canada
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Abstract
OBJECTIVES Assess the impact of heterogeneity among established sepsis criteria (Sepsis-1, Sepsis-3, Centers for Disease Control and Prevention Adult Sepsis Event, and Centers for Medicare and Medicaid severe sepsis core measure 1) through the comparison of corresponding sepsis cohorts. DESIGN Retrospective analysis of data extracted from electronic health record. SETTING Single, tertiary-care center in St. Louis, MO. PATIENTS Adult, nonsurgical inpatients admitted between January 1, 2012, and January 6, 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In the electronic health record data, 286,759 encounters met inclusion criteria across the study period. Application of established sepsis criteria yielded cohorts varying in prevalence: Centers for Disease Control and Prevention Adult Sepsis Event (4.4%), Centers for Medicare and Medicaid severe sepsis core measure 1 (4.8%), International Classification of Disease code (7.2%), Sepsis-3 (7.5%), and Sepsis-1 (11.3%). Between the two modern established criteria, Sepsis-3 (n = 21,550) and Centers for Disease Control and Prevention Adult Sepsis Event (n = 12,494), the size of the overlap was 7,763. The sepsis cohorts also varied in time from admission to sepsis onset (hr): Sepsis-1 (2.9), Sepsis-3 (4.1), Centers for Disease Control and Prevention Adult Sepsis Event (4.6), and Centers for Medicare and Medicaid severe sepsis core measure 1 (7.6); sepsis discharge International Classification of Disease code rate: Sepsis-1 (37.4%), Sepsis-3 (40.1%), Centers for Medicare and Medicaid severe sepsis core measure 1 (48.5%), and Centers for Disease Control and Prevention Adult Sepsis Event (54.5%); and inhospital mortality rate: Sepsis-1 (13.6%), Sepsis-3 (18.8%), International Classification of Disease code (20.4%), Centers for Medicare and Medicaid severe sepsis core measure 1 (22.5%), and Centers for Disease Control and Prevention Adult Sepsis Event (24.1%). CONCLUSIONS The application of commonly used sepsis definitions on a single population produced sepsis cohorts with low agreement, significantly different baseline demographics, and clinical outcomes.
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Townsend SR, Phillips GS, Duseja R, Tefera L, Cruikshank D, Dickerson R, Nguyen HB, Schorr CA, Levy MM, Dellinger RP, Conway WA, Browner WS, Rivers EP. Effects of Compliance with the Early Management Bundle (SEP-1) on Mortality Changes among Medicare Beneficiaries with Sepsis: A Propensity Score Matched Cohort Study. Chest 2021; 161:392-406. [PMID: 34364867 DOI: 10.1016/j.chest.2021.07.2167] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/06/2021] [Accepted: 07/19/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND U.S. hospitals have reported compliance with the SEP-1 quality measure to Medicare since 2015. Finding an association between compliance and outcomes is essential to gauge measure effectiveness. RESEARCH QUESTION What is the association between compliance with SEP-1 and 30-day mortality among Medicare beneficiaries? STUDY DESIGN AND METHODS Studying patient-level data reported to Medicare by 3,241 hospitals from October 1, 2015 to March 31, 2017, we used propensity score matching and a hierarchical general linear model (HGLM) to estimate the treatment effects associated with compliance with SEP-1. Compliance was defined as completion of all qualifying SEP-1 elements including lactate measurements, blood culture collection, broad-spectrum antibiotic administration, 30 ml/kg crystalloid fluid administration, application of vasopressors, and patient reassessment. The primary outcome was a change in 30-day mortality. Secondary outcomes included changes in length-of-stay. RESULTS We completed two matches to evaluate population-level treatment effects. In "Standard-match" 122,870 patients whose care was compliant were matched with the same number whose care was non-compliant. Compliance was associated with a reduction in 30-day mortality: 21.81% versus 27.48% yielding an ARR of 5.67% (95% confidence interval [CI]: 5.33-6.00; P < 0.001). In "Stringent-match" 107,016 patients whose care was compliant were matched with the same number whose care was non-compliant. Compliance was associated with a reduction in 30-day mortality: 22.22% versus 26.28% yielding an ARR of 4.06% (95% CI: 3.70-4.41; P < 0.001). At the subject-level, our HGLM model found compliance associated with lower 30-day risk-adjusted mortality (adjusted conditional odds ratio = 0.829; 95% CI: 0.812-0.846; P < 0001). Multiple elements correlated with lower mortality. Median length-of-stay was shorter among cases whose care was compliant (5 vs. 6 days; IQR: 3-9 vs. 4-10; P < 0.001). INTERPRETATION Compliance with SEP-1 was associated with lower 30-day mortality. Rendering SEP-1 compliant care may reduce the incidence of avoidable deaths.
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Affiliation(s)
- Sean R Townsend
- Division of Pulmonary, Critical Care Medicine, California Pacific Medical Center, San Francisco, CA; Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA.
| | - Gary S Phillips
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH
| | - Reena Duseja
- Center for Clinical Standards and Quality, Centers for Medicare and Medicaid Services, Baltimore, MD
| | - Lemeneh Tefera
- Department of Emergency Medicine, Alameda Health System, Oakland, CA
| | | | | | - H Bryant Nguyen
- Division of Pulmonary, Critical Care, Hyperbaric, Allergy and Sleep Medicine, Loma Linda University, Loma Linda, CA
| | | | - Mitchell M Levy
- Division of Pulmonary, Critical Care and Sleep Medicine, Rhode Island Hospital, Providence, RI; Warren Alpert School of Medicine at Brown University, Providence, RI
| | | | - William A Conway
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI; Wayne State University, Detroit, MI
| | - Warren S Browner
- California Pacific Medical Center Research Institute, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | - Emanuel P Rivers
- Wayne State University, Detroit, MI; Department of Emergency Medicine and Surgery, Henry Ford Hospital, Detroit, MI
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Liengsawangwong R, Kumar S, Ortiz RA, Hill J. HEALTH INFORMATICS TOOL TOWARD SEPSIS SCREENING. PERSPECTIVES IN HEALTH INFORMATION MANAGEMENT 2021; 18:1g. [PMID: 34858119 PMCID: PMC8580458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
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Barbash IJ, Davis BS, Yabes JG, Seymour CW, Angus DC, Kahn JM. Treatment Patterns and Clinical Outcomes After the Introduction of the Medicare Sepsis Performance Measure (SEP-1). Ann Intern Med 2021; 174:927-935. [PMID: 33872042 PMCID: PMC8844885 DOI: 10.7326/m20-5043] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Medicare requires that hospitals report on their adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). OBJECTIVE To evaluate the effect of SEP-1 on treatment patterns and patient outcomes. DESIGN Longitudinal study of hospitals using repeated cross-sectional cohorts of patients. SETTING 11 hospitals within an integrated health system. PATIENTS 54 225 encounters between January 2013 and December 2017 for adults with sepsis who were hospitalized through the emergency department. INTERVENTION Onset of the SEP-1 reporting requirement in October 2015. MEASUREMENTS Changes in SEP-1-targeted processes, including antibiotic administration, lactate measurement, and fluid administration at 3 hours from sepsis onset; repeated lactate and vasopressor administration for hypotension within 6 hours of sepsis onset; and sepsis outcomes, including risk-adjusted intensive care unit (ICU) admission, in-hospital mortality, and home discharge among survivors. RESULTS Two years after its implementation, SEP-1 was associated with variable changes in process measures, with the greatest effect being an increase in lactate measurement within 3 hours of sepsis onset (absolute increase, 23.7 percentage points [95% CI, 20.7 to 26.7 percentage points]; P < 0.001). There were small increases in antibiotic administration (absolute increase, 4.7 percentage points [CI, 1.9 to 7.6 percentage points]; P = 0.001) and fluid administration of 30 mL/kg of body weight within 3 hours of sepsis onset (absolute increase, 3.4 percentage points [CI, 1.5 to 5.2 percentage points]; P < 0.001). There was no change in vasopressor administration. There was a small increase in ICU admissions (absolute increase, 2.0 percentage points [CI, 0 to 4.0 percentage points]; P = 0.055) and no changes in mortality (absolute change, 0.1 percentage points [CI, -0.9 to 1.1 percentage points]; P = 0.87) or discharge to home. LIMITATION Data are from a single health system. CONCLUSION Implementation of the SEP-1 mandatory reporting program was associated with variable changes in process measures, without improvements in clinical outcomes. Revising the measure may optimize its future effect. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Affiliation(s)
- Ian J Barbash
- University of Pittsburgh School of Medicine and UPMC Health System, Pittsburgh, Pennsylvania (I.J.B., C.W.S.)
| | - Billie S Davis
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (B.S.D., J.G.Y.)
| | - Jonathan G Yabes
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (B.S.D., J.G.Y.)
| | - Chris W Seymour
- University of Pittsburgh School of Medicine and UPMC Health System, Pittsburgh, Pennsylvania (I.J.B., C.W.S.)
| | - Derek C Angus
- University of Pittsburgh School of Medicine, University of Pittsburgh Graduate School of Public Health, and UPMC Health System, Pittsburgh, Pennsylvania (D.C.A., J.M.K.)
| | - Jeremy M Kahn
- University of Pittsburgh School of Medicine, University of Pittsburgh Graduate School of Public Health, and UPMC Health System, Pittsburgh, Pennsylvania (D.C.A., J.M.K.)
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Lee AHY, Aaronson E, Hibbert KA, Flynn MH, Rutkey H, Mort E, Sonis JD, Safavi KC. Design and Implementation of a Real-time Monitoring Platform for Optimal Sepsis Care in an Emergency Department: Observational Cohort Study. J Med Internet Res 2021; 23:e26946. [PMID: 34185009 PMCID: PMC8277370 DOI: 10.2196/26946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/14/2021] [Accepted: 04/30/2021] [Indexed: 11/19/2022] Open
Abstract
Background Sepsis is the leading cause of death in US hospitals. Compliance with bundled care, specifically serial lactates, blood cultures, and antibiotics, improves outcomes but is often delayed or missed altogether in a busy practice environment. Objective This study aims to design, implement, and validate a novel monitoring and alerting platform that provides real-time feedback to frontline emergency department (ED) providers regarding adherence to bundled care. Methods This single-center, prospective, observational study was conducted in three phases: the design and technical development phase to build an initial version of the platform; the pilot phase to test and refine the platform in the clinical setting; and the postpilot rollout phase to fully implement the study intervention. Results During the design and technical development, study team members and stakeholders identified the criteria for patient inclusion, selected bundle measures from the Center for Medicare and Medicaid Sepsis Core Measure for alerting, and defined alert thresholds, message content, delivery mechanisms, and recipients. Additional refinements were made based on 70 provider survey results during the pilot phase, including removing alerts for vasopressor initiation and modifying text in the pages to facilitate patient identification. During the 48 days of the postpilot rollout phase, 15,770 ED encounters were tracked and 711 patient encounters were included in the active monitoring cohort. In total, 634 pages were sent at a rate of 0.98 per attending physician shift. Overall, 38.3% (272/711) patients had at least one page. The missing bundle elements that triggered alerts included: antibiotics 41.6% (136/327), repeat lactate 32.4% (106/327), blood cultures 20.8% (68/327), and initial lactate 5.2% (17/327). Of the missing Sepsis Core Measures elements for which a page was sent, 38.2% (125/327) were successfully completed on time. Conclusions A real-time sepsis care monitoring and alerting platform was created for the ED environment. The high proportion of patients with at least one alert suggested the significant potential for such a platform to improve care, whereas the overall number of alerts per clinician suggested a low risk of alarm fatigue. The study intervention warrants a more rigorous evaluation to ensure that the added alerts lead to better outcomes for patients with sepsis.
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Affiliation(s)
- Andy Hung-Yi Lee
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Emily Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Kathryn A Hibbert
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Micah H Flynn
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Hayley Rutkey
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Elizabeth Mort
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Jonathan D Sonis
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Kyan C Safavi
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
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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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Peled H, Dau NQ, Schoepflin Sanders S. Modify Centers for Medicare & Medicaid Services' Sepsis Core Measure (SEP-1) Now to Optimize Care for COVID-19. Ann Intern Med 2021; 174:860-861. [PMID: 33587685 PMCID: PMC7888050 DOI: 10.7326/m20-8266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
In the commentary, the authors urge the Centers for Medicare & Medicaid Services to remove lactate measurement from the national Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) during the COVID-19 crisis.
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Affiliation(s)
- Harry Peled
- Providence St. Jude Medical Center, Fullerton, California (H.P.)
| | - Nhu Quyen Dau
- Marshall B. Ketchum University College of Pharmacy, Fullerton, California (N.Q.D.)
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Chiotos K, Weiss SL. A Wrinkle in Time to Antibiotics in Sepsis: When Should ONE Hour Be the Goal? J Pediatr 2021; 233:13-15. [PMID: 33545195 DOI: 10.1016/j.jpeds.2021.01.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 01/29/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Kathleen Chiotos
- Division of Critical Care Medicine; Division of Infectious Diseases, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine; Pediatric Sepsis Program, Children's Hospital of Philadelphia; Antimicrobial Stewardship Program, Children's Hospital of Philadelphia
| | - Scott L Weiss
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine; Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
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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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Rhee C, Chiotos K, Cosgrove SE, Heil EL, Kadri SS, Kalil AC, Gilbert DN, Masur H, Septimus EJ, Sweeney DA, Strich JR, Winslow DL, Klompas M. Infectious Diseases Society of America Position Paper: Recommended Revisions to the National Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) Sepsis Quality Measure. Clin Infect Dis 2021; 72:541-552. [PMID: 32374861 DOI: 10.1093/cid/ciaa059] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/20/2020] [Indexed: 12/18/2022] Open
Abstract
The Centers for Medicare & Medicaid Services' Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) measure has appropriately established sepsis as a national priority. However, the Infectious Diseases Society of America (IDSA and five additional endorsing societies) is concerned about SEP-1's potential to drive antibiotic overuse because it does not account for the high rate of sepsis overdiagnosis and encourages aggressive antibiotics for all patients with possible sepsis, regardless of the certainty of diagnosis or severity of illness. IDSA is also concerned that SEP-1's complex "time zero" definition is not evidence-based and is prone to inter-observer variation. In this position paper, IDSA outlines several recommendations aimed at reducing the risk of unintended consequences of SEP-1 while maintaining focus on its evidence-based elements. IDSA's core recommendation is to limit SEP-1 to septic shock, for which the evidence supporting the benefit of immediate antibiotics is greatest. Prompt empiric antibiotics are often appropriate for suspected sepsis without shock, but IDSA believes there is too much heterogeneity and difficulty defining this population, uncertainty about the presence of infection, and insufficient data on the necessity of immediate antibiotics to support a mandatory treatment standard for all patients in this category. IDSA believes guidance on managing possible sepsis without shock is more appropriate for guidelines that can delineate the strengths and limitations of supporting evidence and allow clinicians discretion in applying specific recommendations to individual patients. Removing sepsis without shock from SEP-1 will mitigate the risk of unnecessary antibiotic prescribing for noninfectious syndromes, simplify data abstraction, increase measure reliability, and focus attention on the population most likely to benefit from immediate empiric broad-spectrum antibiotics.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kathleen Chiotos
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sameer S Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska School of Medicine, Omaha, Nebraska, USA
| | - David N Gilbert
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Henry Masur
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Edward J Septimus
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Internal Medicine, Texas A&M College of Medicine, Houston, Texas, USA
| | - Daniel A Sweeney
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Diego School of Medicine, San Diego, California, USA
| | - Jeffrey R Strich
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Dean L Winslow
- Division of Infectious Diseases, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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49
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Pakyz AL, Orndahl CM, Johns A, Harless DW, Morgan DJ, Bearman G, Hohmann SF, Stevens MP. Impact of the Centers for Medicare and Medicaid Services Sepsis Core Measure on Antibiotic Use. Clin Infect Dis 2021; 72:556-565. [PMID: 32827032 DOI: 10.1093/cid/ciaa456] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 07/28/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services (CMS) implemented a core measure sepsis (SEP-1) bundle in 2015. One element was initiation of broad-spectrum antibiotics within 3 hours of diagnosis. The policy has the potential to increase antibiotic use and Clostridioides difficile infection (CDI). We evaluated the impact of SEP-1 implementation on broad-spectrum antibiotic use and CDI occurrence rates. METHODS Monthly adult antibiotic data for 4 antibiotic categories (surgical prophylaxis, broad-spectrum for community-acquired infections, broad-spectrum for hospital-onset/multidrug-resistant [MDR] organisms, and anti-methicillin-resistant Staphylococcus aureus [MRSA]) from 111 hospitals participating in the Clinical Data Base Resource Manager were evaluated in periods before (October 2014-September 2015) and after (October 2015-June 2017) policy implementation. Interrupted time series analyses, using negative binomial regression, evaluated changes in antibiotic category use and CDI rates. RESULTS At the hospital level, there was an immediate increase in the level of broad-spectrum agents for hospital-onset/MDR organisms (+2.3%, P = .0375) as well as a long-term increase in trend (+0.4% per month, P = .0273). There was also an immediate increase in level of overall antibiotic use (+1.4%, P = .0293). CDI rates unexpectedly decreased at the time of SEP-1 implementation. When analyses were limited to patients with sepsis, there was a significant level increase in use of all antibiotic categories at the time of SEP-1 implementation. CONCLUSIONS SEP-1 implementation was associated with immediate and long-term increases in broad-spectrum hospital-onset/MDR organism antibiotics. Antimicrobial stewardship programs should evaluate sepsis treatment for opportunities to de-escalate broad therapy as indicated.
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Affiliation(s)
- Amy L Pakyz
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - Christine M Orndahl
- Department of Biostatistics, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Alicia Johns
- Department of Biostatistics, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - David W Harless
- Department of Economics, Virginia Commonwealth University School of Business, Richmond, Virginia, USA
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Veterans Affairs Maryland Healthcare System, Baltimore, Maryland, USA
| | - Gonzalo Bearman
- Department of Hospital Epidemiology and Infection Control, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Samuel F Hohmann
- Vizient, Inc, Chicago, Illinois, USA.,Department of Health Systems Management, Rush University, Chicago, Illinois, USA
| | - Michael P Stevens
- Department of Hospital Epidemiology and Infection Control, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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50
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Fabre V, Sharara SL, Salinas AB, Carroll KC, Desai S, Cosgrove SE. Does This Patient Need Blood Cultures? A Scoping Review of Indications for Blood Cultures in Adult Nonneutropenic Inpatients. Clin Infect Dis 2021; 71:1339-1347. [PMID: 31942949 DOI: 10.1093/cid/ciaa039] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/13/2020] [Indexed: 12/15/2022] Open
Abstract
Guidance regarding indications for initial or follow-up blood cultures is limited. We conducted a scoping review of articles published between January 2004 and June 2019 that reported the yield of blood cultures and/or their impact in the clinical management of fever and common infectious syndromes in nonneutropenic adult inpatients. A total of 2893 articles were screened; 50 were included. Based on the reported incidence of bacteremia, syndromes were categorized into low, moderate, and high pretest probability of bacteremia. Routine blood cultures are recommended in syndromes with a high likelihood of bacteremia (eg, endovascular infections) and those with moderate likelihood when cultures from the primary source of infection are unavailable or when prompt initiation of antibiotics is needed prior to obtaining primary source cultures. In syndromes where blood cultures are low-yield, blood cultures can be considered for patients at risk of adverse events if a bacteremia is missed (eg, patient with pacemaker and severe purulent cellulitis). If a patient has adequate source control and risk factors or concern for endovascular infection are not present, most streptococci or Enterobacterales bacteremias do not require routine follow-up blood cultures.
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Affiliation(s)
- Valeria Fabre
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sima L Sharara
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alejandra B Salinas
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karen C Carroll
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sanjay Desai
- Department of Medicine, Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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