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van Staa TP, Pate A, Martin GP, Sharma A, Dark P, Felton T, Zhong X, Bladon S, Cunningham N, Gilham EL, Brown CS, Mirfenderesky M, Palin V, Ashiru-Oredope D. Sepsis and case fatality rates and associations with deprivation, ethnicity, and clinical characteristics: population-based case-control study with linked primary care and hospital data in England. Infection 2024; 52:1469-1479. [PMID: 38627354 PMCID: PMC11288984 DOI: 10.1007/s15010-024-02235-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/12/2024] [Indexed: 08/02/2024]
Abstract
PURPOSE Sepsis is a life-threatening organ dysfunction caused by dysregulated host response to infection. The purpose of the study was to measure the associations of specific exposures (deprivation, ethnicity, and clinical characteristics) with incident sepsis and case fatality. METHODS Two research databases in England were used including anonymized patient-level records from primary care linked to hospital admission, death certificate, and small-area deprivation. Sepsis cases aged 65-100 years were matched to up to six controls. Predictors for sepsis (including 60 clinical conditions) were evaluated using logistic and random forest models; case fatality rates were analyzed using logistic models. RESULTS 108,317 community-acquired sepsis cases were analyzed. Severe frailty was strongly associated with the risk of developing sepsis (crude odds ratio [OR] 14.93; 95% confidence interval [CI] 14.37-15.52). The quintile with most deprived patients showed an increased sepsis risk (crude OR 1.48; 95% CI 1.45-1.51) compared to least deprived quintile. Strong predictors for sepsis included antibiotic exposure in prior 2 months, being house bound, having cancer, learning disability, and diabetes mellitus. Severely frail patients had a case fatality rate of 42.0% compared to 24.0% in non-frail patients (adjusted OR 1.53; 95% CI 1.41-1.65). Sepsis cases with recent prior antibiotic exposure died less frequently compared to non-users (adjusted OR 0.7; 95% CI 0.72-0.76). Case fatality strongly decreased over calendar time. CONCLUSION Given the variety of predictors and their level of associations for developing sepsis, there is a need for prediction models for risk of developing sepsis that can help to target preventative antibiotic therapy.
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Affiliation(s)
- Tjeerd Pieter van Staa
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, Vaughan House, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK.
| | - Alexander Pate
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, Vaughan House, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Glen P Martin
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, Vaughan House, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Anita Sharma
- Chadderton South Health Centre, Eaves Lane, Chadderton, Oldham, OL9 8RG, UK
| | - Paul Dark
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Tim Felton
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Intensive Care Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Xiaomin Zhong
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, Vaughan House, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Sian Bladon
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, Vaughan House, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Neil Cunningham
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London, SW1P 3JR, UK
| | - Ellie L Gilham
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London, SW1P 3JR, UK
| | - Colin S Brown
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London, SW1P 3JR, UK
- NIHR Health Protection Unit in Healthcare-Associated Infection & Antimicrobial Resistance, Imperial College London, London, UK
| | - Mariyam Mirfenderesky
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London, SW1P 3JR, UK
| | - Victoria Palin
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, Vaughan House, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, The University of Manchester, Manchester, M13 9WL, UK
| | - Diane Ashiru-Oredope
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London, SW1P 3JR, UK
- School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK
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Sankaran R, Gulseren B, Prescott HC, Langa KM, Nguyen T, Ryan AM. Identifying Sources of Inter-Hospital Variation in Episode Spending for Sepsis Care. Med Care 2024; 62:441-448. [PMID: 38625015 PMCID: PMC11161310 DOI: 10.1097/mlr.0000000000002000] [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: 04/17/2024]
Abstract
OBJECTIVE To evaluate inter-hospital variation in 90-day total episode spending for sepsis, estimate the relative contributions of each component of spending, and identify drivers of spending across the distribution of episode spending on sepsis care. DATA SOURCES/STUDY SETTING Medicare fee-for-service claims for beneficiaries (n=324,694) discharged from acute care hospitals for sepsis, defined by MS-DRG, between October 2014 and September 2018. RESEARCH DESIGN Multiple linear regression with hospital-level fixed effects was used to identify average hospital differences in 90-day episode spending. Separate multiple linear regression and quantile regression models were used to evaluate drivers of spending across the episode spending distribution. RESULTS The mean total episode spending among hospitals in the most expensive quartile was $30,500 compared with $23,150 for the least expensive hospitals ( P <0.001). Postacute care spending among the most expensive hospitals was almost double that of least expensive hospitals ($7,045 vs. $3,742), accounting for 51% of the total difference in episode spending between the most expensive and least expensive hospitals. Female patients, patients with more comorbidities, urban hospitals, and BPCI-A-participating hospitals were associated with significantly increased episode spending, with the effect increasing at the right tail of the spending distribution. CONCLUSION Inter-hospital variation in 90-day episode spending on sepsis care is driven primarily by differences in post-acute care spending.
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Affiliation(s)
- Roshun Sankaran
- Department of Radiology, University of California San Diego, San Diego, CA
| | - Baris Gulseren
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
- Center for Evaluating Health Reform, University of Michigan, Ann Arbor, MI
| | - Hallie C. Prescott
- Michigan Medicine, Division of Pulmonary and Critical Care Medicine, Ann Arbor, MI
| | - Kenneth M. Langa
- Michigan Medicine, Department of Internal Medicine, Ann Arbor, MI
| | - Thuy Nguyen
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
- Center for Evaluating Health Reform, University of Michigan, Ann Arbor, MI
| | - Andew M Ryan
- Center for Health Policy, Department of Health Services, Policy, and Practice, Brown University, Providence, RI
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Takahashi N, Imaeda T, Oami T, Abe T, Shime N, Komiya K, Kawamura H, Yamao Y, Fushimi K, Nakada TA. Incidence and mortality of community-acquired and nosocomial infections in Japan: a nationwide medical claims database study. BMC Infect Dis 2024; 24:518. [PMID: 38783190 PMCID: PMC11112762 DOI: 10.1186/s12879-024-09353-6] [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] [Received: 12/20/2023] [Accepted: 04/26/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND It is important to determine the prevalence and prognosis of community-acquired infection (CAI) and nosocomial infection (NI) to develop treatment strategies and appropriate medical policies in aging society. METHODS Patients hospitalized between January 2010 and December 2019, for whom culture tests were performed and antibiotics were administered, were selected using a national claims-based database. The annual trends in incidence and in-hospital mortality were calculated and evaluated by dividing the patients into four age groups. RESULTS Of the 73,962,409 inpatients registered in the database, 9.7% and 4.7% had CAI and NI, respectively. These incidences tended to increase across the years in both the groups. Among the patients hospitalized with infectious diseases, there was a significant increase in patients aged ≥ 85 years (CAI: + 1.04%/year and NI: + 0.94%/year, P < 0.001), while there was a significant decrease in hospitalization of patients aged ≤ 64 years (CAI: -1.63%/year and NI: -0.94%/year, P < 0.001). In-hospital mortality was significantly higher in the NI than in the CAI group (CAI: 8.3%; NI: 14.5%, adjusted mean difference 4.7%). The NI group had higher organ support, medical cost per patient, and longer duration of hospital stay. A decreasing trend in mortality was observed in both the groups (CAI: -0.53%/year and NI: -0.72%/year, P < 0.001). CONCLUSION The present analysis of a large Japanese claims database showed that NI is a significant burden on hospitalized patients in aging societies, emphasizing the need to address particularly on NI.
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Affiliation(s)
- Nozomi Takahashi
- Centre for Heart Lung Innovation, St. Paul's Hospital, The University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Taro Imaeda
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takehiko Oami
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Toshikazu Abe
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
- Ad Hoc Committee On Clinical Research Using DPC, The Japanese Association for Infectious Diseases, Tokyo, Japan
| | - Kosaku Komiya
- Ad Hoc Committee On Clinical Research Using DPC, The Japanese Association for Infectious Diseases, Tokyo, Japan
- Respiratory Medicine and Infectious Diseases, Faculty of Medicine, Oita University, Oita, Japan
| | - Hideki Kawamura
- Ad Hoc Committee On Clinical Research Using DPC, The Japanese Association for Infectious Diseases, Tokyo, Japan
- Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan
| | - Yasuo Yamao
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, Tokyo, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
- Ad Hoc Committee On Clinical Research Using DPC, The Japanese Association for Infectious Diseases, Tokyo, Japan
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Zhong X, Ashiru-Oredope D, Pate A, Martin GP, Sharma A, Dark P, Felton T, Lake C, MacKenna B, Mehrkar A, Bacon SC, Massey J, Inglesby P, Goldacre B, Hand K, Bladon S, Cunningham N, Gilham E, Brown CS, Mirfenderesky M, Palin V, van Staa TP. Clinical and health inequality risk factors for non-COVID-related sepsis during the global COVID-19 pandemic: a national case-control and cohort study. EClinicalMedicine 2023; 66:102321. [PMID: 38192590 PMCID: PMC10772239 DOI: 10.1016/j.eclinm.2023.102321] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 01/10/2024] Open
Abstract
Background Sepsis, characterised by significant morbidity and mortality, is intricately linked to socioeconomic disparities and pre-admission clinical histories. This study aspires to elucidate the association between non-COVID-19 related sepsis and health inequality risk factors amidst the pandemic in England, with a secondary focus on their association with 30-day sepsis mortality. Methods With the approval of NHS England, we harnessed the OpenSAFELY platform to execute a cohort study and a 1:6 matched case-control study. A sepsis diagnosis was identified from the incident hospital admissions record using ICD-10 codes. This encompassed 248,767 cases with non-COVID-19 sepsis from a cohort of 22.0 million individuals spanning January 1, 2019, to June 31, 2022. Socioeconomic deprivation was gauged using the Index of Multiple Deprivation score, reflecting indicators like income, employment, and education. Hospitalisation-related sepsis diagnoses were categorised as community-acquired or hospital-acquired. Cases were matched to controls who had no recorded diagnosis of sepsis, based on age (stepwise), sex, and calendar month. The eligibility criteria for controls were established primarily on the absence of a recorded sepsis diagnosis. Associations between potential predictors and odds of developing non-COVID-19 sepsis underwent assessment through conditional logistic regression models, with multivariable regression determining odds ratios (ORs) for 30-day mortality. Findings The study included 224,361 (10.2%) cases with non-COVID-19 sepsis and 1,346,166 matched controls. The most socioeconomic deprived quintile was associated with higher odds of developing non-COVID-19 sepsis than the least deprived quintile (crude OR 1.80 [95% CI 1.77-1.83]). Other risk factors (after adjusting comorbidities) such as learning disability (adjusted OR 3.53 [3.35-3.73]), chronic liver disease (adjusted OR 3.08 [2.97-3.19]), chronic kidney disease (stage 4: adjusted OR 2.62 [2.55-2.70], stage 5: adjusted OR 6.23 [5.81-6.69]), cancer, neurological disease, immunosuppressive conditions were also associated with developing non-COVID-19 sepsis. The incidence rate of non-COVID-19 sepsis decreased during the COVID-19 pandemic and rebounded to pre-pandemic levels (April 2021) after national lockdowns had been lifted. The 30-day mortality risk in cases with non-COVID-19 sepsis was higher for the most deprived quintile across all periods. Interpretation Socioeconomic deprivation, comorbidity and learning disabilities were associated with an increased odds of developing non-COVID-19 related sepsis and 30-day mortality in England. This study highlights the need to improve the prevention of sepsis, including more precise targeting of antimicrobials to higher-risk patients. Funding The UK Health Security Agency, Health Data Research UK, and National Institute for Health Research.
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Affiliation(s)
- Xiaomin Zhong
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, M13 9PL, UK
| | - Diane Ashiru-Oredope
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London SW1P 3JR, UK
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - Alexander Pate
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, M13 9PL, UK
| | - Glen P. Martin
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, M13 9PL, UK
| | - Anita Sharma
- Chadderton South Health Centre, Eaves Lane, Chadderton, Oldham OL9 8RG, UK
| | - Paul Dark
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Tim Felton
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Intensive Care Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Claire Lake
- Maples Medical Centre, 2 Scout Dr, Baguley, Manchester M23 2SY, UK
| | - Brian MacKenna
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
- NHS England, Wellington House, Waterloo Road, London SE1 8UG, UK
| | - Amir Mehrkar
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Sebastian C.J. Bacon
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Jon Massey
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Peter Inglesby
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Ben Goldacre
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Kieran Hand
- Pharmacy Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Sian Bladon
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, M13 9PL, UK
| | - Neil Cunningham
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London SW1P 3JR, UK
| | - Ellie Gilham
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London SW1P 3JR, UK
| | - Colin S. Brown
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London SW1P 3JR, UK
- NIHR Health Protection Unit in Healthcare-Associated Infection & Antimicrobial Resistance, Imperial College London, London, UK
| | - Mariyam Mirfenderesky
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London SW1P 3JR, UK
| | - Victoria Palin
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, M13 9PL, UK
- Division of Developmental Biology and Medicine, Maternal and Fetal Research Centre, The University of Manchester, St Marys Hospital, Oxford Road, Manchester M13 9WL, UK
| | - Tjeerd Pieter van Staa
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, M13 9PL, UK
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Hollenbeak CS, Henning DJ, Geeting GK, Ledeboer NA, Faruqi IA, Pierce CG, Thomas CB, O'Neal HR. Costs and Consequences of a Novel Emergency Department Sepsis Diagnostic Test: The IntelliSep Index. Crit Care Explor 2023; 5:e0942. [PMID: 37465702 PMCID: PMC10351935 DOI: 10.1097/cce.0000000000000942] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
Sepsis causes 270,000 deaths and costs $38 billion annually in the United States. Most cases of sepsis present in the emergency department (ED), where rapid diagnosis remains challenging. The IntelliSep Index (ISI) is a novel diagnostic test that analyzes characteristics of WBC structure and provides a reliable early signal for sepsis. This study performs a cost-consequence analysis of the ISI relative to procalcitonin for early sepsis diagnosis in the ED. PERSPECTIVE U.S. healthcare system. SETTING Community hospital ED. METHODS A decision tree analysis was performed comparing ISI with procalcitonin. Model parameters included prevalence of sepsis, sensitivity and specificity of diagnostic tests (both ISI and procalcitonin), costs of hospitalization, and mortality rate stratified by diagnostic test result. Mortality and prevalence of sepsis were estimated from best available literature. Costs were estimated based on an analysis of a large, national discharge dataset, and adjusted to 2018 U.S. dollars. Outcomes included expected costs and survival. RESULTS Assuming a confirmed sepsis prevalence of 16.9% (adjudicated to Sepsis-3), the ISI strategy had an expected cost per patient of $3,849 and expected survival rate of 95.08%, whereas the procalcitonin strategy had an expected cost of $4,656 per patient and an expected survival of 94.98%. ISI was both less costly and more effective than procalcitonin, primarily because of fewer false-negative results. These results were robust in sensitivity analyses. CONCLUSIONS ISI was both less costly and more effective in preventing mortality than procalcitonin, primarily because of fewer false-negative results. The ISI may provide health systems with a higher-value diagnostic test in ED sepsis evaluation. Additional work is needed to validate these results in clinical practice.
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Affiliation(s)
- Christopher S Hollenbeak
- Department of Health Policy and Administration, The Pennsylvania State University, University Park, PA
| | - Daniel J Henning
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Glenn K Geeting
- Department of Emergency Medicine, Grant Memorial Hospital, Petersburg, WV
| | - Nathan A Ledeboer
- Department of Clinical Microbiology and Molecular Diagnostics, Medical College of Wisconsin, Milwaukee, WI
| | - Imran A Faruqi
- Department of Clinical Medicine, School of Medicine, Louisiana State University Health Sciences Center, Baton Rouge, LA
| | | | - Christopher B Thomas
- Department of Clinical Medicine, School of Medicine, Louisiana State University Health Sciences Center, Baton Rouge, LA
| | - Hollis R O'Neal
- Department of Clinical Medicine, School of Medicine, Louisiana State University Health Sciences Center, Baton Rouge, LA
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Wełna M, Adamik B, Kübler A, Goździk W. The NUTRIC Score as a Tool to Predict Mortality and Increased Resource Utilization in Intensive Care Patients with Sepsis. Nutrients 2023; 15:nu15071648. [PMID: 37049489 PMCID: PMC10097365 DOI: 10.3390/nu15071648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/24/2023] [Accepted: 03/26/2023] [Indexed: 03/31/2023] Open
Abstract
The Nutrition Risk in Critically Ill score (NUTRIC) is an important nutritional risk assessment instrument for patients in the intensive care unit (ICU). The purpose of this study was to evaluate the power of the score to predict mortality in patients treated for sepsis and to forecast increased resource utilization and nursing workload in the ICU. The NUTRIC score predicted mortality (AUC 0.833, p < 0.001) with the optimal cut-off value of 6 points. Among patients with a score ≥ 6 on ICU admission, the 28-day mortality was 61%, and 10% with a score < 6 (p < 0.001). In addition, a NUTRIC score of ≥6 was associated with a more intense use of ICU resources, as evidenced by a higher proportion of patients requiring vasopressor infusion (98 vs. 82%), mechanical ventilation (99 vs. 87%), renal replacement therapy (54 vs. 26%), steroids (68 vs. 31%), and blood products (60 vs. 43%); the nursing workload was also significantly higher in this group. In conclusion, the NUTRIC score obtained at admission to the ICU provided a good discriminative value for mortality and makes it possible to identify patients who will ultimately require intense use of ICU resources and an associated increase in the nursing workload during treatment.
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Wang C, Xu H, Gao R, Leng F, Huo F, Li Y, Liu S, Xu M, Bai J. CD19 +CD24 hiCD38 hi regulatory B cells deficiency revealed severity and poor prognosis in patients with sepsis. BMC Immunol 2022; 23:54. [PMID: 36357845 PMCID: PMC9648441 DOI: 10.1186/s12865-022-00528-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 10/20/2022] [Indexed: 11/12/2022] Open
Abstract
Background Sepsis still remains a major challenge in intensive care medicine with unacceptably high mortality among patients with septic shock. Due to current limitations of human CD19+CD24hiCD38hi Breg cells (Bregs) studies among sepsis, here, we tried to evaluate Bregs in severity and prognostic value in patients with sepsis. Methods Peripheral blood from 58 patients with sepsis and 22 healthy controls was analyzed using flow cytometry to evaluate the frequency and number of Bregs. All cases were divided into non-survived or survived group after 28 days followed up. Spearman's correlation analysis was performed on Bregs frequency and clinical indices. The area under the curve was acquired using the receiver operating characteristic analysis to assess the sensitivity and specificity of Bregs for outcome of sepsis. Survival curve analysis and binary logistic regression were applied to estimate the value of Bregs in prognosis among cases with sepsis. Results Sepsis patients had decreased proportions and number of Bregs. Sepsis patients with low frequency of Bregs were associated with an increased risk of septic shock. Bregs frequency is inversely associated with lactate, SOFA, and APACHE II and positively correlated with Tregs frequency. Low levels of Bregs closely correlated with septic outcomes. Numbers of Bregs were prediction factors for poor prognosis. Conclusions Frequency and number of Bregs decreased, and Bregs deficiency revealed poor prognosis in patients with sepsis. Supplementary Information The online version contains supplementary material available at 10.1186/s12865-022-00528-x.
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Affiliation(s)
- Chunmei Wang
- grid.89957.3a0000 0000 9255 8984Department of Emergency Medicine and Critical Care, Shanghai East Hospital, Nanjing Medical University, Nanjing, 211166 Jiangsu Province China ,grid.24516.340000000123704535Department of Emergency Medicine and Critical Care, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Shanghai, 200120 China
| | - Huihui Xu
- grid.9227.e0000000119573309Key Laboratory of Molecular Virology and Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, Shanghai, China ,grid.410726.60000 0004 1797 8419University of Chinese Academy of Sciences, Beijing, China
| | - Rui Gao
- grid.452252.60000 0004 8342 692XDepartment of Respiratory and Critical Care Medicine, Affiliated Hospital of Jining Medical University, Jining, 272067 Shandong Province China
| | - Fengying Leng
- grid.24516.340000000123704535Department of Emergency Medicine and Critical Care, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Shanghai, 200120 China
| | - Fangjie Huo
- Department of Respiratory Medicine, Xi’an No. 4 Hospital, Xi’an, 710004 Shanxi Province China
| | - Yinzhen Li
- grid.24516.340000000123704535Department of Emergency Medicine and Critical Care, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Shanghai, 200120 China ,grid.24516.340000000123704535Medical School, Tongji University, Shanghai, 200120 China
| | - Siting Liu
- grid.24516.340000000123704535Department of Emergency Medicine and Critical Care, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Shanghai, 200120 China
| | - Mingzheng Xu
- grid.24516.340000000123704535Department of Emergency Medicine and Critical Care, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Shanghai, 200120 China
| | - Jianwen Bai
- grid.89957.3a0000 0000 9255 8984Department of Emergency Medicine and Critical Care, Shanghai East Hospital, Nanjing Medical University, Nanjing, 211166 Jiangsu Province China ,grid.24516.340000000123704535Department of Emergency Medicine and Critical Care, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Shanghai, 200120 China
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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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Kostaki A, Wacker JW, Safarika A, Solomonidi N, Katsaros K, Giannikopoulos G, Koutelidakis IM, Hogan CA, Uhle F, Liesenfeld O, Sweeney TE, Giamarellos-Bourboulis EJ. A 29-MRNA HOST RESPONSE WHOLE-BLOOD SIGNATURE IMPROVES PREDICTION OF 28-DAY MORTALITY AND 7-DAY INTENSIVE CARE UNIT CARE IN ADULTS PRESENTING TO THE EMERGENCY DEPARTMENT WITH SUSPECTED ACUTE INFECTION AND/OR SEPSIS. Shock 2022; 58:224-230. [PMID: 36125356 PMCID: PMC9512237 DOI: 10.1097/shk.0000000000001970] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 03/28/2022] [Accepted: 07/19/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT Background: Risk stratification of emergency department patients with suspected acute infections and/or suspected sepsis remains challenging. We prospectively validated a 29-messenger RNA host response classifier for predicting severity in these patients. Methods: We enrolled adults presenting with suspected acute infections and at least one vital sign abnormality to six emergency departments in Greece. Twenty-nine target host RNAs were quantified on NanoString nCounter and analyzed with the Inflammatix Severity 2 (IMX-SEV-2) classifier to determine risk scores as low, moderate, and high severity. Performance of IMX-SEV-2 for prediction of 28-day mortality was compared with that of lactate, procalcitonin, and quick sequential organ failure assessment (qSOFA). Results: A total of 397 individuals were enrolled; 38 individuals (9.6%) died within 28 days. Inflammatix Severity 2 classifier predicted 28-day mortality with an area under the receiver operator characteristics curve of 0.82 (95% confidence interval [CI], 0.74-0.90) compared with lactate, 0.66 (95% CI, 0.54-0.77); procalcitonin, 0.67 (95% CI, 0.57-0.78); and qSOFA, 0.81 (95% CI, 0.72-0.89). Combining qSOFA with IMX-SEV-2 improved prognostic accuracy from 0.81 to 0.89 (95% CI, 0.82-0.96). The high-severity (rule-in) interpretation band of IMX-SEV-2 demonstrated 96.9% specificity for predicting 28-day mortality, whereas the low-severity (rule-out) band had a sensitivity of 78.9%. Similarly, IMX-SEV-2 alone accurately predicted the need for day-7 intensive care unit care and further boosted overall accuracy when combined with qSOFA. Conclusions: Inflammatix Severity 2 classifier predicted 28-day mortality and 7-day intensive care unit care with high accuracy and boosted the accuracy of clinical scores when used in combination.
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Affiliation(s)
- Antigone Kostaki
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Greece
| | | | - Asimina Safarika
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Greece
| | - Nicky Solomonidi
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Greece
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Lian H, Zhang H, Ding X, Wang X. The importance of a sepsis layered early warning system for critical patients. Am J Transl Res 2022; 14:5229-5242. [PMID: 36105025 PMCID: PMC9452367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/12/2022] [Indexed: 06/15/2023]
Abstract
Critical illness, particularly sepsis, is associated with high mortality, so prevention is more important than effective therapy. Advances in medical science have provided more opportunities for early warning and early intervention to avoid the development of critical illness. Existing early warning systems (EWS) have the advantages of high efficiency and convenience. However, with the development of medical technology, they do not completely meet clinical needs. EWS should contain elements that meet many dimensions of clinical requirements, including risk warning, response warning, injury warning, critical warning, and death warning. By summarizing previous studies, we outlined a layered EWS that follows RISK bundles. RISK represents different warning sign categories: R: host response, I: organ injury, S: changes in vital signs, and K: gradual appearance of "killed" organs. We plan to construct a complete layered EWS to guide clinical activities and subsequent clinical studies in the near future.
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Affiliation(s)
- Hui Lian
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing 100730, P. R. China
| | - Hongmin Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing 100730, P. R. China
| | - Xin Ding
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing 100730, P. R. China
| | - Xiaoting Wang
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing 100730, P. R. China
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing 100730, P. R. China
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Hospital-onset sepsis and community-onset sepsis in critical care units in Japan: a retrospective cohort study based on a Japanese administrative claims database. Crit Care 2022; 26:136. [PMID: 35562773 PMCID: PMC9107171 DOI: 10.1186/s13054-022-04013-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 05/02/2022] [Indexed: 12/29/2022] Open
Abstract
Background Hospital- and community-onset sepsis are significant sepsis subgroups. Japanese data comparing these subgroups are limited. This study aimed to describe the epidemiology of hospital- and community-onset sepsis in critical care units in Japan. Methods We performed a retrospective cohort study using the Japanese Diagnosis and Procedure Combination database. Adult patients admitted to critical care units with sepsis from April 2010 to March 2020 were included. Sepsis cases were identified based on ICD-10 codes for infectious diseases, procedure codes for blood culture tests, and medication codes for antimicrobials. Patients’ characteristics, in-hospital mortality, and resource utilization were assessed. The in-hospital mortality between groups was compared using the Poisson regression generalized linear mixed-effect model. Results Of 516,124 patients, 52,183 (10.1%) had hospital-onset sepsis and 463,940 (89.9%) had community-onset sepsis. Hospital-onset sepsis was characterized by younger age, infrequent emergency hospitalization, frequent surgery under general anesthesia, and frequent organ support upon critical care unit admission compared to community-onset sepsis. In-hospital mortality was higher for hospital-onset than for community-onset sepsis (35.5% versus 19.2%; unadjusted mean difference, 16.3% [95% confidence interval (CI) 15.9–16.7]; adjusted mean difference, 15.6% [95% CI 14.9–16.2]). Mean hospital length of stay was longer for hospital-onset than for community-onset sepsis (47 days versus 30 days; unadjusted mean difference, 17 days [95% CI 16–17]; adjusted mean difference, 13 days [95% CI 12–14]). Conclusion Patients with hospital-onset sepsis admitted to critical care units in Japan had a poorer prognosis and more resource utilization including organ support rate, number of days with critical care unit surcharge codes, and hospital length of stay than those with community-onset sepsis. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04013-0.
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12
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Gandhi N, Schulman KA. New Medicare Technology Add-On Payment Could Be Used As A Market Support Mechanism To Accelerate Antibiotic Innovation. Health Aff (Millwood) 2021; 40:1926-1934. [PMID: 34871069 DOI: 10.1377/hlthaff.2021.00062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite growing antibiotic resistance, the clinical drug development pipeline for antibiotics has been sparse largely because of an unsustainable business model. We illustrate three models to accelerate antibiotic development, using Medicare new technology add-on payments as a market support mechanism. The first two models subsidize drug development for Medicare beneficiaries, and the third model applies a payment for every patient with a resistant infection to essentially create a funding pool. We found that the reimbursement required to sustain research and development would range from $637 to $121,365, depending on the payment model and the incidence of the resistant infection in question. With a $300 million public research subsidy, the payment for an antibiotic would drop to between $273 and $10,396 per course. Our market support model could increase the likelihood of attracting private investment for antibiotic development.
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Affiliation(s)
- Neil Gandhi
- Neil Gandhi is a resident in emergency medicine at the University of California Los Angeles, in Los Angeles, California. He was a graduate student at the Stanford University School of Medicine, in Stanford, California, when this work was performed
| | - Kevin A Schulman
- Kevin A. Schulman is a professor of medicine at the Stanford University School of Medicine and a professor at the Graduate School of Business, Stanford University
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Alberto L, Marshall AP, Walker RM, Pálizas F, Aitken LM. Sensitivity and specificity of a quick sequential [Sepsis-Related] organ failure assessment sepsis screening tool. Int J Clin Pract 2021; 75:e14874. [PMID: 34529874 DOI: 10.1111/ijcp.14874] [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: 08/22/2019] [Revised: 08/06/2021] [Accepted: 09/10/2021] [Indexed: 11/30/2022] Open
Abstract
AIM There is limited evidence on the diagnostic accuracy of a quick Sequential [Sepsis-Related] Organ Failure Assessment (qSOFA) sepsis screening (SS) tool in developing nation health settings. The aim of this study was to test the diagnostic accuracy of a qSOFA-based SS tool, and the predictive validity of the qSOFA score in hospital ward patients from Argentina. METHODS Prospective observational study. Patients (≥18 years, without sepsis) were recruited within 24-48 hours of admission to a 169-bed tertiary referral private hospital in Buenos Aires. The index test was the qSOFA-based SS tool, and the reference standard sepsis diagnosed at discharge blindly evaluated with reference to the Sepsis-3. RESULTS In 1151 patients (median age 69.9 [IQR, 29.0]); 47 (4.1%) had sepsis, 413 (35.9%) had infection and 691 (60.0%) other diagnoses at discharge. The qSOFA-based SS tool (index test) had moderate sensitivity (60%), good specificity (89%), a very low positive (19%) and very high negative (98%) predictive value for sepsis diagnosed at discharge according to the Sepsis-3 criteria (reference standard). For the same outcome, the qSOFA score in isolation had a reasonable predictive validity area under receiver operating characteristics curve 0.77 (95% CI 0.70-0.83) P < 0.001. CONCLUSION The qSOFA score could reasonably discriminate patients at risk of developing sepsis; qSOFA-based screening may be valuable where no screening criteria are in place.
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Affiliation(s)
- Laura Alberto
- School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Andrea P Marshall
- School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
- Gold Coast University Hospital, Gold Coast Hospital and Health Service, Gold Coast, Australia
| | - Rachel M Walker
- School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
- Division of Surgery, Princess Alexandra Hospital, Brisbane, Australia
| | - Fernando Pálizas
- Intensive Care Units, Clínicas Bazterrica and Santa Isabel, Ciudad de Buenos Aires, Argentina
| | - Leanne M Aitken
- School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
- School of Health Sciences at City, University of London, London, UK
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Sivayoham N, Hussain AN, Shabbo L, Christie D. An observational cohort study of the performance of the REDS score compared to the SIRS criteria, NEWS2, CURB65, SOFA, MEDS and PIRO scores to risk-stratify emergency department suspected sepsis. Ann Med 2021; 53:1863-1874. [PMID: 34686088 PMCID: PMC8547872 DOI: 10.1080/07853890.2021.1992495] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 10/07/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To compare the performance of the Risk-stratification of Emergency Department suspected Sepsis (REDS) score to the SIRS criteria, NEWS2, CURB65, SOFA, MEDS and PIRO scores, to risk-stratify Emergency Department (ED) suspected sepsis patients for mortality. METHOD A retrospective observational cohort study of prospectively collected data. Adult patients admitted from the ED after receiving intravenous antibiotics for suspected sepsis in the year 2020, were studied. Patients with COVID-19 were excluded. The scores stated above were calculated for each patient. Receiver operator characteristics (ROC) curves were constructed for each score for the primary outcome measure, all-cause in-hospital mortality. The area under the ROC (AUROC) curves and cut-off points were identified by the statistical software. Scores above the cut-off point were deemed high-risk. The test characteristics of the high-risk groups were calculated. Comparisons were based on the AUROC curve and sensitivity for mortality of the high-risk groups. Previously published cut-off points were also studied. Calibration was also studied. RESULTS Of the 2594 patients studied, 332 (12.8%) died. The AUROC curve for the REDS score 0.73 (95% confidence interval [CI] 0.72-0.75) was significantly greater than the AUROC curve for the SIRS criteria 0.51 (95% CI 0.49-0.53), p < .0001 and the NEWS2 score 0.69 (95% CI 0.67-0.70), p = .005, and similar to all other scores studied. Sensitivity for mortality at the respective cut-off points identified (REDS ≥3, NEWS2 ≥ 8, CURB65 ≥ 3, SOFA ≥3, MEDS ≥10 and PIRO ≥10) was greatest for the REDS score at 80.1% (95% CI 75.4-84.3) and significantly greater than the other scores. The sensitivity for mortality for an increase of two points from baseline in the SOFA score was 63% (95% CI 57.5-68.2). CONCLUSIONS In this single centre study, the REDS score had either a greater AUROC curve or sensitivity for mortality compared to the comparator scores, at the respective cut-off points identified.KEY MESSAGESThe REDS score is a simple and objective scoring system to risk-stratify for mortality in emergency department (MED) patients with suspected sepsis.The REDS score is better or equivalent to existing scoring systems in its discrimination for mortality.
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Affiliation(s)
- Narani Sivayoham
- Department of Emergency Medicine, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Adil N. Hussain
- Department of Emergency Medicine, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Luke Shabbo
- Department of Emergency Medicine, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Dylon Christie
- Department of Emergency Medicine, St George’s University Hospitals NHS Foundation Trust, London, UK
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15
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Early palliative intervention in septic patients reduces healthcare utilization. Am J Emerg Med 2021; 50:773-777. [PMID: 34698640 DOI: 10.1016/j.ajem.2021.09.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/24/2021] [Accepted: 09/27/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION While the role of palliative care in the emergency department is recognized, barriers against the effective integration of palliative interventions and emergency care remain. We examined the association between goals-of-care and palliative care consultations and healthcare utilization outcomes in older adult patients who presented to the emergency department (ED) with sepsis. METHODS We performed a retrospective review of 197 patients aged 65 years and older who presented to the ED with sepsis or septic shock. Healthcare utilization outcomes were compared between patients divided into 3 groups: no palliative care consultation, palliative care consultation within 4 days of admission (i.e., early consultation), and palliative care consultation after 4 days of admission (i.e., late consultation). RESULTS 51% of patients did not receive any palliative consultation, 39% of patients underwent an early palliative care consultation (within 4 days), and 10% of patients underwent a late palliative care consultation (after 4 days). Patients who received late palliative care consultation had a significantly increased number of procedures, total length of stay, ICU length of stay, and cost (p < .01, p < .001, p < .05, p < .001; respectively). Regarding early palliative care consultation, there were no statistically significant associations between this intervention and our outcomes of interest; however, we noted a trend towards decreased total length of stay and decreased healthcare cost. CONCLUSION In patients aged 65 years and older who presented to the ED with sepsis, early palliative consultations were associated with reduced healthcare utilization as compared to late palliative consultations.
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The Cost of ARDS: A Systematic Review. Chest 2021; 161:684-696. [PMID: 34478719 DOI: 10.1016/j.chest.2021.08.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 08/08/2021] [Accepted: 08/10/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND ARDS is an inflammatory condition of the lungs and is a common condition in adult ICUs. The resources required and costs of care for patients with ARDS are significant because of the severity of the illness and extended ICU lengths of stay. RESEARCH QUESTION What are the costs associated with ARDS? STUDY DESIGN AND METHODS We systematically searched the literature through April 29, 2021, for articles relevant to ARDS and costs. MEDLINE, Embase, Central, and EconLit databases were searched, and articles that reported on cost data from an original publication in adult patients with ARDS were included. Two authors independently assessed articles for inclusion and extracted data elements related to costs, methodology, health-care system type, economic perspective, and clinical data. Publication quality was assessed using a modified version of the Quality of Health Economic Studies Instrument. RESULTS Four thousand six hundred sixty-three publications were found, of which 110 were included for full-text review (κ = 0.72). A total of 22 publications (49,483 patients) were suitable for data extraction. The publications represented a broad range of health-care systems, economic perspectives, costing methodology, and time frames. Mean inpatient costs ranged from $8,476 (2021 US dollars [USD]) to $547,974 (2021 USD) and were highest in publications of lower quality and in American health systems and were associated with trauma cohorts. Outpatient costs were highest in publications with higher readmission rates, longer durations of follow-up, and in American health systems. INTERPRETATION A wide range of costing data is available for ARDS. A comprehensive synthesis of this literature frames the reasons for this and allows estimates to reflect the context in which they were assessed. This information will be of value to researchers and administrators interested in the economics of caring for patients with ARDS. TRIAL REGISTRY PROSPERO; No.: CRD42020192487.
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Prasad PA, Fang MC, Martinez SP, Liu KD, Kangelaris KN. Identifying the Sickest During Triage: Using Point-of-Care Severity Scores to Predict Prognosis in Emergency Department Patients With Suspected Sepsis. J Hosp Med 2021; 16:453-461. [PMID: 34328843 PMCID: PMC8340957 DOI: 10.12788/jhm.3642] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 04/27/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Sepsis progresses rapidly and is associated with considerable morbidity and mortality. Bedside risk stratification scores can quickly identify patients at greatest risk of poor outcomes; however, there is lack of consensus on the best scale to use. OBJECTIVE To compare the ability of quick Sequential Organ Failure Assessment (qSOFA), the National Early Warning System (NEWS2), and the Shock Index-which does not require mental status assessment-to predict poor outcomes among patients with suspected sepsis during triage. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of adults presenting to an academic emergency department (ED) from June 2012 to December 2018 who had blood cultures and intravenous antibiotics within 24 hours. MAIN OUTCOMES AND MEASURES Clinical data were collected from the electronic health record. Patients were considered positive at qSOFA ≥2, Shock Index >0.7, or NEWS2 ≥5 scores. We calculated test characteristics and area under the receiver operating characteristics curves (AUROCs) to predict in-hospital mortality and ED-to-intensive care unit (ICU) admission. RESULTS We included 23,837 ED patients; 1,921(8.1%) were qSOFA-positive, 4,273 (17.9%) Shock Index-positive, and 11,832 (49.6%) NEWS2-positive. There were 1,427 (6.0%) deaths and 3,149 (13.2%) ED-to-ICU admissions in the sample. NEWS2 had the highest sensitivity for in-hospital mortality (76.0%) and ED-to-ICU admission (78.9%). qSOFA had the highest specificity for in-hospital mortality (93.4%) and ED-to-ICU admission (95.2%). Shock Index exhibited the highest AUROC for in-hospital mortality (0.648; 95 CI, 0.635-0.662) and ED-to-ICU admission (0.680; 95% CI, 0.617-0.689). Test characteristics were similar among those with sepsis. CONCLUSIONS Institution priorities should drive score selection, balancing sensitivity and specificity. In our study, qSOFA was highly specific and NEWS2 was the most sensitive for ruling out patients at high risk. Performance of the Shock Index fell between qSOFA and NEWS2 and could be considered because it is easy to implement.
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Affiliation(s)
- Priya A Prasad
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California
- Corresponding Author: Priya A Prasad, PhD, MPH;
| | - Margaret C Fang
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California
| | - Sandra P Martinez
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California
| | - Kathleen D Liu
- Divisions of Nephrology and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Kirsten N Kangelaris
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California
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A Locally Optimized Data-Driven Tool to Predict Sepsis-Associated Vasopressor Use in the ICU. Crit Care Med 2021; 49:e1196-e1205. [PMID: 34259450 PMCID: PMC8602707 DOI: 10.1097/ccm.0000000000005175] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To train a model to predict vasopressor use in ICU patients with sepsis and optimize external performance across hospital systems using domain adaptation, a transfer learning approach. DESIGN Observational cohort study. SETTING Two academic medical centers from January 2014 to June 2017. PATIENTS Data were analyzed from 14,512 patients (9,423 at the development site and 5,089 at the validation site) who were admitted to an ICU and met Center for Medicare and Medicaid Services definition of severe sepsis either before or during the ICU stay. Patients were excluded if they never developed sepsis, if the ICU length of stay was less than 8 hours or more than 20 days or if they developed shock up to the first 4 hours of ICU admission. MEASUREMENTS AND MAIN RESULTS Forty retrospectively collected features from the electronic medical records of adult ICU patients at the development site (four hospitals) were used as inputs for a neural network Weibull-Cox survival model to derive a prediction tool for future need of vasopressors. Domain adaptation updated parameters to optimize model performance in the validation site (two hospitals), a different healthcare system over 2,000 miles away. The cohorts at both sites were randomly split into training and testing sets (80% and 20%, respectively). When applied to the test set in the development site, the model predicted vasopressor use 4-24 hours in advance with an area under the receiver operator characteristic curve, specificity, and positive predictive value ranging from 0.80 to 0.81, 56.2% to 61.8%, and 5.6% to 12.1%, respectively. Domain adaptation improved performance of the model to predict vasopressor use within 4 hours at the validation site (area under the receiver operator characteristic curve 0.81 [CI, 0.80-0.81] from 0.77 [CI, 0.76-0.77], p < 0.01; specificity 59.7% [CI, 58.9-62.5%] from 49.9% [CI, 49.5-50.7%], p < 0.01; positive predictive value 8.9% [CI, 8.5-9.4%] from 7.3 [7.1-7.4%], p < 0.01). CONCLUSIONS Domain adaptation improved performance of a model predicting sepsis-associated vasopressor use during external validation.
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Pre-transplant T-cell Clonality: An Observational Study of a Biomarker for Prediction of Sepsis in Liver Transplant Recipients. Ann Surg 2021; 274:411-418. [PMID: 34132702 DOI: 10.1097/sla.0000000000004998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE This study investigated the ability of pre-transplant T-cell clonality to predict sepsis after liver transplant (LT). SUMMARY BACKGROUND DATA Sepsis is a leading cause of death in LT recipients. Currently, no biomarkers predict sepsis before clinical symptom manifestation. METHODS Between December 2013 and March 2018, our institution performed 478 LTs. After exclusions (eg, patients with marginal donor livers, autoimmune disorders, nonabdominal multi-organ, and liver retransplantations), 180 consecutive LT were enrolled. T-cell characterization was assessed within 48 hours before LT (immunoSEQ Assay, Adaptive Biotechnologies, Seattle, WA). Sepsis-2 and Sepsis-3 cases, defined by presence of acute infection plus ≥2 SIRS criteria, or clinical documentation of sepsis, were identified by chart review. Receiver-operating characteristic analyses determined optimal T-cell repertoire clonality for predicting post-LT sepsis. Kaplan-Meier and Cox proportional hazard modeling assessed outcome-associated prognostic variables. RESULTS Patients with baseline T-cell repertoire clonality ≥0.072 were 3.82 (1.25, 11.40; P = 0.02), and 2.40 (1.00, 5.75; P = 0.049) times more likely to develop sepsis 3 and 12 months post-LT, respectively, when compared to recipients with lower (<0.072) clonality. T-cell repertoire clonality was the only predictor of sepsis 3 months post-LT in multivariate analysis (C-Statistic, 0.75). Adequate treatment resulted in equivalent survival rates between both groups: (93.4% vs 96.2%, respectively, P = 0.41) at 12 months post-LT. CONCLUSIONS T-cell repertoire clonality is a novel biomarker predictor of sepsis before development of clinical symptoms. Early sepsis monitoring and management may reduce post-LT mortality. These findings have implications for developing sepsis-prevention protocols in transplantation and potentially other populations.
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Assessment of a Cellular Host Response Test as a Sepsis Diagnostic for Those With Suspected Infection in the Emergency Department. Crit Care Explor 2021; 3:e0460. [PMID: 34151282 PMCID: PMC8208428 DOI: 10.1097/cce.0000000000000460] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: Sepsis is a common cause of morbidity and mortality. A reliable, rapid, and early indicator can help improve efficiency of care and outcomes. To assess the IntelliSep test, a novel in vitro diagnostic that quantifies the state of immune activation by measuring the biophysical properties of leukocytes, as a rapid diagnostic for sepsis and a measure of severity of illness, as defined by Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation-II scores and the need for hospitalization. Design, Setting, SUBJECTS: Adult patients presenting to two emergency departments in Baton Rouge, LA, with signs of infection (two of four systemic inflammatory response syndrome criteria, with at least one being aberration of temperature or WBC count) or suspicion of infection (a clinician order for culture of a body fluid), were prospectively enrolled. Sepsis status, per Sepsis-3 criteria, was determined through a 3-tiered retrospective and blinded adjudication process consisting of objective review, site-level clinician review, and final determination by independent physician adjudicators. MEASUREMENTS AND MAIN RESULTS: Of 266 patients in the final analysis, those with sepsis had higher IntelliSep Index (median = 6.9; interquartile range, 6.1–7.6) than those adjudicated as not septic (median = 4.7; interquartile range, 3.7–5.9; p < 0.001), with an area under the receiver operating characteristic curve of 0.89 and 0.83 when compared with unanimous and forced adjudication standards, respectively. Patients with higher IntelliSep Index had higher Sequential Organ Failure Assessment (3 [interquartile range, 1–5] vs 1 [interquartile range, 0–2]; p < 0.001) and Acute Physiology and Chronic Health Evaluation-II (7 [interquartile range, 3.5–11.5] vs 5 [interquartile range, 2–9]; p < 0.05) and were more likely to be admitted to the hospital (83.6% vs 48.3%; p < 0.001) compared with those with lower IntelliSep Index. CONCLUSIONS: In patients presenting to the emergency department with signs or suspicion of infection, the IntelliSep Index is a promising tool for the rapid diagnosis and risk stratification for sepsis.
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Davis C, Faruki A, Breyer D, Cumbler E, Fisher B, Hassell A, Hess S, Pierce R, Wiler J, Zane R. The Case for Virtual Sepsis Surveillance and Intervention. Telemed J E Health 2021; 28:102-106. [PMID: 33826409 DOI: 10.1089/tmj.2020.0513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Study Objective: To determine whether deployment of an integrated virtual sepsis surveillance program could improve time to antibiotics and mortality in a longitudinal cohort of non-present on admission (NPOA) sepsis cases. Methods: We used an uncontrolled pre- and poststudy design to compare time to antibiotics and mortality between a time-based cohort of NPOA sepsis cases separated by the deployment of a virtual sepsis surveillance program. Results: A total of 566 NPOA sepsis cases were included in this study. Three hundred and thirty-five cases compromised the preintervention arm, whereas the postintervention cohort included 231 cases. After deployment of the virtual sepsis surveillance program, median time to antibiotics improved from 92 to 59 min (p < 0.001). Mortality was reduced from 30% to 21% (p = 0.015). Conclusion: Deployment of a virtual sepsis surveillance program resulted in a decreased time to antibiotics and an overall reduction in NPOA sepsis mortality.
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Affiliation(s)
- Christopher Davis
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Adeel Faruki
- Department of Anesthesia, UCHealth, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Diana Breyer
- Department of Anesthesia, UCHealth, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ethan Cumbler
- Departments of Medicine and Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Brett Fisher
- Department of Anesthesia, UCHealth, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Amy Hassell
- Department of Anesthesia, UCHealth, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Steve Hess
- Department of Anesthesia, UCHealth, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Read Pierce
- Division of Hospital Medicine, Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Jennifer Wiler
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Richard Zane
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Singal AK, Ahmed Z, Axley P, Arora S, Arab JP, Haas A, Kuo YF, Kamath PS. Hospitalizations for Acute on Chronic Liver Failure at Academic Compared to Non-academic Centers Have Higher Mortality. Dig Dis Sci 2021; 66:1306-1314. [PMID: 32318884 DOI: 10.1007/s10620-020-06263-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/08/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIM Acute on chronic liver failure (ACLF) in patients with cirrhosis has high short-term mortality. Data comparing ACLF admissions to academic centers (AC) and non-academic centers (NAC) are scanty. METHODS National Inpatient Sample (2006-2014) was queried for admissions with cirrhosis and ACLF using the ICD-09 codes, and was stratified to AC or NAC. RESULTS Of 1,928,764 admissions with cirrhosis (2006-2014), 112,174 (5. 9%) had ACLF. 6.7% of 1,018,568 cirrhosis admissions to AC had ACLF versus 5% of 910,196 admissions to NAC, P < 0.0001. Proportion of ACLF admissions to AC increased from 49% during 2006-2008 to 59% during 2012-2014. In a cohort of 73,630 ACLF admissions (36,615 each to AC and NAC) matched for patient demographics, cirrhosis etiology, number of comorbidities, elective versus emergent admission, ACLF grade, and type of organ failure. In-hospital mortality declined by 7% over the study period, but remained higher in AC (46% vs. 42%, P < 0.001), with 11% increased odds for in-hospital mortality compared to admission to NAC. Further admissions to AC versus NAC had higher median (IQR) length of stay at 13 (6-25) versus 11 (5-20) days, with higher median (IQR) hospital charges: 138,239 (66,772-275,603) versus 116,209 (55,767-232,699) USD, P < 0.001 for both. CONCLUSION Patients with ACLF have high in-hospital mortality. Further, this is higher among admissions to AC. Although the in-hospital mortality is improving, strategies are needed on early identification of patients with futility of care for early discussion on goals of care, and optimal utilization of hospital resources among admissions with ACLF.
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Affiliation(s)
- Ashwani K Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, Transplant Hepatologist and Chief Clinical Research Affairs, Avera McKennan University Hospital Transplant Institute, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, 57105, USA.
| | - Zunirah Ahmed
- Department of Internal Medicine, University of Alabama at Birmingham, Montgomery, AL, USA
| | - Page Axley
- Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sumant Arora
- Division of Gastroenterology, Department of Medicine, University of Iowa Hospital & Clinics, Iowa, USA
| | - Juan P Arab
- Department of Gastroenterology and Hepatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Allen Haas
- Department of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
| | - Yong-Fang Kuo
- Department of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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Early recognition of surgical patients with sepsis: Contribution of nursing records. Appl Nurs Res 2020; 57:151352. [PMID: 32896443 DOI: 10.1016/j.apnr.2020.151352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/05/2020] [Accepted: 08/23/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study aimed to analyze the contribution of nursing records to the early identification and management of sepsis in surgical patients at a university hospital. METHOD This is a study with a quantitative, retrospective, descriptive, and correlational design. Data collection was performed through hospital information systems in the first semester of 2017 with the approval of the research ethics committee. We included 28 patients who met the inclusion criteria of the study. RESULTS The analysis of the content of the records evidenced the development of the first signs of systemic inflammatory response syndrome (SIRS) and organ dysfunction until the fifth day of hospitalization in 19 patients (67.8%). Confirmation or hypothesis of sepsis diagnosis occurred until the 10th day of hospitalization in 15 patients (53.5%). The analysis of the content of the records showed that the first signs of SIRS were predominantly identified in the electronic patient monitoring system in 26 cases (92.9%), whereas the first signs of organ dysfunction were described in the nursing staff records in 24 patients (85.7%). CONCLUSION The results confirm the importance of the quality of nursing records for risk identification, early recognition, and proper management of sepsis in surgical patients, aiming at achieving greater effectiveness in the management of healthcare processes.
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Epidemiology and burden of sepsis acquired in hospitals and intensive care units: a systematic review and meta-analysis. Intensive Care Med 2020; 46:1536-1551. [PMID: 32591853 PMCID: PMC7381455 DOI: 10.1007/s00134-020-06106-2] [Citation(s) in RCA: 146] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/11/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE Sepsis is recognized as a global public health problem, but the proportion due to hospital-acquired infections remains unclear. We aimed to summarize the epidemiological evidence related to the burden of hospital-acquired (HA) and ICU-acquired (ICU-A) sepsis. METHODS We searched MEDLINE, Embase and the Global Index Medicus from 01/2000 to 03/2018. We included studies conducted hospital-wide or in intensive care units (ICUs), including neonatal units (NICUs), with data on the incidence/prevalence of HA and ICU-A sepsis and the proportion of community and hospital/ICU origin. We did random-effects meta-analyses to obtain pooled estimates; inter-study heterogeneity and risk of bias were assessed. RESULTS Of the 13,239 studies identified, 51 met the inclusion criteria; 22 were from low- and middle-income countries. Twenty-eight studies were conducted in ICUs, 13 in NICUs, and ten hospital-wide. The proportion of HA sepsis among all hospital-treated sepsis cases was 23.6% (95% CI 17-31.8%, range 16-36.4%). In the ICU, 24.4% (95% CI 16.7-34.2%, range 10.3-42.5%) of cases of sepsis with organ dysfunction were acquired during ICU stay and 48.7% (95% CI 38.3-59.3%, range 18.7-69.4%) had a hospital origin. The pooled hospital incidence of HA sepsis with organ dysfunction per 1000 patients was 9.3 (95% CI 7.3-11.9, range 2-20.6)). In the ICU, the pooled incidence of HA sepsis with organ dysfunction per 1000 patients was 56.5 (95% CI 35-90.2, range 9.2-254.4) and it was particularly high in NICUs. Mortality of ICU patients with HA sepsis with organ dysfunction was 52.3% (95% CI 43.4-61.1%, range 30.1-64.6%). There was a significant inter-study heterogeneity. Risk of bias was low to moderate in ICU-based studies and moderate to high in hospital-wide and NICU studies. CONCLUSION HA sepsis is of major public health importance, and the burden is particularly high in ICUs. There is an urgent need to improve the implementation of global and local infection prevention and management strategies to reduce its high burden among hospitalized patients.
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Abstract
The aim of this study is to examine the incidence trend of sepsis over 11 years and compared mortality outcomes among Taiwanese patients with sepsis admitted from emergency department (ED) and non-ED routes. We used a nationwide health insurance database from Taiwan, which comprise of 23 million beneficiaries. Patients with sepsis were identified by ICD-9 CM codes for infection and organ dysfunction from 2001 to 2012. We performed propensity score matching and compared mortality rates between ED-admitted and non ED-admitted patients.During the 11-year study period, we identified 1,256,684 patients with sepsis. 493,397 (29.3%) were admitted through the ED, and 763,287 (70.7%) were admitted directly to the floor. For patients with sepsis, mortality in ED-admitted patients decreased from 27.2% in 2002 to 21.1% in 2012 while that in non-ED admitted patients decreased from 35.3% in 2002 to 30.7% in 2012. Although patients with sepsis admitted through the ED had a higher incidence of organ dysfunction than patients who were directly admitted, they had more favorable outcomes in mortality, length of intensive care unit stay, and hospital stay. After propensity score matching, ED-admitted patients had a 7% lower risk of 90-day mortality (HR, 0.93, 95% CI, 0.89-0.97) compared with directly admitted patients. During the study period, mortality declined faster among ED admitted sepsis patients than directly admitted sepsis patients. Results of this study should be interpreted in light of limitations. Like other administrative database studies, treatment details are not available. Further clinical studies evaluating the treatment and outcome difference between ED and non-ED admitted sepsis patients are warranted.
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Chen YJ, Chen FL, Chen JH, Wu MTM, Chien DS, Ko Y. Costs and length of sepsis-related hospitalizations in Taiwan. Medicine (Baltimore) 2020; 99:e20476. [PMID: 32481457 DOI: 10.1097/md.0000000000020476] [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] [Indexed: 11/26/2022] Open
Abstract
To investigate the healthcare expenditures and length of stay (LOS) of sepsis-related hospitalizations in Taiwan.This is a retrospective claim database study. Data were obtained from the two-million-sample longitudinal health and welfare database (LHWD). Adult patients hospitalized with sepsis between 2010 and 2014 were identified by International Classification of Diseases 9th Edition Clinical Modification (ICD-9-CM) codes, and these patients were divided into three levels of sepsis severity. The amount and distribution of their total medical expenditures were investigated.In total, 62,517 patients with 97,790 sepsis-related hospitalizations were included in the present study. It was found that ward fees and medicines comprised the largest component of expenses for sepsis-related hospitalizations. In addition, our study results indicated that the median sepsis-related hospitalization cost was 66.4 thousand New Taiwan Dollar (NT dollars) in 2014, and a significant temporal change was found between 2010 and 2014. The median LOS in a hospital and in an intensive care unit were 11 and 7 days, respectively. Both expenditures and LOS were found to increase with sepsis severity.This study provides an updated and better understanding of the costs and LOS of sepsis-related hospitalizations in Taiwan. It was found that ward fees and medicine fees were the major components of hospital costs.
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Affiliation(s)
| | - Fu-Lun Chen
- Division of Infectious Diseases, Wan Fang Hospital, Taipei Medical University
| | - Jin-Hua Chen
- Research Center of Biostatistics and Graduate Institute of Data Science, College of Management
| | - Man-Tzu Marcie Wu
- Department of Pharmacy, Wan Fang Hospital, Taipei Medical University
| | | | - Yu Ko
- Department of Pharmacy, College of Pharmacy
- Research Center for Pharmacoeconomics, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
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Clinician Perception of a Machine Learning-Based Early Warning System Designed to Predict Severe Sepsis and Septic Shock. Crit Care Med 2020; 47:1477-1484. [PMID: 31135500 DOI: 10.1097/ccm.0000000000003803] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To assess clinician perceptions of a machine learning-based early warning system to predict severe sepsis and septic shock (Early Warning System 2.0). DESIGN Prospective observational study. SETTING Tertiary teaching hospital in Philadelphia, PA. PATIENTS Non-ICU admissions November-December 2016. INTERVENTIONS During a 6-week study period conducted 5 months after Early Warning System 2.0 alert implementation, nurses and providers were surveyed twice about their perceptions of the alert's helpfulness and impact on care, first within 6 hours of the alert, and again 48 hours after the alert. MEASUREMENTS AND MAIN RESULTS For the 362 alerts triggered, 180 nurses (50% response rate) and 107 providers (30% response rate) completed the first survey. Of these, 43 nurses (24% response rate) and 44 providers (41% response rate) completed the second survey. Few (24% nurses, 13% providers) identified new clinical findings after responding to the alert. Perceptions of the presence of sepsis at the time of alert were discrepant between nurses (13%) and providers (40%). The majority of clinicians reported no change in perception of the patient's risk for sepsis (55% nurses, 62% providers). A third of nurses (30%) but few providers (9%) reported the alert changed management. Almost half of nurses (42%) but less than a fifth of providers (16%) found the alert helpful at 6 hours. CONCLUSIONS In general, clinical perceptions of Early Warning System 2.0 were poor. Nurses and providers differed in their perceptions of sepsis and alert benefits. These findings highlight the challenges of achieving acceptance of predictive and machine learning-based sepsis alerts.
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Baghdadi JD, Brook RH, Uslan DZ, Needleman J, Bell DS, Cunningham WE, Wong MD. Association of a Care Bundle for Early Sepsis Management With Mortality Among Patients With Hospital-Onset or Community-Onset Sepsis. JAMA Intern Med 2020; 180:707-716. [PMID: 32250412 PMCID: PMC7136852 DOI: 10.1001/jamainternmed.2020.0183] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE The Early Management Bundle for Severe Sepsis/Septic Shock (SEP-1) is a quality metric based on a care bundle for early sepsis management. Published evidence on the association of SEP-1 with mortality is mixed and largely excludes cases of hospital-onset sepsis. OBJECTIVE To assess the association of the SEP-1 bundle with mortality and organ dysfunction in cohorts with hospital-onset or community-onset sepsis. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from 4 University of California hospitals from October 1, 2014, to October 1, 2017. Adult inpatients with a diagnosis consistent with sepsis or disseminated infection and laboratory or vital signs meeting the Sepsis-3 (Third International Consensus Definitions for Sepsis and Septic Shock) criteria were divided into community-onset sepsis and hospital-onset sepsis cohorts based on whether time 0 of sepsis occurred after arrival in the emergency department or an inpatient area. Data were analyzed from April to October 2019. Additional analyses were performed from December 2019 to January 2020. EXPOSURES Administration of SEP-1 and 4 individual bundle components (serum lactate level testing, blood culture, broad-spectrum intravenous antibiotic treatment, and intravenous fluid treatment). MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality. The secondary outcome was days requiring vasopressor support, measured as vasopressor days. RESULTS Among the 6404 patient encounters identified (3535 men [55.2%]; mean [SD] age, 64.0 [18.2] years), 2296 patients (35.9%) had hospital-onset sepsis. Among 4108 patients (64.1%) with community-onset sepsis, serum lactate level testing within 3 hours of time 0 was associated with reduced mortality (absolute difference, -7.61%; 95% CI, -14.70% to -0.54%). Blood culture (absolute difference, -1.10 days; 95% CI, -1.85 to -0.34 days) and broad-spectrum intravenous antibiotic treatment (absolute difference, -0.62 days; 95% CI, -1.02 to -0.22 days) were associated with fewer vasopressor days. Among patients with hospital-onset sepsis, broad-spectrum intravenous antibiotic treatment was the only bundle component significantly associated with any improved outcome (mortality difference, -5.20%; 95% CI, -9.84% to -0.56%). Care that was adherent to the complete SEP-1 bundle was associated with increased vasopressor days in patients with community-onset sepsis (absolute difference, 0.31 days; 95% CI, 0.11-0.51 days) but was not significantly associated with reduced mortality in either cohort (absolute difference, -0.07%; 95% CI, -3.02% to 2.88% in community-onset; absolute difference, -0.42%; 95% CI, -6.77% to 5.93% in hospital-onset). CONCLUSIONS AND RELEVANCE SEP-1-adherent care was not associated with improved outcomes of sepsis. Although multiple components of SEP-1 were associated with reduced mortality or decreased days of vasopressor therapy for patients who presented with sepsis in the emergency department, only broad-spectrum intravenous antibiotic treatment was associated with reduced mortality when time 0 occurred in an inpatient unit. Current sepsis quality metrics may need refinement.
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Affiliation(s)
- Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland, Baltimore
| | - Robert H Brook
- RAND Corporation, Santa Monica, California.,David Geffen School of Medicine, UCLA (University of California, Los Angeles)
| | | | - Jack Needleman
- Department of Health Policy and Management, Fielding School of Public Health, UCLA
| | | | - William E Cunningham
- Department of Health Policy and Management, Fielding School of Public Health, UCLA.,Division of General Internal Medicine, UCLA
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Baghdadi JD, Wong MD, Uslan DZ, Bell D, Cunningham WE, Needleman J, Kerbel R, Brook R. Adherence to the SEP-1 Sepsis Bundle in Hospital-Onset v. Community-Onset Sepsis: a Multicenter Retrospective Cohort Study. J Gen Intern Med 2020; 35:1153-1160. [PMID: 32040837 PMCID: PMC7174506 DOI: 10.1007/s11606-020-05653-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 09/26/2019] [Accepted: 12/10/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Sepsis is the leading cause of in-hospital death. The SEP-1 sepsis bundle is a protocol for early sepsis care that requires providers to diagnose and treat sepsis quickly. Limited evidence suggests that adherence to the sepsis bundle is lower in cases of hospital-onset sepsis. OBJECTIVE To compare sepsis bundle adherence in hospital-onset vs. community-onset sepsis. DESIGN Retrospective cohort study using multivariable analysis of clinical data. PARTICIPANTS A total of 4658 inpatients age 18 or older were identified by diagnosis codes consistent with sepsis or disseminated infection. SETTING Four university hospitals in California between 2014 and 2016. MAIN OUTCOMES AND MEASURES The primary outcome was adherence to key components of the sepsis bundle defined by the Centers for Medicare and Medicaid Services in their core measure, SEP-1. Covariates included clinical characteristics related to the patient, infection, and pathogen. KEY RESULTS Compared with community-onset, cases of hospital-onset sepsis were less likely to receive SEP-1 adherent care (relative risk 0.33, 95% confidence interval 0.29-0.38, p < 0.001). With the exception of vasopressors (RR 1.11, p = 0.002), each component of SEP-1 evaluated-blood cultures (RR 0.76, p < 0.001), serum lactate (RR 0.51, p < 0001), broad-spectrum antibiotics (RR 0.62, p < 0.001), intravenous fluids (0.47, p < 0.001), and follow-up lactate (RR 0.71, p < 0.001)-was less likely to be performed within the recommended time frame in hospital-onset sepsis. Within the hospital, cases of hospital-onset sepsis arising on the ward were less likely to receive SEP-1-adherent care than were cases arising in the intensive care unit (RR 0.68, p = 0.004). CONCLUSIONS Inpatients with hospital-onset sepsis receive different management than individuals with community-onset sepsis. It remains to be determined whether system-level factors, provider-level factors, or factors related to measurement explain the observed variation in care or whether variation in care affects outcomes.
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Affiliation(s)
- Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Mitchell D Wong
- UCLA Division of General Internal Medicine, Los Angeles, CA, USA
| | - Daniel Z Uslan
- UCLA Division of Infectious Diseases, Los Angeles, CA, USA
| | - Douglas Bell
- UCLA Division of General Internal Medicine, Los Angeles, CA, USA
| | - William E Cunningham
- UCLA Fielding School of Public Health, Department of Health Policy and Management, Los Angeles, CA, USA
| | - Jack Needleman
- UCLA Fielding School of Public Health, Department of Health Policy and Management, Los Angeles, CA, USA
| | | | - Robert Brook
- UCLA Department of Medicine, Los Angeles, CA, USA
- RAND Corporation, Santa Monica, CA, USA
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, USA
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Rhee C, Wang R, Zhang Z, Fram D, Kadri SS, Klompas M. Epidemiology of Hospital-Onset Versus Community-Onset Sepsis in U.S. Hospitals and Association With Mortality: A Retrospective Analysis Using Electronic Clinical Data. Crit Care Med 2019; 47:1169-1176. [PMID: 31135503 PMCID: PMC6697188 DOI: 10.1097/ccm.0000000000003817] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Prior studies have reported that hospital-onset sepsis is associated with higher mortality rates than community-onset sepsis. Most studies, however, have used inconsistent case-finding methods and applied limited risk-adjustment for potential confounders. We used consistent sepsis criteria and detailed electronic clinical data to elucidate the epidemiology and mortality associated with hospital-onset sepsis. DESIGN Retrospective cohort study. SETTING 136 U.S. hospitals in the Cerner HealthFacts dataset. PATIENTS Adults hospitalized in 2009-2015. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified sepsis using Centers for Disease Control and Prevention Adult Sepsis Event criteria and estimated the risk of in-hospital death for hospital-onset sepsis versus community-onset sepsis using logistic regression models. In patients admitted without community-onset sepsis, we estimated risk of death associated with hospital-onset sepsis using Cox regression models with sepsis as a time-varying covariate. Models were adjusted for baseline characteristics and severity of illness. Among 2.2 million hospitalizations, there were 95,154 sepsis cases: 83,620 (87.9%) community-onset sepsis and 11,534 (12.1%) hospital-onset sepsis (0.5% of hospitalized cohort). Compared to community-onset sepsis, hospital-onset sepsis patients were younger (median 66 vs 68 yr) but had more comorbidities (median Elixhauser score 14 vs 11), higher Sequential Organ Failure Assessment scores (median 4 vs 3), higher ICU admission rates (61% vs 44%), longer hospital length of stay (median 19 vs 8 d), and higher in-hospital mortality (33% vs 17%) (p < 0.001 for all comparisons). On multivariate analysis, hospital-onset sepsis was associated with higher mortality versus community-onset sepsis (odds ratio, 2.1; 95% CI, 2.0-2.2) and patients admitted without sepsis (hazard ratio, 3.0; 95% CI, 2.9-3.2). CONCLUSIONS Hospital-onset sepsis complicated one in 200 hospitalizations and accounted for one in eight sepsis cases, with one in three patients dying in-hospital. Hospital-onset sepsis preferentially afflicted ill patients but even after risk-adjustment, they were twice as likely to die as community-onset sepsis patients; in patients admitted without sepsis, hospital-onset sepsis tripled the risk of death. Hospital-onset sepsis is an important target for surveillance, prevention, and quality improvement initiatives.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Rui Wang
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
| | - Zilu Zhang
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
| | | | - Sameer S. Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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Huang CT, Ruan SY, Tsai YJ, Ku SC, Yu CJ. Clinical Trajectories and Causes of Death in Septic Patients with a Low APACHE II Score. J Clin Med 2019; 8:jcm8071064. [PMID: 31330785 PMCID: PMC6678558 DOI: 10.3390/jcm8071064] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/14/2019] [Accepted: 07/17/2019] [Indexed: 02/07/2023] Open
Abstract
Clinical course and mortality in septic patients with low disease severity remain poorly understood and is worth further investigation. We enrolled septic patients admitted to intensive care units (ICUs) between 2010 and 2014 with Acute Physiology and Chronic Health Evaluation II (APACHE II) scores of ≤15. We sought to determine their clinical trajectories and causes of death, and to analyze risk factors associated with in-hospital mortality. A total of 352 patients were included, of whom 89 (25%) did not survive to hospital discharge, at a rate higher than predicted (<21%) by the APACHE II score. Approximately one third (31/89) of non-survivors succumbed to index sepsis; however, more patients (34/89) died of subsequent sepsis. New-onset ICU sepsis developed in 99 (28%) patients and was an independent risk factor for mortality. In addition, septic patients with comorbid malignancy or index infection acquired in the hospital settings were more likely to have in-hospital mortality than those without. In conclusion, septic patients with low APACHE II scores were at a higher mortality risk than expected, and subsequent sepsis rather than index sepsis was the primary cause of death. This study provides insight into unexpected clinical trajectories and outcomes of septic patients with low disease severity at ICU admission and highlights the need for more research and clinical attention in this patient population.
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Affiliation(s)
- Chun-Ta Huang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
- Graduate Institute of Clinical Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Sheng-Yuan Ruan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Yi-Ju Tsai
- Graduate Institute of Biomedical and Pharmaceutical Science, College of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan
| | - Shih-Chi Ku
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan.
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
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Leisman DE, Angel C, Schneider SM, D’Amore JA, D’Angelo JK, Doerfler ME. Sepsis Presenting in Hospitals versus Emergency Departments: Demographic, Resuscitation, and Outcome Patterns in a Multicenter Retrospective Cohort. J Hosp Med 2019; 14:340-348. [PMID: 30986182 PMCID: PMC6625440 DOI: 10.12788/jhm.3188] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Differences between hospital-presenting sepsis (HPS) and emergency department-presenting sepsis (EDPS) are not well described. OBJECTIVES We aimed to (1) quantify the prevalence of HPS versus EDPS cases and outcomes; (2) compare HPS versus EDPS characteristics at presentation; (3) compare HPS versus EDPS in process and patient outcomes; and (4) estimate risk differences in patient outcomes attributable to initial resuscitation disparities. DESIGN Retrospective consecutive-sample cohort. SETTING Nine hospitals from October 1, 2014, to March 31, 2016. PATIENTS All hospitalized patients with sepsis or septic shock, as defined by simultaneous (1) infection, (2) ≥2 Systemic Inflammatory Response Syndrome (SIRS) criteria, and (3) ≥1 acute organ dysfunction criterion. EDPS met inclusion criteria while physically in the emergency department (ED). HPS met the criteria after leaving the ED. MEASUREMENTS We assessed overall HPS versus EDPS contributions to case prevalence and outcomes, and then compared group differences. Process outcomes included 3-hour bundle compliance and discrete bundle elements (eg, time to antibiotics). The primary patient outcome was hospital mortality. RESULTS Of 11,182 sepsis hospitalizations, 2,509 (22.4%) were hospital-presenting. HPS contributed 785 (35%) sepsis mortalities. HPS had more frequent heart failure (OR: 1.31, CI: 1.18-1.47), renal failure (OR: 1.62, CI: 1.38-1.91), gastrointestinal source of infection (OR: 1.84, CI: 1.48-2.29), euthermia (OR: 1.45, CI: 1.10-1.92), hypotension (OR: 1.85, CI: 1.65-2.08), or impaired gas exchange (OR: 2.46, CI: 1.43-4.24). HPS were admitted less often from skilled nursing facilities (OR: 0.44, CI: 0.32-0.60), had chronic obstructive pulmonary disease (OR: 0.53, CI: 0.36-0.78), tachypnea (OR: 0.76, CI: 0.58-0.98), or acute kidney injury (OR: 0.82, CI: 0.68-0.97). In a propensity-matched cohort (n = 3,844), HPS patients had less than half the odds of 3-hour bundle compliant care (17.0% vs 30.3%, OR: 0.47, CI: 0.40-0.57) or antibiotics within three hours (66.2% vs 83.8%, OR: 0.38, CI: 0.32-0.44) vs EDPS. HPS was associated with higher mortality (31.2% vs 19.3%, OR: 1.90, CI: 1.64-2.20); 23.3% of this association was attributable to differences in initial resuscitation (resuscitation-adjusted OR: 1.69, CI: 1.43-2.00). CONCLUSIONS HPS differed from EDPS by admission source, comorbidities, and clinical presentation. These patients received markedly less timely initial resuscitation; this disparity explained a moderate proportion of mortality differences.
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Affiliation(s)
- Daniel E Leisman
- Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Emergency Medicine, Hofstra-Northwell School of Medicine, Hempstead, New York
- Global Sepsis Alliance, Jena,
Germany
- Corresponding Author: Daniel E Leisman, BS; E-mail: ; Telephone: 516-941-8468
| | - Catalina Angel
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sandra M Schneider
- Department of Emergency Medicine, Hofstra-Northwell School of Medicine, Hempstead, New York
- American College of Emergency Physicians, Irving, Texas
| | - Jason A D’Amore
- Department of Emergency Medicine, Hofstra-Northwell School of Medicine, Hempstead, New York
| | - John K D’Angelo
- Department of Emergency Medicine, Hofstra-Northwell School of Medicine, Hempstead, New York
| | - Martin E Doerfler
- Department of Medicine, Hofstra-Northwell School of Medicine, Hempstead, New York
- Department of Science Education, Hofstra-Northwell School of Medicine, Hempstead, New York
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Frequency and mortality of septic shock in Europe and North America: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:196. [PMID: 31151462 PMCID: PMC6545004 DOI: 10.1186/s13054-019-2478-6] [Citation(s) in RCA: 237] [Impact Index Per Article: 47.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/15/2019] [Indexed: 12/20/2022]
Abstract
Background Septic shock is the most severe form of sepsis, in which profound underlying abnormalities in circulatory and cellular/metabolic parameters lead to substantially increased mortality. A clear understanding and up-to-date assessment of the burden and epidemiology of septic shock are needed to help guide resource allocation and thus ultimately improve patient care. The aim of this systematic review and meta-analysis was therefore to provide a recent evaluation of the frequency of septic shock in intensive care units (ICUs) and associated ICU and hospital mortality. Methods We searched MEDLINE, Embase, and the Cochrane Library from 1 January 2005 to 20 February 2018 for observational studies that reported on the frequency and mortality of septic shock. Four reviewers independently selected studies and extracted data. Disagreements were resolved via consensus. Random effects meta-analyses were performed to estimate pooled frequency of septic shock diagnosed at admission and during the ICU stay and to estimate septic shock mortality in the ICU, hospital, and at 28 or 30 days. Results The literature search identified 6291 records of which 71 articles met the inclusion criteria. The frequency of septic shock was estimated at 10.4% (95% CI 5.9 to 16.1%) in studies reporting values for patients diagnosed at ICU admission and at 8.3% (95% CI 6.1 to 10.7%) in studies reporting values for patients diagnosed at any time during the ICU stay. ICU mortality was 37.3% (95% CI 31.5 to 43.5%), hospital mortality 39.0% (95% CI 34.4 to 43.9%), and 28-/30-day mortality 36.7% (95% CI 32.8 to 40.8%). Significant between-study heterogeneity was observed. Conclusions Our literature review reaffirms the continued common occurrence of septic shock and estimates a high mortality of around 38%. The high level of heterogeneity observed in this review may be driven by variability in defining and applying the diagnostic criteria, as well as differences in treatment and care across settings and countries. Electronic supplementary material The online version of this article (10.1186/s13054-019-2478-6) contains supplementary material, which is available to authorized users.
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Ozawa M, Ichiyanagi O, Fujita S, Naito S, Fukuhara H, Suenaga S, Takai S, Narisawa T, Hosoya N, Ishii T, Yamanobe T, Muto A, Suzuki H, Nishida H, Kato T, Tsuchiya N. Risk of SOFA Deterioration in Conservative Treatment for Emphysematous Pyelonephritis: Pitfalls of Current Trends in Therapeutics from Multicenter Clinical Experience. Curr Urol 2019; 12:134-141. [PMID: 31316321 PMCID: PMC6613313 DOI: 10.1159/000489431] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 09/20/2017] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION We investigated relationships between therapeutic outcomes of patients with emphysematous pyelonephritis (EPN) and changes in the Sequential Organ Failure Assessment (SOFA) score. MATERIALS AND METHODS We retrospectively evaluated EPN patients treated in our hospitals using the SOFA score incorporated in the Sepsis-3 updated in 2016. RESULTS Seventeen typical EPN patients were included in this study, and were treated with medical management with no drainage (n = 3), retrograde stenting (n = 10), or percutaneous drainage (n = 3). One patient without drainage died of sepsis, yielding an overall mortality rate of 5.9%. Twelve patients recovered without increase in the SOFA score during hospitalization. However, the SOFA score deteriorated in the other patients from admission, with the initial scores not significantly different from those of the 12 cases. The changes in the SOFA score were significantly affected by the selected approaches of drainage (100% patients for no drainage, 22% for stenting, and 0% for percutaneous drainage, p = 0.029), but not by other clinical data. CONCLUSION Most EPN patients can currently be conservatively managed successfully. However, it should be noted that less-invasive management could cause deterioration in SOFA after admission, yielding a risk of septic mortality.
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Affiliation(s)
- Michinobu Ozawa
- Department of Urology, Okitama Public General Hospital, Kawanishi, Japan
- Department of Urology, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Osamu Ichiyanagi
- Department of Urology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Suguru Fujita
- Department of Urology, Yamagata University Faculty of Medicine, Yamagata, Japan
- Department of Urology, Nihonkai General Hospital, Yamagata, Japan
| | - Sei Naito
- Department of Urology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Hiroki Fukuhara
- Department of Urology, Yamagata University Faculty of Medicine, Yamagata, Japan
- Department of Urology, Nihonkai General Hospital, Yamagata, Japan
| | - Shinta Suenaga
- Department of Urology, Tsuruoka Municipal Shonai Hospital, Tsuruoka, Japan
| | - Satoshi Takai
- Department of Urology, Okitama Public General Hospital, Kawanishi, Japan
| | - Takafumi Narisawa
- Department of Urology, Okitama Public General Hospital, Kawanishi, Japan
- Department of Urology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Noriyuki Hosoya
- Department of Urology, Yamagata Prefectural Kahoku Hospital, Yamagata, Japan
| | - Tatsuya Ishii
- Department of Urology, South Miyagi Medical Center, Miyagi, Japan
- Department of Urology, Yamagata City Hospital Saiseikan, Yamagata, Japan
| | - Takuya Yamanobe
- Department of Urology, Yamagata University Faculty of Medicine, Yamagata, Japan
- Department of Urology, Yamagata Prefectural Kahoku Hospital, Yamagata, Japan
| | - Akinori Muto
- Department of Urology, Yamagata Prefectural Shinjo Hospital, Shinjo, Japan
| | - Hitoshi Suzuki
- Department of Urology, Yamagata City Hospital Saiseikan, Yamagata, Japan
| | - Hayato Nishida
- Department of Urology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Tomoyuki Kato
- Department of Urology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Norihiko Tsuchiya
- Department of Urology, Yamagata University Faculty of Medicine, Yamagata, Japan
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Abstract
To investigate the epidemiology trend and characteristics of sepsis-related hospitalizations in Taiwan, and to compare the differences among different severity levels of sepsis.This study is a retrospective national claim database analysis. Hospitalized adult patients with sepsis between 2010 and 2014 were identified from the Two-Million-Sample Longitudinal Health and Welfare Database (LHWD) by the International Classification of Diseases 9th Edition Clinical Modification (ICD-9-CM). The patients were divided into 3 severity groups based on their medical records during hospitalization.The study results showed that in Taiwan, there were 643 new cases of sepsis in 100,000 Taiwanese. The mortality of all septic patients in Taiwan was 287 per 100,000 people, and the case fatality was 29.2%. It was found that the mortality and incidence of sepsis in Taiwan have increased year by year, but there has been no significant change over time. In addition, demographic variation exists in the epidemiology of sepsis. In all the rates investigated, the men's were higher than the women's and the elderly's were higher than the youths'. The analysis results also showed that the respiratory system was the most common site of organ failure in septic patients.The incidence and mortality of any severity level of sepsis were 643, and 287 per 100,000 people in Taiwan, respectively, and the average case fatality was 29.2% during the study period (2010-2014). The respiratory system was the major infected site and site of organ dysfunction, especially in the more severe levels.
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Affiliation(s)
| | - Fu-Lun Chen
- Division of Infectious Diseases, Wan Fang Hospital
| | - Jin-Hua Chen
- Research Center of Biostatistics and Graduate Institute of Data Science, College of Management
| | - Man-Tzu Marcie Wu
- Department of Pharmacy, Wan Fang Hospital, Taipei Medical University
| | | | | | - Yu Ko
- Department of Pharmacy, College of Pharmacy
- Research Center for Pharmacoeconomics, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
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Le S, Hoffman J, Barton C, Fitzgerald JC, Allen A, Pellegrini E, Calvert J, Das R. Pediatric Severe Sepsis Prediction Using Machine Learning. Front Pediatr 2019; 7:413. [PMID: 31681711 PMCID: PMC6798083 DOI: 10.3389/fped.2019.00413] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 09/25/2019] [Indexed: 12/22/2022] Open
Abstract
Background: Early detection of pediatric severe sepsis is necessary in order to optimize effective treatment, and new methods are needed to facilitate this early detection. Objective: Can a machine-learning based prediction algorithm using electronic healthcare record (EHR) data predict severe sepsis onset in pediatric populations? Methods: EHR data were collected from a retrospective set of de-identified pediatric inpatient and emergency encounters for patients between 2-17 years of age, drawn from the University of California San Francisco (UCSF) Medical Center, with encounter dates between June 2011 and March 2016. Results: Pediatric patients (n = 9,486) were identified and 101 (1.06%) were labeled with severe sepsis following the pediatric severe sepsis definition of Goldstein et al. (1). In 4-fold cross-validation evaluations, the machine learning algorithm achieved an AUROC of 0.916 for discrimination between severe sepsis and control pediatric patients at the time of onset and AUROC of 0.718 at 4 h before onset. The prediction algorithm significantly outperformed the Pediatric Logistic Organ Dysfunction score (PELOD-2) (p < 0.05) and pediatric Systemic Inflammatory Response Syndrome (SIRS) (p < 0.05) in the prediction of severe sepsis 4 h before onset using cross-validation and pairwise t-tests. Conclusion: This machine learning algorithm has the potential to deliver high-performance severe sepsis detection and prediction through automated monitoring of EHR data for pediatric inpatients, which may enable earlier sepsis recognition and treatment initiation.
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Affiliation(s)
- Sidney Le
- Dascena Inc., Oakland, CA, United States
| | | | - Christopher Barton
- Dascena Inc., Oakland, CA, United States.,Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Prioli KM, Karp JK, Lyons NM, Chrebtow V, Herman JH, Pizzi LT. Economic Implications of Pathogen Reduced and Bacterially Tested Platelet Components: A US Hospital Budget Impact Model. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2018; 16:889-899. [PMID: 30062464 PMCID: PMC6244623 DOI: 10.1007/s40258-018-0409-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND US FDA draft guidance includes pathogen reduction (PR) or secondary rapid bacterial testing (RT) in its recommendations for mitigating risk of platelet component (PC) bacterial contamination. An interactive budget impact model was created for hospitals to use when considering these technologies. METHODS A Microsoft Excel model was built and populated with base-case costs and probabilities identified through literature search and a survey of US hospital transfusion service directors. Annual costs of PC acquisition, testing, wastage, dispensing/transfusion, sepsis, shelf life, and reimbursement for a mid-sized hospital that purchases all of its PCs were compared for four scenarios: 100% conventional PCs (C-PC), 100% RT-PC, 100% PR-PC, and 50% RT-PC/50% PR-PC. RESULTS Annual total costs were US$3.64, US$3.67, and US$3.96 million when all platelets were C-PC, RT-PC, or PR-PC, respectively, or US$3.81 million in the 50% RT-PC/50% PR-PC scenario. The annual net cost of PR-PC, obtained by subtracting annual reimbursements from annual total costs, is 6.18% above that of RT-PC. Maximum usable shelf lives for C-PC, RT-PC, and PR-PC are 3.0, 5.0, and 3.6 days, respectively; hospitals obtain PR-PC components earliest at 1.37 days. CONCLUSION The model predicts minimal cost increase for PR-PC versus RT-PC, including cost offsets such as elimination of bacterial detection and irradiation, and reimbursement. Additional safety provided by PR, including risk mitigation of transfusion-transmission of a broad spectrum of viruses, parasites, and emerging pathogens, may justify this increase. Effective PC shelf life may increase with RT, but platelets can be available sooner with PR due to elimination of bacterial detection, depending on blood center logistics.
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Affiliation(s)
- Katherine M. Prioli
- Center for Health Outcomes, Policy, and Economics, Rutgers University, 160 Frelinghuysen Road, Suite 417, Piscataway, NJ 08854 USA
| | - Julie Katz Karp
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University Hospital, 111 South 11th Street, Philadelphia, PA 19107 USA
| | - Nina M. Lyons
- Thomas Jefferson University, 901 Walnut Street, Suite 901, Philadelphia, PA 19107 USA
| | - Vera Chrebtow
- Global Marketing and Communications, Cerus Corporation, 2550 Stanwell Drive, Concord, CA 94520 USA
| | - Jay H. Herman
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University Hospital, 111 South 11th Street, Philadelphia, PA 19107 USA
| | - Laura T. Pizzi
- Center for Health Outcomes, Policy, and Economics, Rutgers University, 160 Frelinghuysen Road, Suite 417, Piscataway, NJ 08854 USA
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Paoli CJ, Reynolds MA, Sinha M, Gitlin M, Crouser E. Epidemiology and Costs of Sepsis in the United States-An Analysis Based on Timing of Diagnosis and Severity Level. Crit Care Med 2018; 46:1889-1897. [PMID: 30048332 PMCID: PMC6250243 DOI: 10.1097/ccm.0000000000003342] [Citation(s) in RCA: 372] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To characterize the current burden, outcomes, and costs of managing sepsis patients in U.S. hospitals. DESIGN A retrospective observational study was conducted using the Premier Healthcare Database, which represents ~20% of U.S. inpatient discharges among private and academic hospitals. Hospital costs were obtained from billing records per the cost accounting method used by each hospital. Descriptive statistics were performed on patient demographics, characteristics, and clinical and economic outcomes for the index hospitalization and 30-day readmissions. SETTING Sepsis patient hospitalizations, including inpatient, general ward, and ICU (intermediate and/or step-down). PATIENTS Adults over 18 years old with a hospital discharge diagnosis code of sepsis from January 1, 2010, to September 30, 2016. INTERVENTIONS None. This was a retrospective observational study of deidentified data. MEASUREMENTS AND MAIN RESULTS The final study cohort consisted of 2,566,689 sepsis cases, representing patients with a mean age of 65 years (50.8% female). Overall mortality was 12.5% but varied greatly by severity (5.6%, 14.9%, and 34.2%) for sepsis without organ dysfunction, severe sepsis, and septic shock, respectively. Costs followed a similar pattern increasing by severity level: $16,324, $24,638, and $38,298 and varied widely by sepsis present at admission ($18,023) and not present at admission ($51,022). CONCLUSIONS The highest burden of incidence and total costs occurred in the lowest severity sepsis cohort population. Sepsis cases not diagnosed until after admission, and those with increasing severity had a higher economic burden and mortality on a case-by-case basis. Methods to improve early identification of sepsis may provide opportunities for reducing the severity and economic burden of sepsis in the United States.
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Affiliation(s)
- Carly J. Paoli
- Health Economics and Reimbursement, Beckman Coulter, Inc., Brea, CA
| | - Mark A. Reynolds
- Health Economics and Reimbursement, Beckman Coulter, Inc., Brea, CA
| | - Meenal Sinha
- Premier Applied Sciences, Premier, Inc., Charlotte, NC
| | - Matthew Gitlin
- Health Economics and Outcomes Research, BluePath Solutions, Los Angeles, CA
| | - Elliott Crouser
- Critical Care Medicine, Ohio State University Wexner Medical Center, Columbus, OH
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Fitzgerald JC, Ross ME, Thomas NJ, Weiss SL, Balamuth F, Anderson AH. Risk factors and inpatient outcomes associated with acute kidney injury at pediatric severe sepsis presentation. Pediatr Nephrol 2018; 33:1781-1790. [PMID: 29948309 DOI: 10.1007/s00467-018-3981-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 04/23/2018] [Accepted: 05/02/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Little data exist on acute kidney injury (AKI) risk factors in pediatric sepsis. We identified risk factors and inpatient outcomes associated with AKI at sepsis recognition in children with severe sepsis. METHODS Retrospective, cross-sectional study with inpatient outcome description of 315 patients > 1 month to < 20 years old with severe sepsis in a pediatric intensive care unit over 3 years. Exposures included demographics, vitals, and laboratory data. The primary outcome was kidney disease: Improving Global Outcomes creatinine-defined AKI within 24 h of sepsis recognition. Factors associated with AKI and AKI severity were identified using multivariable Poisson and multinomial logistic regression, respectively. RESULTS AKI was present in 42% (133/315) of severe sepsis patients, and 26% (83/315) had severe (stage 2/3) AKI. In multivariable-adjusted analysis, hematologic/immunologic comorbidities, malignancies, chronic kidney disease (CKD), abdominal infection, admission illness severity, and minimum systolic blood pressure (SBP) ≤ 5th percentile for age and sex within 24 h of sepsis recognition were associated with AKI. Factors associated with mild AKI were CKD and abdominal infection, while factors associated with severe AKI were younger age, hematologic/immunologic comorbidities, malignancy, abdominal infection, and minimum SBP ≤ 5th percentile. Patients with AKI had increased hospital mortality (17 vs. 8%, P = 0.02) and length of stay [median 20 (IQR 10-47) vs. 16 days (IQR 7-37), P = 0.03]. CONCLUSIONS In pediatric severe sepsis, AKI is associated with age, comorbidities, infection characteristics, and hypotension. Future evaluation of risk factors for AKI progression during sepsis is warranted to minimize AKI progression in this high-risk population.
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Affiliation(s)
- Julie C Fitzgerald
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 8th Floor Main Hospital, Room 8571, Philadelphia, PA, 19104, USA. .,Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, USA.
| | - Michelle E Ross
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children's Hospital, Penn State University College of Medicine, Hershey, PA, USA
| | - Scott L Weiss
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 8th Floor Main Hospital, Room 8571, Philadelphia, PA, 19104, USA
| | - Fran Balamuth
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amanda Hyre Anderson
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Validation of the Sepsis Severity Score Compared with Updated Severity Scores in Predicting Hospital Mortality in Sepsis Patients. Shock 2018; 47:720-725. [PMID: 27984522 DOI: 10.1097/shk.0000000000000818] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Recently, the Sepsis Severity Score (SSS) was constructed to predict mortality in sepsis patients. The aim of this study was to compare performance of the SSS with the Acute Physiology and Chronic Health Evaluation (APACHE) II-IV, Simplified Acute Physiology Score (SAPS) II, and SAPS 3 scores in predicting hospital outcome in sepsis patients. METHODS A retroprospective analysis was conducted in the medical intensive care unit of a tertiary university hospital. RESULTS A total of 913 patients were enrolled; 476 of these patients (52.1%) had septic shock. The median SSS was 80 (range 20-137). The SSS presented good discrimination with an area under the receiver operating characteristic curve (AUC) of 0.892. However, the AUC of the SSS did not differ significantly from that of APACHE II (P = 0.07), SAPS II (P = 0.06), and SAPS 3 (P = 0.11). The APACHE IV score showed the best discrimination with an AUC of 0.948 and the overall performance by a Brier score of 0.096. The AUC of the APACHE IV score was statistically greater than the SSS, APACHE II, SAPS II, and SAPS 3 (P <0.0001 for all) and APACHE III (P = 0.0002). The calibration of all scores was poor with the Hosmer-Lemeshow goodness-of-fit H test <0.05. CONCLUSIONS The SSS provided as good discrimination as the APACHE II, SAPS II, and SAPS 3 scores. However, the APACHE IV score had the best discrimination and overall performance in our sepsis patients. The SSS needs to be adapted and modified with new parameters to improve its performance.
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McCoy A, Das R. Reducing patient mortality, length of stay and readmissions through machine learning-based sepsis prediction in the emergency department, intensive care unit and hospital floor units. BMJ Open Qual 2017; 6:e000158. [PMID: 29450295 PMCID: PMC5699136 DOI: 10.1136/bmjoq-2017-000158] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 09/12/2017] [Accepted: 09/21/2017] [Indexed: 12/29/2022] Open
Abstract
Introduction Sepsis management is a challenge for hospitals nationwide, as severe sepsis carries high mortality rates and costs the US healthcare system billions of dollars each year. It has been shown that early intervention for patients with severe sepsis and septic shock is associated with higher rates of survival. The Cape Regional Medical Center (CRMC) aimed to improve sepsis-related patient outcomes through a revised sepsis management approach. Methods In collaboration with Dascena, CRMC formed a quality improvement team to implement a machine learning-based sepsis prediction algorithm to identify patients with sepsis earlier. Previously, CRMC assessed all patients for sepsis using twice-daily systemic inflammatory response syndrome screenings, but desired improvements. The quality improvement team worked to implement a machine learning-based algorithm, collect and incorporate feedback, and tailor the system to current hospital workflow. Results Relative to the pre-implementation period, the post-implementation period sepsis-related in-hospital mortality rate decreased by 60.24%, sepsis-related hospital length of stay decreased by 9.55% and sepsis-related 30-day readmission rate decreased by 50.14%. Conclusion The machine learning-based sepsis prediction algorithm improved patient outcomes at CRMC.
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Affiliation(s)
- Andrea McCoy
- Cape Regional Medical Center, Cape May Court House, New Jersey, USA
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López-Mestanza C, Andaluz-Ojeda D, Gómez-López JR, Bermejo-Martín JF. Clinical factors influencing mortality risk in hospital-acquired sepsis. J Hosp Infect 2017; 98:194-201. [PMID: 28882641 DOI: 10.1016/j.jhin.2017.08.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 08/29/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Identification of factors that confer an increased risk of mortality in hospital-acquired sepsis (HAS) is necessary to help prevent, and improve the outcome of, this condition. AIM To evaluate the clinical characteristics and factors associated with mortality in patients with HAS. METHODS Retrospective study of patients with HAS in a major Spanish Hospital from 2011 to 2015. Data from adults receiving any of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes associated with sepsis were collected. Those fulfilling the SEPSIS-2 definition with no evidence of infection during the first 48 h following hospitalization were included (N = 196). Multivariate analysis was employed to identify the risk factors of mortality. FINDINGS HAS patients were found to have many of the risk factors associated with cardiovascular disease (male sex, ageing, antecedent of cardiac disease, arterial hypertension, dyslipidaemia, smoking habit) and cancer. Vascular disease or chronic kidney disease were associated with 28-day mortality. Time from hospital admission to sepsis diagnosis, and the presence of organ failure were risk factors for 28-day and hospital mortality. Experiencing more than one episode of sepsis increased the risk of hospital mortality. 'Sepsis code' for the early identification of sepsis was protective against hospital mortality. CONCLUSION This study identifies several major factors associated with mortality in patients suffering from HAS. Implementation of surveillance programmes for the early identification and treatment of sepsis translate into a clear benefit.
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Affiliation(s)
- C López-Mestanza
- BIO∙SEPSIS (Laboratory of Biomedical Research in Sepsis), Hospital Clínico Universitario de Valladolid, SACYL, Valladolid, Spain.
| | - D Andaluz-Ojeda
- Critical Care Medicine Service, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - J R Gómez-López
- General Surgery Service, Hospital de Medina del Campo, SACYL, Medina del Campo-Valladolid, Spain
| | - J F Bermejo-Martín
- BIO∙SEPSIS (Laboratory of Biomedical Research in Sepsis), Hospital Clínico Universitario de Valladolid, SACYL, Valladolid, Spain
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What Is the National Burden of Sepsis in U.S. Emergency Departments? It Depends on the Definition. Crit Care Med 2017; 45:1569-1571. [PMID: 28816842 DOI: 10.1097/ccm.0000000000002561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Prasad PA, Shea ER, Shiboski S, Sullivan MC, Gonzales R, Shimabukuro D. Relationship Between a Sepsis Intervention Bundle and In-Hospital Mortality Among Hospitalized Patients: A Retrospective Analysis of Real-World Data. Anesth Analg 2017; 125:507-513. [PMID: 28514322 DOI: 10.1213/ane.0000000000002085] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Sepsis is a systemic response to infection that can lead to tissue damage, organ failure, and death. Efforts have been made to develop evidence-based intervention bundles to identify and manage sepsis early in the course of the disease to decrease sepsis-related morbidity and mortality. We evaluated the relationship between a minimally invasive sepsis intervention bundle and in-hospital mortality using robust methods for observational data. METHODS We performed a retrospective cohort study at the University of California, San Francisco, Medical Center among adult patients discharged between January 1, 2012, and December 31, 2014, and who received a diagnosis of severe sepsis/septic shock (SS/SS). Sepsis intervention bundle elements included measurement of blood lactate; drawing of blood cultures before starting antibiotics; initiation of broad spectrum antibiotics within 3 hours of sepsis presentation in the emergency department or 1 hour of presentation on an inpatient unit; administration of intravenous fluid bolus if the patient was hypotensive or had a lactate level >4 mmol/L; and starting intravenous vasopressors if the patient remained hypotensive after fluid bolus administration. Poisson regression for a binary outcome variable was used to estimate an adjusted incidence-rate ratio (IRR) comparing mortality in groups defined by bundle compliance measured as a binary predictor, and to estimate an adjusted number needed to treat (NNT). RESULTS Complete bundle compliance was associated with a 31% lower risk of mortality (adjusted IRR, 0.69, 95% confidence interval [CI], 0.53-0.91), adjusting for SS/SS presentation in the emergency department, SS/SS present on admission (POA), age, admission severity of illness and risk of mortality, Medicaid/Medicare payor status, immunocompromised host status, and congestive heart failure POA. The adjusted NNT to save one life was 15 (CI, 8-69). Other factors independently associated with mortality included SS/SS POA (adjusted IRR, 0.55; CI, 0.32-0.92) and increased age (adjusted IRR, 1.13 per 10-year increase in age; CI, 1.03-1.24). CONCLUSIONS The University of California, San Francisco, sepsis bundle was associated with a decreased risk of in-hospital mortality across hospital units after robust control for confounders and risk adjustment. The adjusted NNT provides a reasonable and achievable goal to observe measureable improvements in outcomes for patients diagnosed with SS/SS.
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Affiliation(s)
- Priya A Prasad
- From the *Division of General Internal Medicine, School of Medicine, University of California, San Francisco, California; †Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, California; ‡Department of Quality, Sepsis Program, University of California, San Francisco, California; and §Department of Anesthesia and Perioperative Care, School of Medicine, University of California, San Francisco, California
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Abstract
BACKGROUND Sepsis most often presents to the ED, and delayed detection is harmful. WBC count is often used to detect sepsis, but changes in WBC count size also correspond to sepsis. We sought to determine if volume increases of circulating immune cells add value to the WBC count for early sepsis detection in the ED. METHODS A blinded, prospective cohort study was conducted in two different ED populations within a large academic hospital. RESULTS Neutrophil and monocyte volume parameters were measured in conjunction with routine CBC testing on a UniCel DxH 800 analyzer at the time of ED admission and were evaluated for the detection of sepsis. There were 1,320 subjects in the ED consecutively enrolled and categorized as control subjects (n = 879) and those with systemic inflammatory response syndrome (SIRS) (n = 203), infection (n = 140), or sepsis (n = 98). Compared with other parameters, monocyte distribution width (MDW) best discriminated sepsis from all other conditions (area under the curve [AUC], 0.79; 95% CI, 0.73-0.84; sensitivity, 0.77; specificity, 0.73; MDW threshold, 20.50), sepsis from SIRS (AUC, 0.74; 95% CI, 0.67-0.84), and severe sepsis from noninfected patients in the ED (AUC, 0.88; 95% CI, 0.75-0.99; negative predictive value, 99%). The added value of MDW to WBC count was statistically significant (AUC, 0.89 for MDW + WBC vs 0.81 for WBC alone; P < .01); a decision curve analysis also showed improved performance compared with WBC count alone. CONCLUSIONS The incorporation of MDW with WBC count is shown in this prospective cohort study to improve detection of sepsis compared with WBC count alone at the time of admission in the ED. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02232750; URL: www.clinicaltrials.gov.
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Rothman M, Levy M, Dellinger RP, Jones SL, Fogerty RL, Voelker KG, Gross B, Marchetti A, Beals J. Sepsis as 2 problems: Identifying sepsis at admission and predicting onset in the hospital using an electronic medical record–based acuity score. J Crit Care 2017; 38:237-244. [DOI: 10.1016/j.jcrc.2016.11.037] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 11/08/2016] [Accepted: 11/23/2016] [Indexed: 12/14/2022]
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Oud L. Determinants of Home Discharge Among Survivors of Necrotizing Fasciitis: A Population-Level Analysis. J Clin Med Res 2016; 8:537-43. [PMID: 27298663 PMCID: PMC4894024 DOI: 10.14740/jocmr2573w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2016] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The majority of patients with necrotizing fasciitis (NF) in the United Sates survive their illness, and there is increasing interest in addressing the ability of survivors to return to their community following hospitalization. However, there are no data on the factors affecting home discharge among survivors of NF. METHODS We used the Texas Inpatient Public Use Data File to conduct a retrospective population-based examination of hospitalizations with NF aged 15 years or older between 2001 and 2010. Multivariate logistic regression modeling was used to explore predictors of home discharge among hospital survivors. RESULTS There were 10,724 NF hospitalizations surviving to discharge during study period, of which 62.5% were discharged home. The following key predictors have adversely affected odds of home discharge (odds ratio and 95% confidence intervals): age ≥ 75 years (0.349 (0.292 - 0.417)), Medicare insurance (0.582 (0.510 - 0.663)), congestive heart failure (0.836 (0.719 - 0.972)), chronic liver disease (0.684 (0.522 - 0.895)), respiratory failure (0.464 (0.386 - 0.558)), neurological failure (0.573 (0.418 - 0.787)), and need for mechanical ventilation (0.339 (0.199 - 0.578)). Increased odds of home discharge were found among males (1.116 (1.058 - 1.285)), Hispanics (1.193 (1.056 - 1.349)), those lacking health insurance (2.161 (1.183 - 2.521)) or managed at a teaching hospital (1.264 (1.127 - 1.418)). CONCLUSIONS In this first population-level examination of the determinants of home discharge among survivors of NF, older age, Medicare insurance, selected comorbidities, and development of organ failure decreased patients' odds of home discharge. Unexpectedly, male gender, Hispanic ethnicity, lack of health insurance, and being managed at a teaching hospital were associated with favorable impact on patients' discharge disposition. Further studies are warranted in other populations and healthcare environments to corroborate the present findings and to refine our understanding of the factors affecting short-term outcomes among NF survivors.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, 701 W. 5th St., Odessa, TX 79763, USA.
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Jones SL, Ashton CM, Kiehne L, Gigliotti E, Bell-Gordon C, Pinn TT, Tran SK, Nicolas JC, Rose AL, Shirkey BA, Disbot M, Masud F, Wray NP. The Sepsis Early Recognition and Response Initiative (SERRI). Jt Comm J Qual Patient Saf 2016; 42:122-38. [DOI: 10.1016/s1553-7250(16)42015-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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