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Alrawashdeh M, Klompas M, Rhee C. The Impact of Common Variations in Sequential Organ Failure Assessment Score Calculation on Sepsis Measurement Using Sepsis-3 Criteria: A Retrospective Analysis Using Electronic Health Record Data. Crit Care Med 2024; 52:1380-1390. [PMID: 38780372 DOI: 10.1097/ccm.0000000000006338] [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: 05/25/2024]
Abstract
OBJECTIVES To assess the impact of different methods of calculating Sequential Organ Failure Assessment (SOFA) scores using electronic health record data on the incidence, outcomes, agreement, and predictive validity of Sepsis-3 criteria. DESIGN Retrospective observational study. SETTING Five Massachusetts hospitals. PATIENTS Hospitalized adults, 2015 to 2022. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We defined sepsis as a suspected infection (culture obtained and antibiotic administered) with a concurrent increase in SOFA score by greater than or equal to 2 points (Sepsis-3 criteria). Our reference SOFA implementation strategy imputed normal values for missing data, used Pa o2 /F io2 ratios for respiratory scores, and assumed normal baseline SOFA scores for community-onset sepsis. We then implemented SOFA scores using different missing data imputation strategies (averaging worst values from preceding and following days vs. carrying forward nonmissing values), imputing respiratory scores using Sp o2 /F io2 ratios, and incorporating comorbidities and prehospital laboratory data into baseline SOFA scores. Among 1,064,459 hospitalizations, 297,512 (27.9%) had suspected infection and 141,052 (13.3%) had sepsis with an in-hospital mortality rate of 10.3% using the reference SOFA method. The percentage of patients missing SOFA components for at least 1 day in the infection window was highest for Pa o2 /F io2 ratios (98.6%), followed by Sp o2 /F io2 ratios (73.5%), bilirubin (68.5%), and Glasgow Coma Scale scores (57.2%). Different missing data imputation strategies yielded near-perfect agreement in identifying sepsis (kappa 0.99). However, using Sp o2 /F io2 imputations yielded higher sepsis incidence (18.3%), lower mortality (8.1%), and slightly lower predictive validity for mortality (area under the receiver operating curves [AUROC] 0.76 vs. 0.78). For community-onset sepsis, incorporating comorbidities and historical laboratory data into baseline SOFA score estimates yielded lower sepsis incidence (6.9% vs. 11.6%), higher mortality (13.4% vs. 9.6%), and higher predictive validity (AUROC 0.79 vs. 0.75) relative to the reference SOFA implementation. CONCLUSIONS Common variations in calculating respiratory and baseline SOFA scores, but not in handling missing data, lead to substantial differences in observed incidence, mortality, agreement, and predictive validity of Sepsis-3 criteria.
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Affiliation(s)
- Mohammad Alrawashdeh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
- Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA
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Stangl F, Wagenlehner F, Schneidewind L, Kranz J. [Urosepsis: pathophysiology, diagnosis, and management-an update]. UROLOGIE (HEIDELBERG, GERMANY) 2024; 63:543-550. [PMID: 38639782 DOI: 10.1007/s00120-024-02336-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/21/2024] [Indexed: 04/20/2024]
Abstract
Urinary tract infections vary widely in their clinical spectrum, ranging from uncomplicated cystitis to septic shock. Urosepsis accounts for 9-31% of all cases of septicemia and is often associated with nosocomial infections. A major risk factor for urosepsis is the presence of obstructive uropathy, caused by conditions such as urolithiasis, tumors, or strictures. The severity and course of urosepsis depend on both the virulence of the pathogen and the patient's specific immune response. Prompt therapy, including antimicrobial treatment and eradication of the infection source, along with supportive measures for circulatory and respiratory stabilization, and adjunctive therapies such as hemodialysis and glucocorticoid therapy, is crucial. Due to demographic changes, an increase in cases of urosepsis is expected-thus, it is of utmost importance for urologists to be familiar with targeted diagnostics and effective treatment.
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Affiliation(s)
- Fabian Stangl
- Universitätsklinik für Urologie, Universität Bern, Bern, Schweiz
| | - Florian Wagenlehner
- Klinik für Urologie, Kinderurologie und Andrologie, Justus-Liebig-Universität Gießen, Gießen, Deutschland
| | | | - Jennifer Kranz
- Klinik für Urologie und Kinderurologie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
- Universitätsklinik und Poliklinik für Urologie, Universitätsklinikum Halle (Saale), Halle (Saale), Deutschland.
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Advani SD, Cawcutt K, Klompas M, Marschall J, Meddings J, Patel PK. The next frontier of healthcare-associated infection (HAI) surveillance metrics: Beyond device-associated infections. Infect Control Hosp Epidemiol 2024; 45:693-697. [PMID: 38221847 DOI: 10.1017/ice.2023.283] [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: 01/16/2024]
Abstract
In recent years, it has become increasingly evident that surveillance metrics for invasive device-associated infections (ie, central-line-associated bloodstream infections, ventilator-associated pneumonias, and catheter-associated urinary tract infections) do not capture all harms; they capture only a subset of healthcare-associated infections (HAIs). Although prevention of device-associated infections remains critical, we need to address the full spectrum of potential harms from device use and non-device-associated infections. These include complications associated with additional devices, such as peripheral venous and arterial catheters, non-device-associated infections such as nonventilator hospital-acquired pneumonia, and noninfectious device complications such as trauma, thrombosis, and acute lung injury. As authors of the device-associated infection sections in the SHEA/IDSA/APIC Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, we highlight catheter-associated urinary tract infection as an example of the strengths and limitations of the current emphasis on device-associated infection surveillance, suggest performance metrics that present a more comprehensive picture of patient harm, and provide a high-level overview of similar issues with other infection surveillance measures.
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Affiliation(s)
- Sonali D Advani
- Duke University School of Medicine, Durham, North Carolina, United States
| | - Kelly Cawcutt
- University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Michael Klompas
- Brigham and Women's Hospital and Harvard Medical School Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States
| | - Jonas Marschall
- Bern University Hospital, University of Bern, Bern, Switzerland
- Washington University School of Medicine, St. Louis, Missouri, United States
| | - Jennifer Meddings
- University of Michigan Medical School, Veterans' Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States
| | - Payal K Patel
- Intermountain Healthcare, Salt Lake City, Utah, United States
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Rhee C, Strich JR, Chiotos K, Classen DC, Cosgrove SE, Greeno R, Heil EL, Kadri SS, Kalil AC, Gilbert DN, Masur H, Septimus EJ, Sweeney DA, Terry A, Winslow DL, Yealy DM, Klompas M. Improving Sepsis Outcomes in the Era of Pay-for-Performance and Electronic Quality Measures: A Joint IDSA/ACEP/PIDS/SHEA/SHM/SIDP Position Paper. Clin Infect Dis 2024; 78:505-513. [PMID: 37831591 DOI: 10.1093/cid/ciad447] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Indexed: 10/15/2023] Open
Abstract
The Centers for Medicare & Medicaid Services (CMS) introduced the Severe Sepsis/Septic Shock Management Bundle (SEP-1) as a pay-for-reporting measure in 2015 and is now planning to make it a pay-for-performance measure by incorporating it into the Hospital Value-Based Purchasing Program. This joint IDSA/ACEP/PIDS/SHEA/SHM/SIPD position paper highlights concerns with this change. Multiple studies indicate that SEP-1 implementation was associated with increased broad-spectrum antibiotic use, lactate measurements, and aggressive fluid resuscitation for patients with suspected sepsis but not with decreased mortality rates. Increased focus on SEP-1 risks further diverting attention and resources from more effective measures and comprehensive sepsis care. We recommend retiring SEP-1 rather than using it in a payment model and shifting instead to new sepsis metrics that focus on patient outcomes. CMS is developing a community-onset sepsis 30-day mortality electronic clinical quality measure (eCQM) that is an important step in this direction. The eCQM preliminarily identifies sepsis using systemic inflammatory response syndrome (SIRS) criteria, antibiotic administrations or diagnosis codes for infection or sepsis, and clinical indicators of acute organ dysfunction. We support the eCQM but recommend removing SIRS criteria and diagnosis codes to streamline implementation, decrease variability between hospitals, maintain vigilance for patients with sepsis but without SIRS, and avoid promoting antibiotic use in uninfected patients with SIRS. We further advocate for CMS to harmonize the eCQM with the Centers for Disease Control and Prevention's (CDC) Adult Sepsis Event surveillance metric to promote unity in federal measures, decrease reporting burden for hospitals, and facilitate shared prevention initiatives. These steps will result in a more robust measure that will encourage hospitals to pay more attention to the full breadth of sepsis care, stimulate new innovations in diagnosis and treatment, and ultimately bring us closer to our shared goal of improving outcomes for patients.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeffrey R Strich
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Kathleen Chiotos
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David C Classen
- Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ron Greeno
- Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Emily L Heil
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sameer S Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska School of Medicine, Omaha, Nebraska, USA
| | - David N Gilbert
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Henry Masur
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Edward J Septimus
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
- Department of Internal Medicine, Texas A&M College of Medicine, Houston, Texas, USA
| | - Daniel A Sweeney
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Diego School of Medicine, San Diego, California, USA
| | - Aisha Terry
- Department of Emergency Medicine, George Washington University School of Medicine, Washington D.C., USA
| | - Dean L Winslow
- Division of Infectious Diseases, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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5
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Su J, Guan B, Su Q, Hu S, Wu S, Tong Z, Zhou F. Fucoxanthin Ameliorates Sepsis via Modulating Microbiota by Targeting IRF3 Activation. Int J Mol Sci 2023; 24:13803. [PMID: 37762104 PMCID: PMC10530764 DOI: 10.3390/ijms241813803] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 08/26/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
To improve patient survival in sepsis, it is necessary to curtail exaggerated inflammatory responses. Fucoxanthin (FX), a carotenoid derived from brown algae, efficiently suppresses pro-inflammatory cytokine expression via IRF3 activation, thereby reducing mortality in a mouse model of sepsis. However, the effects of FX-targeted IRF3 on the bacterial flora (which is disrupted in sepsis) and the mechanisms by which it impacts sepsis development remain unclear. This study aims to elucidate how FX-targeted IRF3 modulates intestinal microbiota compositions, influencing sepsis development. FX significantly reduced the bacterial load in the abdominal cavity of mice with cecal ligation and puncture (CLP)-induced sepsis via IRF3 activation and increased short-chain fatty acids, like acetic and propionic acids, with respect to their intestines. FX also altered the structure of the intestinal flora, notably elevating beneficial Verrucomicrobiota and Akkermansia spp. while reducing harmful Morganella spp. Investigating the inflammation-flora link, we found positive correlations between the abundances of Morganella spp., Proteus spp., Escherichia spp., and Klebsiella spp. and pro-inflammatory cytokines (IL-6, IL-1β, and TNF-α) induced by CLP. These bacteria were negatively correlated with acetic and propionic acid production. FX alters microbial diversity and promotes short-chain fatty acid production in mice with CLP-induced sepsis, reshaping gut homeostasis. These findings support the value of FX for the treatment of sepsis.
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Affiliation(s)
- Jingqian Su
- Fujian Key Laboratory of Innate Immune Biology, Biomedical Research Center of South China, College of Life Sciences, Fujian Normal University, Fuzhou 350117, China; (B.G.); (Q.S.); (S.H.); (S.W.); (Z.T.); (F.Z.)
- Provincial University Key Laboratory of Microbial Pathogenesis and Interventions, College of Life Sciences, Fujian Normal University, Fuzhou 350117, China
| | - Biyun Guan
- Fujian Key Laboratory of Innate Immune Biology, Biomedical Research Center of South China, College of Life Sciences, Fujian Normal University, Fuzhou 350117, China; (B.G.); (Q.S.); (S.H.); (S.W.); (Z.T.); (F.Z.)
| | - Qiaofen Su
- Fujian Key Laboratory of Innate Immune Biology, Biomedical Research Center of South China, College of Life Sciences, Fujian Normal University, Fuzhou 350117, China; (B.G.); (Q.S.); (S.H.); (S.W.); (Z.T.); (F.Z.)
- Provincial University Key Laboratory of Microbial Pathogenesis and Interventions, College of Life Sciences, Fujian Normal University, Fuzhou 350117, China
| | - Shan Hu
- Fujian Key Laboratory of Innate Immune Biology, Biomedical Research Center of South China, College of Life Sciences, Fujian Normal University, Fuzhou 350117, China; (B.G.); (Q.S.); (S.H.); (S.W.); (Z.T.); (F.Z.)
- Provincial University Key Laboratory of Microbial Pathogenesis and Interventions, College of Life Sciences, Fujian Normal University, Fuzhou 350117, China
| | - Shun Wu
- Fujian Key Laboratory of Innate Immune Biology, Biomedical Research Center of South China, College of Life Sciences, Fujian Normal University, Fuzhou 350117, China; (B.G.); (Q.S.); (S.H.); (S.W.); (Z.T.); (F.Z.)
| | - Zhiyong Tong
- Fujian Key Laboratory of Innate Immune Biology, Biomedical Research Center of South China, College of Life Sciences, Fujian Normal University, Fuzhou 350117, China; (B.G.); (Q.S.); (S.H.); (S.W.); (Z.T.); (F.Z.)
| | - Fen Zhou
- Fujian Key Laboratory of Innate Immune Biology, Biomedical Research Center of South China, College of Life Sciences, Fujian Normal University, Fuzhou 350117, China; (B.G.); (Q.S.); (S.H.); (S.W.); (Z.T.); (F.Z.)
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6
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Affiliation(s)
- Alexander Lawandi
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, QC, Canada
- Department of Critical Care Medicine, McGill University, Montreal, QC, Canada
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7
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Karlic KJ, Clouse TL, Hogan CK, Garland A, Seelye S, Sussman JB, Prescott HC. Comparison of Administrative versus Electronic Health Record-based Methods for Identifying Sepsis Hospitalizations. Ann Am Thorac Soc 2023; 20:1309-1315. [PMID: 37163757 DOI: 10.1513/annalsats.202302-105oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/10/2023] [Indexed: 05/12/2023] Open
Abstract
Rationale: Despite the importance of sepsis surveillance, no optimal approach for identifying sepsis hospitalizations exists. The Centers for Disease Control and Prevention Adult Sepsis Event Definition (CDC-ASE) is an electronic medical record-based algorithm that yields more stable estimates over time than diagnostic coding-based approaches but may still result in misclassification. Objectives: We sought to assess three approaches to identifying sepsis hospitalizations, including a modified CDC-ASE. Methods: This cross-sectional study included patients in the Veterans Affairs Ann Arbor Healthcare System admitted via the emergency department (February 2021 to February 2022) with at least one episode of acute organ dysfunction within 48 hours of emergency department presentation. Patients were assessed for community-onset sepsis using three methods: 1) explicit diagnosis codes, 2) the CDC-ASE, and 3) a modified CDC-ASE. The modified CDC-ASE required at least two systemic inflammatory response syndrome criteria instead of blood culture collection and had a more sensitive definition of respiratory dysfunction. Each method was compared with a reference standard of physician adjudication via medical record review. Patients were considered to have sepsis if they had at least one episode of acute organ dysfunction graded as "definitely" or "probably" infection related on physician review. Results: Of 821 eligible hospitalizations, 449 were selected for physician review. Of these, 98 (21.8%) were classified as sepsis by medical record review, 103 (22.9%) by the CDC-ASE, 132 (29.4%) by the modified CDC-ASE, and 37 (8.2%) by diagnostic codes. Accuracy was similar across the three methods of interest (80.6% for the CDC-ASE, 79.6% for the modified CDC-ADE, and 84.2% for diagnostic codes), but sensitivity and specificity varied. The CDC-ASE algorithm had sensitivity of 58.2% (95% confidence interval [CI], 47.2-68.1%) and specificity of 86.9% (95% CI, 82.9-90.2%). The modified CDC-ASE algorithm had greater sensitivity (69.4% [95% CI, 59.3-78.3%]) but lower specificity (81.8% [95% CI, 77.3-85.7%]). Diagnostic codes had lower sensitivity (32.7% [95% CI, 23.5-42.9%]) but greater specificity (98.6% [95% CI, 96.7-99.55%]). Conclusions: There are several approaches to identifying sepsis hospitalizations for surveillance that have acceptable accuracy. These approaches yield varying sensitivity and specificity, so investigators should carefully consider the test characteristics of each method before determining an appropriate method for their intended use.
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Affiliation(s)
- Kevin J Karlic
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Tori L Clouse
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Cainnear K Hogan
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; and
| | - Allan Garland
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sarah Seelye
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; and
| | - Jeremy B Sussman
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; and
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; and
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Bateson M, Marwick CA, Staines HJ, Patton A, Stewart E, Rooney KD. Performance of bedside tools for predicting infection-related mortality and administrative data for sepsis surveillance: An observational cohort study. PLoS One 2023; 18:e0280228. [PMID: 36862700 PMCID: PMC9980760 DOI: 10.1371/journal.pone.0280228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 12/23/2022] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Measuring sepsis incidence and associated mortality at scale using administrative data is hampered by variation in diagnostic coding. This study aimed first to compare how well bedside severity scores predict 30-day mortality in hospitalised patients with infection, then to assess the ability of combinations of administrative data items to identify patients with sepsis. METHODS This retrospective case note review examined 958 adult hospital admissions between October 2015 and March 2016. Admissions with blood culture sampling were matched 1:1 to admissions without a blood culture. Case note review data were linked to discharge coding and mortality. For patients with infection the performance characteristics of Sequential Organ Failure Assessment (SOFA), National Early Warning System (NEWS), quick SOFA (qSOFA), and Systemic Inflammatory Response Syndrome (SIRS) were calculated for predicting 30-day mortality. Next, the performance characteristics of administrative data (blood cultures and discharge codes) for identifying patients with sepsis, defined as SOFA ≥2 because of infection, were calculated. RESULTS Infection was documented in 630 (65.8%) admissions and 347 (55.1%) patients with infection had sepsis. NEWS (Area Under the Receiver Operating Characteristic, AUROC 0.78 95%CI 0.72-0.83) and SOFA (AUROC 0.77, 95%CI 0.72-0.83), performed similarly well for prediction of 30-day mortality. Having an infection and/or sepsis International Classification of Diseases, Tenth Revision (ICD-10) code (AUROC 0.68, 95%CI 0.64-0.71) performed as well in identifying patients with sepsis as having at least one of: an infection code; sepsis code, or; blood culture (AUROC 0.68, 95%CI 0.65-0.71), Sepsis codes (AUROC 0.53, 95%CI 0.49-0.57) and positive blood cultures (AUROC 0.52, 95%CI 0.49-0.56) performed least well. CONCLUSIONS SOFA and NEWS best predicted 30-day mortality in patients with infection. Sepsis ICD-10 codes lack sensitivity. For health systems without suitable electronic health records, blood culture sampling has potential utility as a clinical component of a proxy marker for sepsis surveillance.
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Affiliation(s)
- Meghan Bateson
- ihub, Healthcare Improvement Scotland, Glasgow, United Kingdom
- * E-mail:
| | - Charis A. Marwick
- Population Health & Genomics Division, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Harry J. Staines
- Healthcare Biometrics, Sigma Statistical Services, Balmullo, United Kingdom
| | - Andrea Patton
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Elaine Stewart
- School of Health and Life Sciences, University of the West of Scotland, Lanarkshire, United Kingdom
| | - Kevin D. Rooney
- Department of Anaesthetics and Intensive Care Medicine, Royal Alexandra Hospital, Paisley, United Kingdom
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Tabaie A, Orenstein EW, Kandaswamy S, Kamaleswaran R. Integrating structured and unstructured data for timely prediction of bloodstream infection among children. Pediatr Res 2023; 93:969-975. [PMID: 35854085 DOI: 10.1038/s41390-022-02116-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/08/2022] [Accepted: 05/08/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hospitalized children with central venous lines (CVLs) are at higher risk of hospital-acquired infections. Information in electronic health records (EHRs) can be employed in training deep learning models to predict the onset of these infections. We incorporated clinical notes in addition to structured EHR data to predict serious bloodstream infections, defined as positive blood culture followed by at least 4 days of new antimicrobial agent administration, among hospitalized children with CVLs. METHODS Structured EHR information and clinical notes were extracted for a retrospective cohort including all hospitalized patients with CVLs at a single tertiary care pediatric health system from 2013 to 2018. Deep learning models were trained to determine the added benefit of incorporating the information embedded in clinical notes in predicting serious bloodstream infection. RESULTS A total of 24,351 patient encounters met inclusion criteria. The best-performing model restricted to structured EHR data had a specificity of 0.951 and positive predictive value (PPV) of 0.056 when the sensitivity was set to 0.85. The addition of contextualized word embeddings improved the specificity to 0.981 and PPV to 0.113. CONCLUSIONS Integrating clinical notes with structured EHR data improved the prediction of serious bloodstream infections among pediatric patients with CVLs. IMPACT Developed an advanced infection prediction model in pediatrics that integrates the structured and unstructured EHRs. Extracted information from clinical notes to do timely prediction in a clinical setting. Developed a deep learning model framework that can be employed in predicting rare events in a complex and dynamic environment.
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Affiliation(s)
- Azade Tabaie
- Department of Biomedical Informatics, Emory School of Medicine, Atlanta, GA, USA.
| | - Evan W Orenstein
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory School of Medicine, Atlanta, GA, USA
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory School of Medicine, Atlanta, GA, USA
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10
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Abstract
IMPORTANCE Multiple classification methods are used to identify sepsis from existing data. In the trauma population, it is unknown how administrative methods compare with clinical criteria for sepsis classification. OBJECTIVES To characterize the agreement between 3 approaches to sepsis classification among critically ill patients with trauma and compare the sepsis-associated risk of adverse outcomes when each method was used to define sepsis. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data collected between January 1, 2012, and December 31, 2020, from patients aged 16 years or older with traumatic injury, admitted to the intensive care unit of a single-institution level 1 trauma center and requiring invasive mechanical ventilation for at least 3 days. Statistical analysis was conducted from August 1, 2021, to March 31, 2022. EXPOSURE Hospital-acquired sepsis, as classified by 3 methods: a novel automated clinical method based on data from the electronic health record, the National Trauma Data Bank (NTDB), and explicit and implicit medical billing codes. MAIN OUTCOMES AND MEASURES The primary outcomes were chronic critical illness and in-hospital mortality. Secondary outcomes included number of days in an intensive care unit, number of days receiving mechanical ventilation, discharge to a skilled nursing or long-term care facility, and discharge to home without assistance. RESULTS Of 3194 patients meeting inclusion criteria, the median age was 49 years (IQR, 31-64 years), 2380 (74%) were male, and 2826 (88%) sustained severe blunt injury (median Injury Severity Score, 29 [IQR, 21-38]). Sepsis was identified in 747 patients (23%) meeting automated clinical criteria, 118 (4%) meeting NTDB criteria, and 529 (17%) using medical billing codes. The Light κ value for 3-way agreement was 0.16 (95% CI, 0.14-0.19). The adjusted relative risk of chronic critical illness was 9.9 (95% CI, 8.0-12.3) for sepsis identified by automated clinical criteria, 5.0 (95% CI, 3.4-7.3) for sepsis identified by the NTDB, and 4.5 (95% CI, 3.6-5.6) for sepsis identified using medical billing codes. The adjusted relative risk for in-hospital mortality was 1.3 (95% CI, 1.0-1.6) for sepsis identified by automated clinical criteria, 2.7 (95% CI, 1.7-4.3) for sepsis identified by the NTDB, and 1.0 (95% CI, 0.7-1.2) for sepsis identified using medical billing codes. CONCLUSIONS AND RELEVANCE In this cohort study of critically ill patients with trauma, administrative methods misclassified sepsis and underestimated the incidence and severity of sepsis compared with an automated clinical method using data from the electronic health record. This study suggests that an automated approach to sepsis classification consistent with Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) clinical criteria is feasible and may improve existing approaches to health services and population-based research in this population.
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Affiliation(s)
- Katherine Stern
- Division of Trauma, Burn, and Critical Care, Department of Surgery, University of Washington, Seattle
- University of Washington School of Public Health, Seattle
- University of San Francisco East Bay General Surgery Residency Program, Oakland, California
| | - Qian Qiu
- Harborview Injury Prevention Center, University of Washington, Seattle
| | - Michael Weykamp
- Division of Trauma, Burn, and Critical Care, Department of Surgery, University of Washington, Seattle
- University of Washington School of Public Health, Seattle
| | - Grant O’Keefe
- Division of Trauma, Burn, and Critical Care, Department of Surgery, University of Washington, Seattle
- Harborview Injury Prevention Center, University of Washington, Seattle
| | - Scott C. Brakenridge
- Division of Trauma, Burn, and Critical Care, Department of Surgery, University of Washington, Seattle
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Hyun DG, Lee SY, Ahn JH, Huh JW, Hong SB, Koh Y, Lim CM, Oh DK, Suh GY, Jeon K, Ko RE, Cho YJ, Lee YJ, Lim SY, Park S, Heo J, Lee JM, Kim KC, Lee YJ, Chang Y, Jeon K, Lee SM, Hong SK, Cho WH, Kwak SH, Lee HB, Ahn JJ, Seong GM, Lee SI, Park S, Park TS, Lee SH, Choi EY, Moon JY. Mortality of patients with hospital-onset sepsis in hospitals with all-day and non-all-day rapid response teams: a prospective nationwide multicenter cohort study. Crit Care 2022; 26:280. [PMID: 36114545 PMCID: PMC9482246 DOI: 10.1186/s13054-022-04149-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background Hospital-onset sepsis is associated with a higher in-hospital mortality rate than community-onset sepsis. Many hospitals have implemented rapid response teams (RRTs) for early detection and timely management of at-risk hospitalized patients. However, the effectiveness of an all-day RRT over a non-all-day RRT in reducing the risk of in-hospital mortality in patient with hospital-onset sepsis is unclear. We aimed to determine the effect of the RRT’s operating hours on in-hospital mortality in inpatient patients with sepsis. Methods We conducted a nationwide cohort study of adult patients with hospital-onset sepsis prospectively collected from the Korean Sepsis Alliance (KSA) Database from 16 tertiary referral or university-affiliated hospitals in South Korea between September of 2019 and February of 2020. RRT was implemented in 11 hospitals, of which 5 (45.5%) operated 24-h RRT (all-day RRT) and the remaining 6 (54.5%) had part-day RRT (non-all-day RRT). The primary outcome was in-hospital mortality between the two groups. Results Of the 405 patients with hospital-onset sepsis, 206 (50.9%) were admitted to hospitals operating all-day RRT, whereas 199 (49.1%) were hospitalized in hospitals with non-all-day RRT. A total of 73 of the 206 patients in the all-day group (35.4%) and 85 of the 199 patients in the non-all-day group (42.7%) died in the hospital (P = 0.133). After adjustments for co-variables, the implementation of all-day RRT was associated with a significant reduction in in-hospital mortality (adjusted odds ratio 0.57; 95% confidence interval 0.35–0.93; P = 0.024). Conclusions In comparison with non-all-day RRTs, the availability of all-day RRTs was associated with reduced in-hospital mortality among patients with hospital-onset sepsis. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04149-z.
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12
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Adams R, Henry KE, Sridharan A, Soleimani H, Zhan A, Rawat N, Johnson L, Hager DN, Cosgrove SE, Markowski A, Klein EY, Chen ES, Saheed MO, Henley M, Miranda S, Houston K, Linton RC, Ahluwalia AR, Wu AW, Saria S. Prospective, multi-site study of patient outcomes after implementation of the TREWS machine learning-based early warning system for sepsis. Nat Med 2022; 28:1455-1460. [PMID: 35864252 DOI: 10.1038/s41591-022-01894-0] [Citation(s) in RCA: 86] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 06/08/2022] [Indexed: 12/20/2022]
Abstract
Early recognition and treatment of sepsis are linked to improved patient outcomes. Machine learning-based early warning systems may reduce the time to recognition, but few systems have undergone clinical evaluation. In this prospective, multi-site cohort study, we examined the association between patient outcomes and provider interaction with a deployed sepsis alert system called the Targeted Real-time Early Warning System (TREWS). During the study, 590,736 patients were monitored by TREWS across five hospitals. We focused our analysis on 6,877 patients with sepsis who were identified by the alert before initiation of antibiotic therapy. Adjusting for patient presentation and severity, patients in this group whose alert was confirmed by a provider within 3 h of the alert had a reduced in-hospital mortality rate (3.3%, confidence interval (CI) 1.7, 5.1%, adjusted absolute reduction, and 18.7%, CI 9.4, 27.0%, adjusted relative reduction), organ failure and length of stay compared with patients whose alert was not confirmed by a provider within 3 h. Improvements in mortality rate (4.5%, CI 0.8, 8.3%, adjusted absolute reduction) and organ failure were larger among those patients who were additionally flagged as high risk. Our findings indicate that early warning systems have the potential to identify sepsis patients early and improve patient outcomes and that sepsis patients who would benefit the most from early treatment can be identified and prioritized at the time of the alert.
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Affiliation(s)
- Roy Adams
- Malone Center for Engineering in Healthcare, Johns Hopkins University, Baltimore, MD, USA.,Department of Psychiatry and Behavioral Science, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Katharine E Henry
- Department of Psychiatry and Behavioral Science, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | | | - Hossein Soleimani
- Health Informatics, University of California, San Francisco, CA, USA
| | - Andong Zhan
- Department of Psychiatry and Behavioral Science, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - Nishi Rawat
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Lauren Johnson
- Department of Quality Improvement, Johns Hopkins Hospital, Baltimore, MD, USA
| | - David N Hager
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sara E Cosgrove
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Edward S Chen
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Mustapha O Saheed
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Maureen Henley
- Department of Quality Improvement, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sheila Miranda
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Katrina Houston
- Department of Quality Improvement, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | | | - Albert W Wu
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Suchi Saria
- Malone Center for Engineering in Healthcare, Johns Hopkins University, Baltimore, MD, USA. .,Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA. .,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Bayesian Health, New York, NY, USA.
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13
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Dougherty H, Eisen S, Fraser LK, Gomes S, Roland D. Piloting a registry for paediatric sepsis: The PoRPoiSe study. J Paediatr Child Health 2022; 58:978-984. [PMID: 35060658 DOI: 10.1111/jpc.15873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/15/2021] [Accepted: 12/21/2021] [Indexed: 11/28/2022]
Abstract
AIM To develop a model for a paediatric sepsis registry for use in emergency care settings. A regional study, in the UK, was undertaken to identify the most basic registry components which are desirable and feasible using the concept of a minimum viable product. METHODS Two-round survey of clinicians using a modified Delphi methodology in conjunction with a regional data collection project in three paediatric emergency departments across London. RESULTS The survey identified 34 desirable information items to be included in a registry. Fifteen of 34 items are currently feasible from our experience of data collection. CONCLUSION The development of a multi-centre paediatric sepsis registry sepsis may have several benefits but is currently extremely limited primarily because of technological fragmentation within our Health Service. Our findings have important implications for researchers wishing to plan sepsis surveillance programmes, locally and internationally.
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Affiliation(s)
- Harry Dougherty
- Paediatric Emergency, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Sarah Eisen
- Children and Young People's Services, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Lauren K Fraser
- Emergency Department, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, United Kingdom
| | - Sylvester Gomes
- Paediatric Emergency, Evelina London Children's Hospital, London, United Kingdom
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester Hospital, Leicester, United Kingdom.,SAPPHIRE Group, Health Sciences, Leicester University, Leicester, United Kingdom
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Schwarzkopf D, Rüddel H, Brinkmann A, Fleischmann-Struzek C, Friedrich ME, Glas M, Gogoll C, Gründling M, Meybohm P, Pletz MW, Schreiber T, Thomas-Rüddel DO, Reinhart K. The German Quality Network Sepsis: Evaluation of a Quality Collaborative on Decreasing Sepsis-Related Mortality in a Controlled Interrupted Time Series Analysis. Front Med (Lausanne) 2022; 9:882340. [PMID: 35573007 PMCID: PMC9094049 DOI: 10.3389/fmed.2022.882340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/31/2022] [Indexed: 11/13/2022] Open
Abstract
Background Sepsis is one of the leading causes of preventable deaths in hospitals. This study presents the evaluation of a quality collaborative, which aimed to decrease sepsis-related hospital mortality. Methods The German Quality Network Sepsis (GQNS) offers quality reporting based on claims data, peer reviews, and support for establishing continuous quality management and staff education. This study evaluates the effects of participating in the GQNS during the intervention period (April 2016-June 2018) in comparison to a retrospective baseline (January 2014-March 2016). The primary outcome was all-cause risk-adjusted hospital mortality among cases with sepsis. Sepsis was identified by International Classification of Diseases (ICD) codes in claims data. A controlled time series analysis was conducted to analyze changes from the baseline to the intervention period comparing GQNS hospitals with the population of all German hospitals assessed via the national diagnosis-related groups (DRGs)-statistics. Tests were conducted using piecewise hierarchical models. Implementation processes and barriers were assessed by surveys of local leaders of quality improvement teams. Results Seventy-four hospitals participated, of which 17 were university hospitals and 18 were tertiary care facilities. Observed mortality was 43.5% during baseline period and 42.7% during intervention period. Interrupted time-series analyses did not show effects on course or level of risk-adjusted mortality of cases with sepsis compared to the national DRG-statistics after the beginning of the intervention period (p = 0.632 and p = 0.512, respectively). There was no significant mortality decrease in the subgroups of patients with septic shock or ventilation >24 h or predefined subgroups of hospitals. A standardized survey among 49 local quality improvement leaders in autumn of 2018 revealed that most hospitals did not succeed in implementing a continuous quality management program or relevant measures to improve early recognition and treatment of sepsis. Barriers perceived most commonly were lack of time (77.6%), staff shortage (59.2%), and lack of participation of relevant departments (38.8%). Conclusion As long as hospital-wide sepsis quality improvement efforts will not become a high priority for the hospital leadership by assuring adequate resources and involvement of all pertinent stakeholders, voluntary initiatives to improve the quality of sepsis care will remain prone to failure.
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Affiliation(s)
- Daniel Schwarzkopf
- Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
- Department for Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Hendrik Rüddel
- Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
- Department for Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Alexander Brinkmann
- Department of Anesthesiology and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Carolin Fleischmann-Struzek
- Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | | | - Michael Glas
- Department for Infectious Diseases and Infection Control, KH Labor GmbH, AMEOS Group, Bernburg, Germany
| | - Christian Gogoll
- Outpatient Services, Evangelische Lungenklinik Berlin-Buch, Berlin, Germany
| | - Matthias Gründling
- Department of Anesthesiology, University Hospital of Greifswald, Greifswald, Germany
| | - Patrick Meybohm
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Mathias W. Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Torsten Schreiber
- Department of Anesthesia and Intensive Care, Zentralklinik Bad Berka, Bad Berka, Germany
| | | | - Konrad Reinhart
- Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
- Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
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15
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Rhee C, Klompas M. Should hospital-onset Adult Sepsis Event surveillance be routine… or even mandatory? ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e32. [PMID: 36310798 PMCID: PMC9614833 DOI: 10.1017/ash.2022.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 01/19/2022] [Indexed: 06/16/2023]
Abstract
Hospital-onset sepsis accounts for 10%-15% of all sepsis cases and is associated with very high mortality rates, yet to date most hospitals have paid little attention to tracking its incidence and outcomes. This contrasts sharply with the substantial effort that hospitals and regulatory agencies spend tracking and reporting a limited subset of healthcare-associated infections. The recent development of the Center for Disease Control and Prevention's hospital-onset Adult Sepsis Event (ASE) definition, however, provides a validated and standardized mechanism for facilities to identify patients with nosocomial sepsis using routinely available electronic health record data. Recent data have demonstrated that hospital-onset ASE surveillance identifies many infections that are largely missed by current reportable healthcare-associated infections and that are associated with much higher mortality rates. Expanding the breadth of surveillance to include these highly consequential infections could help identify new targets for prevention and quality improvement and ultimately catalyze better outcomes for hospitalized patients. More work is needed, however, to characterize the preventability of hospital-onset ASE, develop and validate robust case-mix adjustment tools, and facilitate widespread uptake in hospitals with limited resources.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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16
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Ground truth labels challenge the validity of sepsis consensus definitions in critical illness. J Transl Med 2022; 20:27. [PMID: 35033120 PMCID: PMC8760797 DOI: 10.1186/s12967-022-03228-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/31/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Sepsis is the leading cause of death in the intensive care unit (ICU). Expediting its diagnosis, largely determined by clinical assessment, improves survival. Predictive and explanatory modelling of sepsis in the critically ill commonly bases both outcome definition and predictions on clinical criteria for consensus definitions of sepsis, leading to circularity. As a remedy, we collected ground truth labels for sepsis. METHODS In the Ground Truth for Sepsis Questionnaire (GTSQ), senior attending physicians in the ICU documented daily their opinion on each patient's condition regarding sepsis as a five-category working diagnosis and nine related items. Working diagnosis groups were described and compared and their SOFA-scores analyzed with a generalized linear mixed model. Agreement and discriminatory performance measures for clinical criteria of sepsis and GTSQ labels as reference class were derived. RESULTS We analyzed 7291 questionnaires and 761 complete encounters from the first survey year. Editing rates for all items were > 90%, and responses were consistent with current understanding of critical illness pathophysiology, including sepsis pathogenesis. Interrater agreement for presence and absence of sepsis was almost perfect but only slight for suspected infection. ICU mortality was 19.5% in encounters with SIRS as the "worst" working diagnosis compared to 5.9% with sepsis and 5.9% with severe sepsis without differences in admission and maximum SOFA. Compared to sepsis, proportions of GTSQs with SIRS plus acute organ dysfunction were equal and macrocirculatory abnormalities higher (p < 0.0001). SIRS proportionally ranked above sepsis in daily assessment of illness severity (p < 0.0001). Separate analyses of neurosurgical referrals revealed similar differences. Discriminatory performance of Sepsis-1/2 and Sepsis-3 compared to GTSQ labels was similar with sensitivities around 70% and specificities 92%. Essentially no difference between the prevalence of SIRS and SOFA ≥ 2 yielded sensitivities and specificities for detecting sepsis onset close to 55% and 83%, respectively. CONCLUSIONS GTSQ labels are a valid measure of sepsis in the ICU. They reveal suspicion of infection as an unclear clinical concept and refute an illness severity hierarchy in the SIRS-sepsis-severe sepsis spectrum. Ground truth challenges the accuracy of Sepsis-1/2 and Sepsis-3 in detecting sepsis onset. It is an indispensable intermediate step towards advancing diagnosis and therapy in the ICU and, potentially, other health care settings.
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17
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Rhee C, Yu T, Wang R, Kadri SS, Fram D, Chen HC, Klompas M. Association Between Implementation of the Severe Sepsis and Septic Shock Early Management Bundle Performance Measure and Outcomes in Patients With Suspected Sepsis in US Hospitals. JAMA Netw Open 2021; 4:e2138596. [PMID: 34928358 PMCID: PMC8689388 DOI: 10.1001/jamanetworkopen.2021.38596] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE In October 2015, the Centers for Medicare & Medicaid Services began requiring US hospitals to report adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). OBJECTIVE To evaluate the association of SEP-1 implementation with sepsis treatment patterns and outcomes in diverse hospitals. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study with interrupted time-series analysis and logistic regression models was conducted among adults admitted to 114 hospitals from October 2013 to December 2017 with suspected sepsis (blood culture orders, ≥2 systemic inflammatory response syndrome criteria, and acute organ dysfunction) within 24 hours of hospital arrival. Data analysis was conducted from September 2020 to September 2021. EXPOSURES SEP-1 implementation in the fourth quarter (Q4) of 2015. MAIN OUTCOMES AND MEASURES The primary outcome was quarterly rates of risk-adjusted short-term mortality (in-hospital death or discharge to hospice). Secondary outcomes included lactate testing and administration of anti-methicillin-resistant Staphylococcus aureus (MRSA) or antipseudomonal β-lactam antibiotics within 24 hours of hospital arrival. Generalized estimating equations with robust sandwich variances were used to fit logistic regression models to assess for changes in level or trends in these outcomes, adjusting for baseline characteristics and severity of illness. RESULTS The cohort included 117 510 patients (median [IQR] age, 67 years [55-78] years; 60 530 [51.5%] men and 56 980 [48.5%] women) with suspected sepsis. Lactate testing rates increased from 55.1% (95% CI, 53.9%-56.2%) in Q4 of 2013 to 76.7% (95% CI, 75.4%-78.0%) in Q4 of 2017, with a significant level change following SEP-1 implementation (odds ratio [OR], 1.34; 95% CI, 1.04-1.74). There were increases in use of anti-MRSA antibiotics (19.8% [95% CI, 18.9%-20.7%] in Q4 of 2013 to 26.3% [95% CI, 24.9%-27.7%] in Q4 of 2017) and antipseudomonal antibiotics (27.7% [95% CI, 26.7%-28.8%] in Q4 of 2013 to 40.5% [95% CI, 38.9%-42.0%] in Q4 of 2017), but these trends preceded SEP-1 and did not change with SEP-1 implementation. Unadjusted short-term mortality rates were similar in the pre-SEP-1 period (Q4 of 2013 through Q3 of 2015) vs the post-SEP-1 period (Q1 of 2016 through Q4 of 2017) (20.3% [95% CI, 20.0%-20.6%] vs 20.4% [95% CI, 20.1%-20.7%]), and SEP-1 implementation was not associated with changes in level (OR, 0.94; 95% CI, 0.68-1.29) or trend (OR, 1.00; 95% CI, 0.97-1.04) for risk-adjusted short-term mortality rates. CONCLUSIONS AND RELEVANCE In this cohort study, SEP-1 implementation was associated with an immediate increase in lactate testing rates, no change in already-increasing rates of broad-spectrum antibiotic use, and no change in short-term mortality rates for patients with suspected sepsis. Other approaches to decrease sepsis mortality may be warranted.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Tingting Yu
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Rui Wang
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Sameer S. Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - David Fram
- Commonwealth Informatics, Waltham, Massachusetts
| | | | - Michael Klompas
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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18
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Alrawashdeh M, Klompas M, Kimmel S, Larochelle MR, Gokhale RH, Dantes RB, Hoots B, Hatfield KM, Reddy SC, Fiore AE, Septimus EJ, Kadri SS, Poland R, Sands K, Rhee C. Epidemiology, Outcomes, and Trends of Patients With Sepsis and Opioid-Related Hospitalizations in U.S. Hospitals. Crit Care Med 2021; 49:2102-2111. [PMID: 34314131 PMCID: PMC8602712 DOI: 10.1097/ccm.0000000000005141] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Widespread use and misuse of prescription and illicit opioids have exposed millions to health risks including serious infectious complications. Little is known, however, about the association between opioid use and sepsis. DESIGN Retrospective cohort study. SETTING About 373 U.S. hospitals. PATIENTS Adults hospitalized between January 2009 and September 2015. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Sepsis was identified by clinical indicators of concurrent infection and organ dysfunction. Opioid-related hospitalizations were identified by the International Classification of Diseases, 9th Revision, Clinical Modification codes and/or inpatient orders for buprenorphine. Clinical characteristics and outcomes were compared by sepsis and opioid-related hospitalization status. The association between opioid-related hospitalization and all-cause, in-hospital mortality in patients with sepsis was assessed using mixed-effects logistic models to adjust for baseline characteristics and severity of illness.The cohort included 6,715,286 hospitalizations; 375,479 (5.6%) had sepsis, 130,399 (1.9%) had opioid-related hospitalizations, and 8,764 (0.1%) had both. Compared with sepsis patients without opioid-related hospitalizations (n = 366,715), sepsis patients with opioid-related hospitalizations (n = 8,764) were younger (mean 52.3 vs 66.9 yr) and healthier (mean Elixhauser score 5.4 vs 10.5), had more bloodstream infections from Gram-positive and fungal pathogens (68.9% vs 47.0% and 10.6% vs 6.4%, respectively), and had lower in-hospital mortality rates (10.6% vs 16.2%; adjusted odds ratio, 0.73; 95% CI, 0.60-0.79; p < 0.001 for all comparisons). Of 1,803 patients with opioid-related hospitalizations who died in-hospital, 928 (51.5%) had sepsis. Opioid-related hospitalizations accounted for 1.5% of all sepsis-associated deaths, including 5.7% of sepsis deaths among patients less than 50 years old. From 2009 to 2015, the proportion of sepsis hospitalizations that were opioid-related increased by 77% (95% CI, 40.7-123.5%). CONCLUSIONS Sepsis is an important cause of morbidity and mortality in patients with opioid-related hospitalizations, and opioid-related hospitalizations contribute disproportionately to sepsis-associated deaths among younger patients. In addition to ongoing efforts to combat the opioid crisis, public health agencies should focus on raising awareness about sepsis among patients who use opioids and their providers.
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Affiliation(s)
- Mohammad Alrawashdeh
- Department of Population Medicine, Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston, MA
- Jordan University of Science and Technology, Jordan
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Simeon Kimmel
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Marc R Larochelle
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Runa H. Gokhale
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Raymund B Dantes
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Brooke Hoots
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
- Division of Overdose Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kelly M Hatfield
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Sujan C Reddy
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Anthony E. Fiore
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Edward J Septimus
- Department of Population Medicine, Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston, MA
- Texas A&M College of Medicine, Houston, TX
| | - Sameer S Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Russell Poland
- Clinical Operations Group, HCA Healthcare, Nashville, TN
| | - Kenneth Sands
- Department of Population Medicine, Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston, MA
- Clinical Operations Group, HCA Healthcare, Nashville, TN
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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19
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Conducting Sepsis Surveillance by Applying Sepsis-3 Criteria to Electronic Health Record Data: Promises and Potential Pitfalls. Crit Care Med 2021; 49:1983-1986. [PMID: 34643579 DOI: 10.1097/ccm.0000000000005223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Tabaie A, Orenstein EW, Nemati S, Basu RK, Clifford GD, Kamaleswaran R. Deep Learning Model to Predict Serious Infection Among Children With Central Venous Lines. Front Pediatr 2021; 9:726870. [PMID: 34604142 PMCID: PMC8480258 DOI: 10.3389/fped.2021.726870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/06/2021] [Indexed: 12/23/2022] Open
Abstract
Objective: Predict the onset of presumed serious infection, defined as a positive blood culture drawn and new antibiotic course of at least 4 days (PSI*), among pediatric patients with Central Venous Lines (CVLs). Design: Retrospective cohort study. Setting: Single academic children's hospital. Patients: All hospital encounters from January 2013 to December 2018, excluding the ones without a CVL or with a length-of-stay shorter than 24 h. Measurements and Main Results: Clinical features including demographics, laboratory results, vital signs, characteristics of the CVLs and medications used were extracted retrospectively from electronic medical records. Data were aggregated across all hospitals within a single pediatric health system and used to train a deep learning model to predict the occurrence of PSI* during the next 48 h of hospitalization. The proposed model prediction was compared to prediction of PSI* by a marker of illness severity (PELOD-2). The baseline prevalence of line infections was 0.34% over all segmented 48-h time windows. Events were identified among cases using onset time. All data from admission till the onset was used for cases and among controls we used all data from admission till discharge. The benchmarks were aggregated over all 48 h time windows [N=748,380 associated with 27,137 patient encounters]. The model achieved an area under the receiver operating characteristic curve of 0.993 (95% CI = [0.990, 0.996]), the enriched positive predictive value (PPV) was 23 times greater than the base prevalence. Conversely, prediction by PELOD-2 achieved a lower PPV of 1.5% [0.9%, 2.1%] which was 5 times the baseline prevalence. Conclusion: A deep learning model that employs common clinical features in the electronic health record can help predict the onset of CLABSI in hospitalized children with central venous line 48 hours prior to the time of specimen collection.
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Affiliation(s)
- Azade Tabaie
- Department of Biomedical Informatics, Emory School of Medicine, Atlanta, GA, United States
| | - Evan W. Orenstein
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Shamim Nemati
- Department of Biomedical Informatics, University of California, San Diego, San Diego, CA, United States
| | - Rajit K. Basu
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Gari D. Clifford
- Department of Biomedical Informatics, Emory School of Medicine, Atlanta, GA, United States
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory School of Medicine, Atlanta, GA, United States
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory School of Medicine, Atlanta, GA, United States
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory School of Medicine, Atlanta, GA, United States
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21
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Wong A, Otles E, Donnelly JP, Krumm A, McCullough J, DeTroyer-Cooley O, Pestrue J, Phillips M, Konye J, Penoza C, Ghous M, Singh K. External Validation of a Widely Implemented Proprietary Sepsis Prediction Model in Hospitalized Patients. JAMA Intern Med 2021; 181:1065-1070. [PMID: 34152373 PMCID: PMC8218233 DOI: 10.1001/jamainternmed.2021.2626] [Citation(s) in RCA: 272] [Impact Index Per Article: 90.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE The Epic Sepsis Model (ESM), a proprietary sepsis prediction model, is implemented at hundreds of US hospitals. The ESM's ability to identify patients with sepsis has not been adequately evaluated despite widespread use. OBJECTIVE To externally validate the ESM in the prediction of sepsis and evaluate its potential clinical value compared with usual care. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted among 27 697 patients aged 18 years or older admitted to Michigan Medicine, the academic health system of the University of Michigan, Ann Arbor, with 38 455 hospitalizations between December 6, 2018, and October 20, 2019. EXPOSURE The ESM score, calculated every 15 minutes. MAIN OUTCOMES AND MEASURES Sepsis, as defined by a composite of (1) the Centers for Disease Control and Prevention surveillance criteria and (2) International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnostic codes accompanied by 2 systemic inflammatory response syndrome criteria and 1 organ dysfunction criterion within 6 hours of one another. Model discrimination was assessed using the area under the receiver operating characteristic curve at the hospitalization level and with prediction horizons of 4, 8, 12, and 24 hours. Model calibration was evaluated with calibration plots. The potential clinical benefit associated with the ESM was assessed by evaluating the added benefit of the ESM score compared with contemporary clinical practice (based on timely administration of antibiotics). Alert fatigue was evaluated by comparing the clinical value of different alerting strategies. RESULTS We identified 27 697 patients who had 38 455 hospitalizations (21 904 women [57%]; median age, 56 years [interquartile range, 35-69 years]) meeting inclusion criteria, of whom sepsis occurred in 2552 (7%). The ESM had a hospitalization-level area under the receiver operating characteristic curve of 0.63 (95% CI, 0.62-0.64). The ESM identified 183 of 2552 patients with sepsis (7%) who did not receive timely administration of antibiotics, highlighting the low sensitivity of the ESM in comparison with contemporary clinical practice. The ESM also did not identify 1709 patients with sepsis (67%) despite generating alerts for an ESM score of 6 or higher for 6971 of all 38 455 hospitalized patients (18%), thus creating a large burden of alert fatigue. CONCLUSIONS AND RELEVANCE This external validation cohort study suggests that the ESM has poor discrimination and calibration in predicting the onset of sepsis. The widespread adoption of the ESM despite its poor performance raises fundamental concerns about sepsis management on a national level.
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Affiliation(s)
- Andrew Wong
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Erkin Otles
- Medical Scientist Training Program, University of Michigan Medical School, Ann Arbor.,Department of Industrial and Operations Engineering, University of Michigan College of Engineering, Ann Arbor
| | - John P Donnelly
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor
| | - Andrew Krumm
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor
| | | | | | | | - Marie Phillips
- Health Information Technology and Services, Michigan Medicine, Ann Arbor
| | - Judy Konye
- Nursing Informatics, Michigan Medicine, Ann Arbor
| | | | - Muhammad Ghous
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor
| | - Karandeep Singh
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.,Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor
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22
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Tabaie A, Orenstein EW, Nemati S, Basu RK, Kandaswamy S, Clifford GD, Kamaleswaran R. Predicting presumed serious infection among hospitalized children on central venous lines with machine learning. Comput Biol Med 2021; 132:104289. [PMID: 33667812 PMCID: PMC9207586 DOI: 10.1016/j.compbiomed.2021.104289] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/29/2021] [Accepted: 02/14/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Presumed serious infection (PSI) is defined as a blood culture drawn and new antibiotic course of at least 4 days among pediatric patients with Central Venous Lines (CVLs). Early PSI prediction and use of medical interventions can prevent adverse outcomes and improve the quality of care. METHODS Clinical features including demographics, laboratory results, vital signs, characteristics of the CVLs and medications used were extracted retrospectively from electronic medical records. Data were aggregated across all hospitals within a single pediatric health system and used to train machine learning models (XGBoost and ElasticNet) to predict the occurrence of PSI 8 h prior to clinical suspicion. Prediction for PSI was benchmarked against PRISM-III. RESULTS Our model achieved an area under the receiver operating characteristic curve of 0.84 (95% CI = [0.82, 0.85]), sensitivity of 0.73 [0.69, 0.74], and positive predictive value (PPV) of 0.36 [0.34, 0.36]. The PRISM-III conversely achieved a lower sensitivity of 0.19 [0.16, 0.22] and PPV of 0.30 [0.26, 0.34] at a cut-off of ≥ 10. The features with the most impact on the PSI prediction were maximum diastolic blood pressure prior to PSI prediction (mean SHAP = 3.4), height (mean SHAP = 3.2), and maximum temperature prior to PSI prediction (mean SHAP = 2.6). CONCLUSION A machine learning model using common features in the electronic medical records can predict the onset of serious infections in children with central venous lines at least 8 h prior to when a clinical team drew a blood culture.
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Affiliation(s)
- Azade Tabaie
- Department of Biomedical Informatics, Emory School of Medicine, Atlanta, GA, USA.
| | - Evan W Orenstein
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Shamim Nemati
- Department of Biomedical Informatics, University of California San Diego, San Diego, CA, USA
| | - Rajit K Basu
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Gari D Clifford
- Department of Biomedical Informatics, Emory School of Medicine, Atlanta, GA, USA; Department of Biomedical Engineering, Georgia Institute of Technology and Emory School of Medicine, Atlanta, GA, USA
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory School of Medicine, Atlanta, GA, USA; Department of Biomedical Engineering, Georgia Institute of Technology and Emory School of Medicine, Atlanta, GA, USA
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23
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Page B, Klompas M, Chan C, Filbin MR, Dutta S, McEvoy D, Clark R, Leibowitz M, Rhee C. Surveillance for Healthcare-Associated Infections: Hospital-Onset Adult Sepsis Events versus Current Reportable Conditions. Clin Infect Dis 2021; 73:1013-1019. [PMID: 33780544 DOI: 10.1093/cid/ciab217] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND U.S. hospitals are required by CMS to publicly report CLABSI, CAUTI, C.diffficile, MRSA bacteremia, and selected SSIs for benchmarking and pay-for-performance programs. It is unclear, however, to what extent these conditions capture the full breadth of serious healthcare-associated infections (HAIs). CDC's hospital-onset Adult Sepsis Event (HO-ASE) definition could facilitate more comprehensive and efficient surveillance for serious HAIs, but the overlap between HO-ASE and currently reportable HAIs is unknown. METHODS We retrospectively assessed the overlap between HO-ASEs and reportable HAIs among adults hospitalized between June 2015-June 2018 in 3 hospitals. Medical record reviews were conducted for 110 randomly selected HO-ASE cases to determine clinical correlates. RESULTS Amongst 282,441 hospitalized patients, 2,301 (0.8%) met HO-ASE criteria and 1,260 (0.4%) had reportable HAIs. In-hospital mortality rates were higher with HO-ASEs than reportable HAIs (28.6% vs 12.9%). Mortality rates for HO-ASE missed by reportable HAIs were substantially higher than mortality rates for reportable HAIs missed by HO-ASE (28.1% vs 6.3%). Reportable HAIs were only present in 334/2,301 (14.5%) HO-ASEs, most commonly CLABSIs (6.0% of HO-ASEs), C.difficile (5.0%), and CAUTI (3.0%). On medical record review, most HO-ASEs were caused by pneumonia (39.1%, of which only 34.9% were ventilator-associated), bloodstream infections (17.4%, of which only 10.5% were central line-associated), non-C.difficile intra-abdominal infections (14.5%), urinary infections (7.3%, of which 87.5% were catheter-associated), and skin/soft tissue infections (6.4%). CONCLUSIONS CDC's HO-ASE definition detects many serious nosocomial infections missed by currently reportable HAIs. HO-ASE surveillance could increase the efficiency and clinical significance of surveillance while identifying new targets for prevention.
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Affiliation(s)
- Brady Page
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School / Harvard Pilgrim Health Care Institute, Boston, MA, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
| | - Christina Chan
- Department of Population Medicine, Harvard Medical School / Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sayon Dutta
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Digital Health eCare, Mass General Brigham, Boston, MA, USA
| | - Dustin McEvoy
- Digital Health eCare, Mass General Brigham, Boston, MA, USA
| | - Roger Clark
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, USA
| | - Matthew Leibowitz
- Division of Infectious Diseases, Newton-Wellesley Hospital, Newton, MA, USA
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School / Harvard Pilgrim Health Care Institute, Boston, MA, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
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24
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Prevalence and Clinical Characteristics of Patients With Sepsis Discharge Diagnosis Codes and Short Lengths of Stay in U.S. Hospitals. Crit Care Explor 2021; 3:e0373. [PMID: 33786449 PMCID: PMC7994044 DOI: 10.1097/cce.0000000000000373] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objectives: Some patients diagnosed with sepsis have very brief hospitalizations. Understanding the prevalence and clinical characteristics of these patients may provide insight into how sepsis diagnoses are being applied as well as the breadth of illnesses encompassed by current sepsis definitions. Design: Retrospective observational study. Setting: One-hundred ten U.S. hospitals in the Cerner HealthFacts dataset (primary cohort) and four hospitals in Eastern Massachusetts (secondary cohort used for detailed medical record reviews). Patients: Adults hospitalized from April 2016 to December 2017. Interventions: None. Measurements and Main Results: We identified hospitalizations with International Classification of Diseases, 10th Edition codes for sepsis (including sepsis, septicemia, severe sepsis, and septic shock) and compared “short stay sepsis” patients (defined as discharge alive within 3 d) versus nonshort stay sepsis patients using detailed electronic health record data. In the Cerner cohort, 67,733 patients had sepsis discharge diagnosis codes, including 6,918 (10.2%) with short stays. Compared with nonshort stay sepsis patients, short stay patients were younger (median age 60 vs 67 yr) and had fewer comorbidities (median Elixhauser score 5 vs 13), lower rates of positive blood cultures (8.2% vs 24.1%), lower rates of ICU admission (6.2% vs 31.6%), and less frequently had severe sepsis/septic shock codes (13.5% vs 36.6%). Almost all short stay and nonshort stay sepsis patients met systemic inflammatory response syndrome criteria at admission (84.5% and 87.5%, respectively); 47.2% of those with short stays had Sequential Organ Failure Assessment scores of 2 or greater at admission versus 73.2% of those with longer stays. Findings were similar in the secondary four-hospital cohort. Medical record reviews demonstrated that physicians commonly diagnosed sepsis based on the presence of systemic inflammatory response syndrome criteria, elevated lactates, or positive blood cultures without concurrent organ dysfunction. Conclusions: In this large U.S. cohort, one in 10 patients coded for sepsis were discharged alive within 3 days. Although most short stay patients met systemic inflammatory response syndrome criteria, they met Sepsis-3 criteria less than half the time. Our findings underscore the incomplete uptake of Sepsis-3 definitions, the breadth of illness severities encompassed by both traditional and new sepsis definitions, and the possibility that some patients with sepsis recover very rapidly.
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25
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Too Many Definitions of Sepsis: Can Machine Learning Leverage the Electronic Health Record to Increase Accuracy and Bring Consensus? Crit Care Med 2020; 48:137-141. [PMID: 31939780 DOI: 10.1097/ccm.0000000000004144] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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26
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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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27
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Church DL, Naugler C. Essential role of laboratory physicians in transformation of laboratory practice and management to a value-based patient-centric model. Crit Rev Clin Lab Sci 2020; 57:323-344. [PMID: 32180485 DOI: 10.1080/10408363.2020.1720591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The laboratory is a vital part of the continuum of patient care. In fact, there are few programs in the healthcare system that do not rely on ready access and availability of complex diagnostic laboratory services. The existing transactional model of laboratory "medical practice" will not be able to meet the needs of the healthcare system as it rapidly shifts toward value-based care and precision medicine, which demands that practice be based on total system indicators, clinical effectiveness, and patient outcomes. Laboratory "value" will no longer be focused primarily on internal testing quality and efficiencies but rather on the relative cost of diagnostic testing compared to direct improvement in clinical and system outcomes. The medical laboratory as a "business" focused on operational efficiency and cost-controls must transform to become an essential clinical service that is a tightly integrated equal partner in direct patient care. We would argue that this paradigm shift would not be necessary if laboratory services had remained a "patient-centric" medical practice throughout the last few decades. This review is focused on the essential role of laboratory physicians in transforming laboratory practice and management to a value-based patient-centric model. Value-based practice is necessary not only to meet the challenges of the new precision medicine world order but also to bring about sustainable healthcare service delivery.
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Affiliation(s)
- Deirdre L Church
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christopher Naugler
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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28
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Donnelly JP, Dai Y, Colantonio LD, Zhao H, Safford MM, Baddley JW, Muntner P, Wang HE. Agreement of claims-based methods for identifying sepsis with clinical criteria in the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. BMC Med Res Methodol 2020; 20:54. [PMID: 32131746 PMCID: PMC7057471 DOI: 10.1186/s12874-020-00937-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 02/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Claims-based algorithms are commonly used to identify sepsis in health services research because the laboratory features required to define clinical criteria may not be available in administrative data. METHODS We evaluated claims-based sepsis algorithms among adults in the US aged ≥65 years with Medicare health insurance enrolled in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Suspected infections from baseline (2003-2007) through December 31, 2012 were analyzed. Two claims-based algorithms were evaluated: (1) infection plus organ dysfunction diagnoses or sepsis diagnoses (Medicare-Implicit/Explicit) and (2) Centers for Medicare and Medicaid Services Severe Sepsis/Septic Shock Measure diagnoses (Medicare-CMS). Three classifications based on clinical criteria were used as standards for comparison: (1) the sepsis-related organ failure assessment (SOFA) score (REGARDS-SOFA), (2) "quick" SOFA (REGARDS-qSOFA), and (3) Centers for Disease Control and Prevention electronic health record criteria (REGARDS-EHR). RESULTS There were 2217 suspected infections among 9522 participants included in the current study. The total number of suspected infections classified as sepsis was 468 for Medicare-Implicit/Explicit, 249 for Medicare-CMS, 541 for REGARDS-SOFA, 185 for REGARDS-qSOFA, and 331 for REGARDS-EHR. The overall agreement between Medicare-Implicit/Explicit and REGARDS-SOFA, REGARDS-qSOFA, and REGARDS-EHR was 77, 79, and 81%, respectively, sensitivity was 46, 53, and 57%, and specificity was 87, 82, and 85%. Comparing Medicare-CMS and REGARDS-SOFA, REGARDS-qSOFA, and REGARDS-EHR, agreement was 77, 87, and 85%, respectively, sensitivity was 27, 41, and 36%, and specificity was 94, 92, and 93%. Events meeting the REGARDS-SOFA classification had a lower 90-day mortality rate (140.7 per 100 person-years) compared with the Medicare-CMS (296.1 per 100 person-years), REGARDS-qSOFA (238.6 per 100 person-years), Medicare-Implicit/Explicit (219.4 per 100 person-years), and REGARDS-EHR classifications (201.8 per 100 person-years). CONCLUSION Claims-based sepsis algorithms have high agreement and specificity but low sensitivity when compared with clinical criteria. Both claims-based algorithms identified a patient population with similar 90-day mortality rates as compared with classifications based on qSOFA and EHR criteria but higher mortality relative to SOFA criteria.
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Affiliation(s)
- John P. Donnelly
- Department of Learning Health Sciences, University of Michigan Medical School, NCRC Building 14, #G100, G014-130, 2800 Plymouth Rd, Ann Arbor, MI 48109 USA
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, MI USA
| | - Yuling Dai
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL USA
| | - Lisandro D. Colantonio
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL USA
| | - Hong Zhao
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL USA
| | | | - John W. Baddley
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL USA
| | - Paul Muntner
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL USA
| | - Henry E. Wang
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, TX USA
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29
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Shappell CN, Rhee C. Leveraging electronic health record data to improve sepsis surveillance. BMJ Qual Saf 2020; 29:706-710. [PMID: 32108088 DOI: 10.1136/bmjqs-2020-010847] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Claire N Shappell
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA .,Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA
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30
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Valik JK, Ward L, Tanushi H, Müllersdorf K, Ternhag A, Aufwerber E, Färnert A, Johansson AF, Mogensen ML, Pickering B, Dalianis H, Henriksson A, Herasevich V, Nauclér P. Validation of automated sepsis surveillance based on the Sepsis-3 clinical criteria against physician record review in a general hospital population: observational study using electronic health records data. BMJ Qual Saf 2020; 29:735-745. [PMID: 32029574 PMCID: PMC7467502 DOI: 10.1136/bmjqs-2019-010123] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 01/19/2020] [Accepted: 01/21/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Surveillance of sepsis incidence is important for directing resources and evaluating quality-of-care interventions. The aim was to develop and validate a fully-automated Sepsis-3 based surveillance system in non-intensive care wards using electronic health record (EHR) data, and demonstrate utility by determining the burden of hospital-onset sepsis and variations between wards. METHODS A rule-based algorithm was developed using EHR data from a cohort of all adult patients admitted at an academic centre between July 2012 and December 2013. Time in intensive care units was censored. To validate algorithm performance, a stratified random sample of 1000 hospital admissions (674 with and 326 without suspected infection) was classified according to the Sepsis-3 clinical criteria (suspected infection defined as having any culture taken and at least two doses of antimicrobials administered, and an increase in Sequential Organ Failure Assessment (SOFA) score by >2 points) and the likelihood of infection by physician medical record review. RESULTS In total 82 653 hospital admissions were included. The Sepsis-3 clinical criteria determined by physician review were met in 343 of 1000 episodes. Among them, 313 (91%) had possible, probable or definite infection. Based on this reference, the algorithm achieved sensitivity 0.887 (95% CI: 0.799 to 0.964), specificity 0.985 (95% CI: 0.978 to 0.991), positive predictive value 0.881 (95% CI: 0.833 to 0.926) and negative predictive value 0.986 (95% CI: 0.973 to 0.996). When applied to the total cohort taking into account the sampling proportions of those with and without suspected infection, the algorithm identified 8599 (10.4%) sepsis episodes. The burden of hospital-onset sepsis (>48 hour after admission) and related in-hospital mortality varied between wards. CONCLUSIONS A fully-automated Sepsis-3 based surveillance algorithm using EHR data performed well compared with physician medical record review in non-intensive care wards, and exposed variations in hospital-onset sepsis incidence between wards.
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Affiliation(s)
- John Karlsson Valik
- Division of Infectious Diseases, Department of Medicine, Solna (MedS), Karolinska Institutet, Stockholm, Sweden .,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Logan Ward
- Treat Systems ApS, Aalborg, Denmark.,Center for Model-based Medical Decision Support, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Hideyuki Tanushi
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Kajsa Müllersdorf
- Division of Infectious Diseases, Department of Medicine, Solna (MedS), Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Ternhag
- Division of Infectious Diseases, Department of Medicine, Solna (MedS), Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ewa Aufwerber
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Färnert
- Division of Infectious Diseases, Department of Medicine, Solna (MedS), Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Anders F Johansson
- Department of Clinical microbiology and the Laboratory for Molecular Infection Medicine (MIMS), Umeå University, Umeå, Sweden
| | | | - Brian Pickering
- Department of Anesthesiology and Perioperative medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hercules Dalianis
- Department of Computer and Systems Sciences, Stockholm University, Kista, Sweden
| | - Aron Henriksson
- Department of Computer and Systems Sciences, Stockholm University, Kista, Sweden
| | - Vitaly Herasevich
- Department of Anesthesiology and Perioperative medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Pontus Nauclér
- Division of Infectious Diseases, Department of Medicine, Solna (MedS), Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
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31
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Rhee C, Klompas M. Sepsis trends: increasing incidence and decreasing mortality, or changing denominator? J Thorac Dis 2020; 12:S89-S100. [PMID: 32148931 DOI: 10.21037/jtd.2019.12.51] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Numerous studies suggest that the incidence of sepsis has been steadily increasing over the past several decades while mortality rates are falling. However, reliably assessing trends in sepsis epidemiology is challenging due to changing diagnosis and coding practices over time. Ongoing efforts by clinicians, administrators, policy makers, and patient advocates to increase sepsis awareness, screening, and recognition are leading to more patients being labeled with sepsis. Subjective clinical definitions and heterogeneous presentations also allow for wide discretion in diagnosing sepsis rather than specific infections alone or non-specific syndromes. These factors create a potential ascertainment bias whereby the inclusion of less severely ill patients in sepsis case counts over time leads to a perceived increase in sepsis incidence and decrease in sepsis mortality rates. Analyses that rely on administrative data alone are further confounded by changing coding practices in response to new policies, financial incentives, and efforts to improve documentation. An alternate strategy for measuring sepsis incidence, outcomes, and trends is to use objective and consistent clinical criteria rather than administrative codes or registries to identify sepsis. This is feasible using data routinely found in electronic health record systems, such as blood culture draws and sustained courses of antibiotics to identify infection and laboratory values, vasopressors, and mechanical ventilation to measure acute organ dysfunction. Recent surveillance studies using this approach suggest that sepsis incidence and mortality rates have been essentially stable over the past decade. In this review, we summarize the major epidemiologic studies of sepsis trends, potential biases in these analyses, and the recent change in the surveillance paradigm toward using objective clinical data from electronic health records to more accurately characterize sepsis trends.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
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32
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Hsu HE, Abanyie F, Agus MS, Balamuth F, Brady PW, Brilli RJ, Carcillo JA, Dantes R, Epstein L, Fiore AE, Gerber JS, Gokhale RH, Joyner BL, Kissoon N, Klompas M, Lee GM, Macias CG, Puopolo KM, Sulton CD, Weiss SL, Rhee C. A National Approach to Pediatric Sepsis Surveillance. Pediatrics 2019; 144:peds.2019-1790. [PMID: 31776196 PMCID: PMC6889946 DOI: 10.1542/peds.2019-1790] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2019] [Indexed: 01/21/2023] Open
Abstract
Pediatric sepsis is a major public health concern, and robust surveillance tools are needed to characterize its incidence, outcomes, and trends. The increasing use of electronic health records (EHRs) in the United States creates an opportunity to conduct reliable, pragmatic, and generalizable population-level surveillance using routinely collected clinical data rather than administrative claims or resource-intensive chart review. In 2015, the US Centers for Disease Control and Prevention recruited sepsis investigators and representatives of key professional societies to develop an approach to adult sepsis surveillance using clinical data recorded in EHRs. This led to the creation of the adult sepsis event definition, which was used to estimate the national burden of sepsis in adults and has been adapted into a tool kit to facilitate widespread implementation by hospitals. In July 2018, the Centers for Disease Control and Prevention convened a new multidisciplinary pediatric working group to tailor an EHR-based national sepsis surveillance approach to infants and children. Here, we describe the challenges specific to pediatric sepsis surveillance, including evolving clinical definitions of sepsis, accommodation of age-dependent physiologic differences, identifying appropriate EHR markers of infection and organ dysfunction among infants and children, and the need to account for children with medical complexity and the growing regionalization of pediatric care. We propose a preliminary pediatric sepsis event surveillance definition and outline next steps for refining and validating these criteria so that they may be used to estimate the national burden of pediatric sepsis and support site-specific surveillance to complement ongoing initiatives to improve sepsis prevention, recognition, and treatment.
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Affiliation(s)
- Heather E. Hsu
- Department of Pediatrics, School of Medicine, Boston University and Boston Medical Center, Boston, Massachusetts
| | - Francisca Abanyie
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Michael S.D. Agus
- Division of Medical Critical Care, Department of Pediatrics, Harvard Medical School and Boston Children’s Hospital, Boston, Massachusetts
| | | | - Patrick W. Brady
- Division of Hospital Medicine, Department of Pediatrics, College of Medicine, University of Cincinnati Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Richard J. Brilli
- Division of Critical Care Medicine, Department of Pediatrics, College of Medicine, The Ohio State University and Nationwide Children’s Hospital, Columbus, Ohio
| | - Joseph A. Carcillo
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh and Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Raymund Dantes
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia;,Division of Hospital Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | - Lauren Epstein
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anthony E. Fiore
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Runa H. Gokhale
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Benny L. Joyner
- Department of Pediatrics, Division of Critical Care Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Niranjan Kissoon
- Departments of Pediatrics and Emergency Medicine, University of British Columbia, Vancouver and British Columbia's Children's Hospital, British Columbia, Canada
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School, Harvard University and Harvard Pilgrim Health Care Institute, Boston, Massachusetts;,Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Grace M. Lee
- Department of Pediatrics, School of Medicine, Stanford University and Lucille Packard Children’s Hospital, Palo Alto, California
| | - Charles G. Macias
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Case Western Reserve University and Rainbow Babies and Children’s Hospital, Cleveland, Ohio; and
| | - Karen M. Puopolo
- Neonatology, and Center for Pediatric Clinical Effectiveness, Departments of Pediatrics and
| | - Carmen D. Sulton
- Departments of Pediatrics and Emergency Medicine, School of Medicine, Emory University and Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia
| | - Scott L. Weiss
- Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School, Harvard University and Harvard Pilgrim Health Care Institute, Boston, Massachusetts;,Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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33
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Comparison of Automated Sepsis Identification Methods and Electronic Health Record-based Sepsis Phenotyping: Improving Case Identification Accuracy by Accounting for Confounding Comorbid Conditions. Crit Care Explor 2019; 1:e0053. [PMID: 32166234 PMCID: PMC7063888 DOI: 10.1097/cce.0000000000000053] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. To develop and evaluate a novel strategy that automates the retrospective identification of sepsis using electronic health record data.
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34
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Rhee C, Wang R, Song Y, Zhang Z, Kadri SS, Septimus EJ, Fram D, Jin R, Poland RE, Hickok J, Sands K, Klompas M. Risk Adjustment for Sepsis Mortality to Facilitate Hospital Comparisons Using Centers for Disease Control and Prevention's Adult Sepsis Event Criteria and Routine Electronic Clinical Data. Crit Care Explor 2019; 1:e0049. [PMID: 32166230 PMCID: PMC7063887 DOI: 10.1097/cce.0000000000000049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Variability in hospital-level sepsis mortality rates may be due to differences in case mix, quality of care, or diagnosis and coding practices. Centers for Disease Control and Prevention's Adult Sepsis Event definition could facilitate objective comparisons of sepsis mortality rates between hospitals but requires rigorous risk-adjustment tools. We developed risk-adjustment models for Adult Sepsis Events using administrative and electronic health record data. DESIGN Retrospective cohort study. SETTING One hundred thirty-six U.S. hospitals in Cerner HealthFacts (derivation dataset) and 137 HCA Healthcare hospitals (validation dataset). PATIENTS A total of 95,154 hospitalized adult patients (derivation) and 201,997 patients (validation) meeting Centers for Disease Control and Prevention Adult Sepsis Event criteria. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We created logistic regression models of increasing complexity using administrative and electronic health record data to predict in-hospital mortality. An administrative model using demographics, comorbidities, and coded markers of severity of illness at admission achieved an area under the receiver operating curve of 0.776 (95% CI, 0.770-0.783) in the Cerner cohort, with diminishing calibration at higher baseline risk deciles. An electronic health record-based model that integrated administrative data with laboratory results, vasopressors, and mechanical ventilation achieved an area under the receiver operating curve of 0.826 (95% CI, 0.820-0.831) in the derivation cohort and 0.827 (95% CI, 0.824-0.829) in the validation cohort, with better calibration than the administrative model. Adding vital signs and Glasgow Coma Score minimally improved performance. CONCLUSIONS Models incorporating electronic health record data accurately predict hospital mortality for patients with Adult Sepsis Events and outperform models using administrative data alone. Utilizing laboratory test results, vasopressors, and mechanical ventilation without vital signs may achieve a good balance between data collection needs and model performance, but electronic health record-based models must be attentive to potential variability in data quality and availability. With ongoing testing and refinement of these risk-adjustment models, Adult Sepsis Event surveillance may enable more meaningful comparisons of hospital sepsis outcomes and provide an important window into quality of care.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Rui Wang
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Yue Song
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Zilu Zhang
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medical Oncology, Harvard Medical School/Dana Farber Cancer Institute, Boston, MA
| | - Sameer S Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Edward J Septimus
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Internal Medicine, Texas A&M College of Medicine, Houston, TX
| | | | - Robert Jin
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
| | - Russell E Poland
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Clinical Services Group, HCA Healthcare, Nashville, TN
| | | | - Kenneth Sands
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Clinical Services Group, HCA Healthcare, Nashville, TN
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
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35
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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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36
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Rhee C, Jones TM, Hamad Y, Pande A, Varon J, O’Brien C, Anderson DJ, Warren DK, Dantes RB, Epstein L, Klompas M. Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals. JAMA Netw Open 2019; 2:e187571. [PMID: 30768188 PMCID: PMC6484603 DOI: 10.1001/jamanetworkopen.2018.7571] [Citation(s) in RCA: 304] [Impact Index Per Article: 60.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Sepsis is present in many hospitalizations that culminate in death. The contribution of sepsis to these deaths, and the extent to which they are preventable, is unknown. OBJECTIVE To estimate the prevalence, underlying causes, and preventability of sepsis-associated mortality in acute care hospitals. DESIGN, SETTING, AND PARTICIPANTS Cohort study in which a retrospective medical record review was conducted of 568 randomly selected adults admitted to 6 US academic and community hospitals from January 1, 2014, to December 31, 2015, who died in the hospital or were discharged to hospice and not readmitted. Medical records were reviewed from January 1, 2017, to March 31, 2018. MAIN OUTCOMES AND MEASURES Clinicians reviewed cases for sepsis during hospitalization using Sepsis-3 criteria, hospice-qualifying criteria on admission, immediate and underlying causes of death, and suboptimal sepsis-related care such as inappropriate or delayed antibiotics, inadequate source control, or other medical errors. The preventability of each sepsis-associated death was rated on a 6-point Likert scale. RESULTS The study cohort included 568 patients (289 [50.9%] men; mean [SD] age, 70.5 [16.1] years) who died in the hospital or were discharged to hospice. Sepsis was present in 300 hospitalizations (52.8%; 95% CI, 48.6%-57.0%) and was the immediate cause of death in 198 cases (34.9%; 95% CI, 30.9%-38.9%). The next most common immediate causes of death were progressive cancer (92 [16.2%]) and heart failure (39 [6.9%]). The most common underlying causes of death in patients with sepsis were solid cancer (63 of 300 [21.0%]), chronic heart disease (46 of 300 [15.3%]), hematologic cancer (31 of 300 [10.3%]), dementia (29 of 300 [9.7%]), and chronic lung disease (27 of 300 [9.0%]). Hospice-qualifying conditions were present on admission in 121 of 300 sepsis-associated deaths (40.3%; 95% CI 34.7%-46.1%), most commonly end-stage cancer. Suboptimal care, most commonly delays in antibiotics, was identified in 68 of 300 sepsis-associated deaths (22.7%). However, only 11 sepsis-associated deaths (3.7%) were judged definitely or moderately likely preventable; another 25 sepsis-associated deaths (8.3%) were considered possibly preventable. CONCLUSIONS AND RELEVANCE In this cohort from 6 US hospitals, sepsis was the most common immediate cause of death. However, most underlying causes of death were related to severe chronic comorbidities and most sepsis-associated deaths were unlikely to be preventable through better hospital-based care. Further innovations in the prevention and care of underlying conditions may be necessary before a major reduction in sepsis-associated deaths can be achieved.
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Affiliation(s)
- Chanu Rhee
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Travis M. Jones
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
| | - Yasir Hamad
- Department of Medicine, Washington University School of Medicine at St Louis, St Louis, Missouri
| | - Anupam Pande
- Department of Medicine, Washington University School of Medicine at St Louis, St Louis, Missouri
| | - Jack Varon
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Cara O’Brien
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Deverick J. Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
| | - David K. Warren
- Department of Medicine, Washington University School of Medicine at St Louis, St Louis, Missouri
| | - Raymund B. Dantes
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta, Georgia
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lauren Epstein
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Michael Klompas
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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