Treatment Patterns and Clinical Outcomes After the Introduction of the Medicare Sepsis Performance Measure (SEP-1)

Evaluating Sepsis Bundle Compliance as a Predictor for Patient Outcomes at a Community Hospital: A Retrospective Study

BACKGROUND

Clinicians are encouraged to use the Centers for Medicare & Medicaid Services early management bundle for severe sepsis and septic shock (SEP-1); however, it is unclear whether this process measure improves patient outcomes.

PURPOSE

The purpose of this study was to evaluate whether compliance with the SEP-1 bundle is a predictor of hospital mortality, length of stay (LOS), and intensive care unit LOS at a suburban community hospital.

METHODS

A retrospective observational study was conducted.

RESULTS

A total of 577 patients were included in the analysis. Compliance with the SEP-1 bundle was not a significant predictor for patient outcomes.

CONCLUSIONS

SEP-1 compliance may not equate with quality of health care. Efforts to comply with SEP-1 may help organizations develop systems and structures that improve patient outcomes. Health care leaders should evaluate strategies beyond SEP-1 compliance to ensure continuous improvement of outcomes for patients experiencing sepsis.

Trends in Empiric Broad-Spectrum Antibiotic Use for Suspected Community-Onset Sepsis in US Hospitals

Importance

Little is known about the degree to which suspected sepsis drives broad-spectrum antibiotic use in hospitals, what proportion of antibiotic courses are unnecessarily broad in retrospect, and whether these patterns are changing over time.

Objective

To describe trends in empiric broad-spectrum antibiotic use for suspected community-onset sepsis.

Design, Setting, and Participants

This cross-sectional study used clinical data from adults admitted to 241 US hospitals in the PINC AI Healthcare Database. Eligible participants were aged 18 years or more and were admitted between 2017 and 2021 with suspected community-onset sepsis, defined by a blood culture draw, lactate measurement, and intravenous antibiotic administration on admission.

Exposures

Empiric anti-methicillin-resistant Staphylococcus aureus (MRSA) and/or antipseudomonal β-lactam agent use.

Main Outcomes and Measures

Annual rates of empiric anti-MRSA and/or antipseudomonal β-lactam agent use and the proportion that were likely unnecessary in retrospect based on the absence of β-lactam resistant gram-positive or ceftriaxone-resistant gram-negative pathogens from clinical cultures obtained through hospital day 4. Annual trends were calculated using mixed-effects logistic regression models, adjusting for patient and hospital characteristics.

Results

Among 6 272 538 hospitalizations (median [IQR] age, 66 [53-78] years; 443 465 male [49.6%]; 106 095 Black [11.9%], 65 763 Hispanic [7.4%], 653 907 White [73.1%]), 894 724 (14.3%) had suspected community-onset sepsis, of whom 582 585 (65.1%) received either empiric anti-MRSA (379 987 [42.5%]) or antipseudomonal β-lactam therapy (513 811 [57.4%]); 311 213 (34.8%) received both. Patients with suspected community-onset sepsis accounted for 1 573 673 of 3 141 300 (50.1%) of total inpatient anti-MRSA antibiotic days and 2 569 518 of 5 211 745 (49.3%) of total antipseudomonal β-lactam days. Between 2017 and 2021, the proportion of patients with suspected sepsis administered anti-MRSA or antipseudomonal therapy increased from 63.0% (82 731 of 131 275 patients) to 66.7% (101 003 of 151 435 patients) (adjusted OR [aOR] per year, 1.03; 95% CI, 1.03-1.04). However, resistant organisms were isolated in only 65 434 cases (7.3%) (30 617 gram-positive [3.4%], 38 844 gram-negative [4.3%]) and the proportion of patients who had any resistant organism decreased from 9.6% to 7.3% (aOR per year, 0.87; 95% CI, 0.87-0.88). Most patients with suspected sepsis treated with empiric anti-MRSA and/or antipseudomonal therapy had no resistant organisms (527 356 of 582 585 patients [90.5%]); this proportion increased from 88.0% in 2017 to 91.6% in 2021 (aOR per year, 1.12; 95% CI, 1.11-1.13).

Conclusions and Relevance

In this cross-sectional study of adults admitted to 241 US hospitals, empiric broad-spectrum antibiotic use for suspected community-onset sepsis accounted for half of all anti-MRSA or antipseudomonal therapy; the use of these types of antibiotics increased between 2017 and 2021 despite resistant organisms being isolated in less than 10% of patients treated with broad-spectrum agents.

Association Between Medicare's Sepsis Reporting Policy (SEP-1) and the Documentation of a Sepsis Diagnosis in the Clinical Record

STUDY DESIGN

Interrupted time series analysis of a retrospective, electronic health record cohort.

OBJECTIVE

To determine the association between the implementation of Medicare's sepsis reporting measure (SEP-1) and sepsis diagnosis rates as assessed in clinical documentation.

BACKGROUND

The role of health policy in the effort to improve sepsis diagnosis remains unclear.

PATIENTS AND METHODS

Adult patients hospitalized with suspected infection and organ dysfunction within 6 hours of presentation to the emergency department, admitted to one of 11 hospitals in a multi-hospital health system from January 2013 to December 2017. Clinician-diagnosed sepsis, as reflected by the inclusion of the terms "sepsis" or "septic" in the text of clinical notes in the first two calendar days following presentation.

RESULTS

Among 44,074 adult patients with sepsis admitted to 11 hospitals over 5 years, the proportion with sepsis documentation was 32.2% just before the implementation of SEP-1 in the third quarter of 2015 and increased to 37.3% by the fourth quarter of 2017. Of the 9 post-SEP-1 quarters, 8 had odds ratios for a sepsis diagnosis >1 (overall range: 0.98-1.26; P value for a joint test of statistical significance = 0.005). The effects were clinically modest, with a maximum effect of an absolute increase of 4.2% (95% CI: 0.9-7.8) at the end of the study period. The effect was greater in patients who did not require vasopressors compared with patients who required vasopressors ( P value for test of interaction = 0.02).

CONCLUSIONS

SEP-1 implementation was associated with modest increases in sepsis diagnosis rates, primarily among patients who did not require vasoactive medications.

Sepsis best practices: Definitions, guidelines, and updates

ABSTRACT

Sepsis remains a complex and costly disease with high morbidity and mortality. This article discusses Sepsis-2 and Sepsis-3 definitions, highlighting the 2021 Surviving Sepsis International guidelines as well as the regulatory requirements and reimbursement for the Severe Sepsis and Septic Shock Management Bundle (SEP-1) measure.

Early Physician Gestalt Versus Usual Screening Tools for the Prediction of Sepsis in Critically Ill Emergency Patients

STUDY OBJECTIVE

Compare physician gestalt to existing screening tools for identifying sepsis in the initial minutes of presentation when time-sensitive treatments must be initiated.

METHODS

This prospective observational study conducted with consecutive encounter sampling took place in the emergency department (ED) of an academic, urban, safety net hospital between September 2020 and May 2022. The study population included ED patients who were critically ill, excluding traumas, transfers, and self-evident diagnoses. Emergency physician gestalt was measured using a visual analog scale (VAS) from 0 to 100 at 15 and 60 minutes after patient arrival. The primary outcome was an explicit sepsis hospital discharge diagnosis. Clinical data were recorded for up to 3 hours to compare Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), quick SOFA (qSOFA), Modified Early Warning Score (MEWS), and a logistic regression machine learning model using Least Absolute Shrinkage and Selection Operator (LASSO) for variable selection. The screening tools were compared using receiver operating characteristic analysis and area under the curve calculation (AUC).

RESULTS

A total of 2,484 patient-physician encounters involving 59 attending physicians were analyzed. Two hundred seventy-five patients (11%) received an explicit sepsis discharge diagnosis. When limited to available data at 15 minutes, initial VAS (AUC 0.90; 95% confidence interval [CI] 0.88, 0.92) outperformed all tools including LASSO (0.84; 95% CI 0.82 to 0.87), qSOFA (0.67; 95% CI 0.64 to 0.71), SIRS (0.67; 95% 0.64 to 0.70), SOFA (0.67; 95% CI 0.63 to 0.70), and MEWS (0.66; 95% CI 0.64 to 0.69). Expanding to data available at 60 minutes did not meaningfully change results.

CONCLUSION

Among adults presenting to an ED with an undifferentiated critical illness, physician gestalt in the first 15 minutes of the encounter outperformed other screening methods in identifying sepsis.

Improving Sepsis Outcomes in the Era of Pay-for-Performance and Electronic Quality Measures: A Joint IDSA/ACEP/PIDS/SHEA/SHM/SIDP Position Paper

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.

Primary Infection Site as a Predictor of Sepsis Development in Emergency Department Patients

BACKGROUND

Sepsis is a life-threatening condition but predicting its development and progression remains a challenge.

OBJECTIVE

This study aimed to assess the impact of infection site on sepsis development among emergency department (ED) patients.

METHODS

Data were collected from a single-center ED between January 2016 and December 2019. Patient encounters with documented infections, as defined by the Systematized Nomenclature of Medicine-Clinical Terms for upper respiratory tract (URI), lower respiratory tract (LRI), urinary tract (UTI), or skin or soft-tissue infections were included. Primary outcome was the development of sepsis or septic shock, as defined by Sepsis-1/2 criteria. Secondary outcomes included hospital disposition and length of stay, blood and urine culture positivity, antibiotic administration, vasopressor use, in-hospital mortality, and 30-day mortality. Analysis of variance and various different logistic regression approaches were used for analysis with URI used as the reference variable.

RESULTS

LRI was most associated with sepsis (relative risk ratio [RRR] 5.63; 95% CI 5.07-6.24) and septic shock (RRR 21.2; 95% CI 17.99-24.98) development, as well as hospital admission rates (odds ratio [OR] 8.23; 95% CI 7.41-9.14), intensive care unit admission (OR 4.27; 95% CI 3.84-4.74), in-hospital mortality (OR 6.93; 95% CI 5.60-8.57), and 30-day mortality (OR 7.34; 95% CI 5.86-9.19). UTIs were also associated with sepsis and septic shock development, but to a lesser degree than LRI.

CONCLUSIONS

Primary infection sites including LRI and UTI were significantly associated with sepsis development, hospitalization, length of stay, and mortality among patients presenting with infections in the ED.

Focused Cardiac Ultrasound Findings of Fluid Tolerance and Fluid Resuscitation in Septic Shock

OBJECTIVES

Compliance with the fluid bonus component of the SEP-1 (severe sepsis and septic shock management) bundle remains poor due to concerns for iatrogenic harm from fluid overload. We sought to assess whether patients who received focused cardiac ultrasound (FCU) and were found to be fluid tolerant (FT) were more likely to receive the recommended 30 mL/kg fluid bolus within 3 hours of sepsis identification.

DESIGN

Retrospective, observational cohort study.

SETTING

University-affiliated, tertiary-care hospital in the United States.

PATIENTS

Emergency department patients presenting with septic shock from 2018 to 2021. The primary exposure was receipt of FCU with identification of fluid tolerance 3 hours from onset of septic shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Two hundred ninety-two of 1,024 patients with septic shock received FCU within 3 hours of sepsis onset. One hundred seventy-seven were determined to be FT. One hundred fifteen patients were determined to have poor fluid tolerance (pFT). FT patients were more likely to reach the recommended 30 mL/kg fluid bolus amount compared with pFT (FT 52.0% vs. pFT 31.3%, risk difference: 20.7%, [95% CI, 9.4-31.9]). Patients who did not receive FCU met the bolus requirement 34.3% of the time. FT patients received more fluid within 3 hours (FT 2,271 mL vs. pFT 1,646 mL, mean difference 625 mL [95% CI, 330-919]). Multivariable logistic regression was used to estimate the association between fluid tolerance FCU findings and compliance with 30 mL/kg bolus after adjustment for patient characteristics and markers of hemodynamic instability. FT with associated with a higher likelihood of meeting bolus requirement (odds ratio 2.17 [1.52-3.12]).

CONCLUSIONS

Patients found to be FT by FCU were more likely to receive the recommended 30 mL/kg bolus in the SEP-1 bundle when compared with patients found with pFT or those that did not receive FCU. There was no difference between groups in 28-day mortality, vasopressor requirement, or need for mechanical ventilation.

Institutional Structures and Processes to Support Sepsis Care: A Multihospital Study

OBJECTIVES

To identify opportunities for improving hospital-based sepsis care and to inform an ongoing statewide quality improvement initiative in Michigan.

DESIGN

Surveys on hospital sepsis processes, including a self-assessment of practices using a 3-point Likert scale, were administered to 51 hospitals participating in the Michigan Hospital Medicine Safety Consortium, a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan, at two time points (2020, 2022). Forty-eight hospitals also submitted sepsis protocols for structured review.

SETTING

Multicenter quality improvement consortium.

SUBJECTS

Fifty-one hospitals in Michigan.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the included hospitals, 92.2% (n = 47/51) were nonprofit, 88.2% (n = 45/51) urban, 11.8% (n = 6/51) rural, and 80.4% (n = 41/51) teaching hospitals. One hundred percent (n = 51/51) responded to the survey, and 94.1% (n = 48/51) provided a sepsis policy/protocol. All surveyed hospitals used at least one quality improvement approach, including audit/feedback (98.0%, n = 50/51) and/or clinician education (68.6%, n = 35/51). Protocols included the Sepsis-1 (18.8%, n = 9/48) or Sepsis-2 (31.3%, n = 15/48) definitions; none (n = 0/48) used Sepsis-3. All hospitals (n = 51/51) used at least one process to facilitate rapid sepsis treatment, including order sets (96.1%, n = 49/51) and/or stocking of commonly used antibiotics in at least one clinical setting (92.2%, n = 47/51). Treatment protocols included guidance on antimicrobial therapy (68.8%, n = 33/48), fluid resuscitation (70.8%, n = 34/48), and vasopressor administration (62.5%, n = 30/48). On self-assessment, hospitals reported the lowest scores for peridischarge practices, including screening for cognitive impairment (2.0%, n = 1/51 responded "we are good at this") and providing anticipatory guidance (3.9%, n = 2/51). There were no meaningful associations of the Centers for Medicare and Medicaid Services' Severe Sepsis and Septic Shock: Management Bundle performance with differences in hospital characteristics or sepsis policy document characteristics.

CONCLUSIONS

Most hospitals used audit/feedback, order sets, and clinician education to facilitate sepsis care. Hospitals did not consistently incorporate organ dysfunction criteria into sepsis definitions. Existing processes focused on early recognition and treatment rather than recovery-based practices.

Evaluation of the Recommended 30 cc/kg Fluid Dose for Patients With Septic Shock and Hypoperfusion With Lactate Greater Than 4 mmol/L

The Surviving Sepsis Campaign Guidelines recommend fluid administration of 30 cc/kg ideal body weight (IBW) for patients with sepsis and lactate greater than 4 mmol/L within 3 hours of identification. In this study, we explore the impact of fluid dose on lactate normalization, treatment cost, length of stay, and mortality in patients with lactate greater than 4.

DESIGN

Multicenter retrospective observational study.

SETTING

Eight-hospital urban healthcare system in Northeastern United States.

PATIENTS

Patients with sepsis, initial lactate value greater than 4 mmol/L, and received appropriate antibiotics within 3 hours.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We stratified patients into five groups based on the dose of fluid administered within 3 hours after sepsis identification. The groupings were less than 15 cc/kg IBW, 15.1-25 cc/kg IBW, 25.1-35 cc/kg IBW, 35.1-50 cc/kg IBW, and greater than 50 cc/kg IBW. We used the group that received a fluid dose of 25.1-35 cc/kg IBW, as a reference group. The mean age was 66 years, and 56% were male. Three hundred seventy-one (25%) received less than 15 cc/kg of IBW of crystalloid fluid, 278 (17%) received 15-25 cc/kg of IBW, 316 (21%) received 25.1-35 cc/kg of IBW, 319 (21%) received 35.1-50 cc/kg of IBW, and 207 (14%) received greater than 50 cc/kg of IBW. After multilinear regression, there was no significant difference in lactate normalization between the reference group and any of the other fluid groups. We also found no statistically significant difference in the observed/expected cost, or observed/expected length of stay, between the reference group and any of the other fluid groups. Mortality was higher among patients who received greater than 50 cc/kg IBW when compared to the recommended dose.

CONCLUSIONS

In patients with sepsis and lactate value greater than 4 mmol/L, high or low fluid doses were not associated with better lactate clearance or patient outcomes. Greater than 50 cc/kg IBW dose of fluids within 3 hours is associated with higher mortality.

Overcultured? Blood cultures on discharged ED patients were ordered more frequently after the SEP-1 bundle initiation

INTRODUCTION

In 2015, the Severe Sepsis and Early Septic Shock Management Bundle (SEP-1) tied hospital reimbursement to performance on a series of time sensitive indicators, including ordering blood cultures on patients with severe sepsis or septic shock. This metric could have broadly shaped ordering practices in the Emergency Department (ED), including for patients who did not have severe sepsis or septic shock. In this study, we sought to evaluate whether the frequency of blood culture orders on adult patients discharged from the ED changed after the SEP-1 metric, whether the rates of positivity for pathogens or contaminants changed after the SEP-1 metric, and whether similar changes were seen in orders for other laboratory tests.

METHODS

This was a retrospective evaluation of blood culture orders from discharged adult ED patients from a suburban academic hospital between January 1, 2012 and June 30, 2019. We compared the number of blood cultures per discharged adult patient before and after the SEP-1 metric. We categorized each culture that grew an organism as a pathogen or a contaminant, and we compared rates of pathogen and contaminant growth before and after SEP-1. We compared rates of orders of blood cultures and lactates as labs related to SEP-1 with rates of orders of D-dimers, lipases, human chorionic gonadotropins (HCGs), and brain natriuretic peptides (BNPs) as labs unrelated to SEP-1 before and after the implementation of the SEP-1 metric.

RESULTS

There were 144,343 adult patients discharged from the ED during the study period. A total of 6754 blood cultures were drawn from 3827 of those patient visits. The rate increased from 43.1 cultures per 1000 discharged patients before the SEP-1 metric to 75.9 blood cultures per 1000 discharged patients, an increase of 76.2% (p < 0.001). The cultures had a decreased rate of positivity (from 3.93% before SEP-1 to 3.03% after SEP-1, p = 0.044) and an unchanged rate of blood cultures resulting in a contaminant (2.49% to 1.85%, p = 0.071). Overall, orders of the labs unrelated to SEP-1 increased by an average of 16.8% after the SEP-1 metric and orders of the labs related to SEP-1 increased by an average of 81.0%.

CONCLUSION

After the SEP-1 bundle, blood cultures were ordered more frequently on discharged ED patients. These cultures had a lower rate of positivity for pathogens and an unchanged rate of growth of contaminants. This increase was not matched by a similar increase in other labs. Taken together, these findings suggest that the SEP-1 metric had the unintended consequence of increasing orders of blood cultures on patients healthy enough to be discharged from the ED.

The Importance of Shifting Sepsis Quality Measures From Processes to Outcomes

This Viewpoint discusses the failure of the Centers for Medicare &amp;amp; Medicaid Services’ SEP-1 sepsis outcome improvement initiative to improve patients’ sepsis outcomes and suggests changing the focus of sepsis quality metrics from processes to outcomes.

The CDC antimicrobial use measure is not ready for public reporting or value-based programs

The standardized antimicrobial administration ratio (SAAR) is the metric for reporting antimicrobial use that hospitals will be mandated to use in 2024. We highlight limitations of the SAAR and caution against efforts to use it for public reporting and financial reimbursement. Before the SAAR is ready for public reporting, it needs to include patient-level risk adjustment and antimicrobial resistance data as well as improved hospital location options and revised antimicrobial agent groupings to appropriately reflect and incentivize important stewardship work.

Improving Sepsis Management Through the Emergency Quality Network Sepsis Initiative

BACKGROUND

Public reporting of the Centers for Medicare & Medicaid (CMS) SEP-1 sepsis quality measure is often too late and without the data granularity to inform real-time quality improvement (QI). In response, the American College of Emergency Physicians (ACEP) Emergency Quality Network (E-QUAL) Sepsis Initiative sought to support QI efforts through benchmarking of preliminary draft SEP-1 scores for emergency department (ED) patients. This study sought to determine the anticipatory value of these preliminary SEP-1 benchmarking scores and publicly reported performance.

METHODS

Cross-sectional analysis was performed on QI data collected from hospital-based ED sites participating in the E-QUAL Sepsis Collaborative in 2017 and 2018. Participating EDs submitted SEP-1 benchmarking scores semiannually, which were compared to publicly reported CMS SEP-1 data. EDs also reported implementation data on a variety of sepsis-related QI activities for comparison based on SEP-1 performance.

RESULTS

Among 220 EDs participating in E-QUAL, SEP-1 benchmarking scores showed weak but statistically significant correlation with CMS SEP-1 scores (r = 0.189, p = 0.01). Mean E-QUAL SEP-1 benchmarking scores were higher than mean CMS SEP-1 scores (74.1% vs. 57.2%), with 83.2% of sites reporting a benchmarking score higher than the CMS SEP-1 score. EDs with SEP-1 scores in the bottom 20% reported completion of more sepsis-related QI activities than EDs with average or top 20% SEP-1 scores.

CONCLUSION

Preliminary benchmarking results demonstrate a weak, statistically significant correlation with subsequent publicly reported CMS SEP-1 scores and suggest that ED performance in sepsis care may exceed overall hospital performance inclusive of all inpatients. Sepsis quality measurement and sepsis QI efforts may be best guided by separating ED sepsis cases from in-hospital sepsis cases as is done for other acute time-sensitive conditions.

Quantifying the breadth of antibiotic exposure in sepsis and suspected infection using spectrum scores

A retrospective cohort study. Studies to quantify the breadth of antibiotic exposure across populations remain limited. Therefore, we applied a validated method to describe the breadth of antimicrobial coverage in a multicenter cohort of patients with suspected infection and sepsis. We conducted a retrospective cohort study across 21 hospitals within an integrated healthcare delivery system of patients admitted to the hospital through the ED with suspected infection or sepsis and receiving antibiotics during hospitalization from January 1, 2012, to December 31, 2017. We quantified the breadth of antimicrobial coverage using the Spectrum Score, a numerical score from 0 to 64, in patients with suspected infection and sepsis using electronic health record data. Of 364,506 hospital admissions through the emergency department, we identified 159,004 (43.6%) with suspected infection and 205,502 (56.4%) with sepsis. Inpatient mortality was higher among those with sepsis compared to those with suspected infection (8.4% vs 1.2%; P < .001). Patients with sepsis had higher median global Spectrum Scores (43.8 [interquartile range IQR 32.0-49.5] vs 43.5 [IQR 26.8-47.2]; P < .001) and additive Spectrum Scores (114.0 [IQR 57.0-204.5] vs 87.5 [IQR 45.0-144.8]; P < .001) compared to those with suspected infection. Increased Spectrum Scores were associated with inpatient mortality, even after covariate adjustments (adjusted odds ratio per 10-point increase in Spectrum Score 1.31; 95%CI 1.29-1.33). Spectrum Scores quantify the variability in antibiotic breadth among individual patients, between suspected infection and sepsis populations, over the course of hospitalization, and across infection sources. They may play a key role in quantifying the variation in antibiotic prescribing in patients with suspected infection and sepsis.

Can an End-to-End Telesepsis Solution Improve the Severe Sepsis and Septic Shock Management Bundle-1 Metrics for Sepsis Patients Admitted From the Emergency Department to the Hospital?

Early detection and treatment for sepsis patients are key components to improving sepsis care delivery and increased The Severe Sepsis and Septic Shock Management Bundle (SEP-1) compliance may correlate with improved outcomes.

OBJECTIVES

We assessed the impact of implementing a partially automated end-to-end sepsis solution including electronic medical record-linked automated monitoring, early detection, around-the-clock nurse navigators, and teleconsultation, on SEP-1 compliance in patients with primary sepsis, present at admission, admitted through the emergency department (ER).

DESIGN SETTING AND PARTICIPANTS

After a "surveillance only" training period between September 3, 2020, and October 5, 2020, the automated end-to-end sepsis solution intervention period occurred from October 6, 2020, to January 1, 2021 in five ERs in an academic health system. Patients who screened positive for greater than or equal to 3 sepsis screening criteria (systemic inflammatory response syndrome, quick Sequential Organ Failure Assessment, pulse oximetry), had evidence of infection and acute organ dysfunction, and were receiving treatment consistent with infection or sepsis were included.

MAIN OUTCOMES AND MEASURES

SEP-1 compliance during the "surveillance only" period compared to the intervention period.

RESULTS

During the intervention period, 56,713 patients presented to the five ERs; 20,213 (35.6%) met electronic screening criteria for potential sepsis; 1,233 patients had a primary diagnosis of sepsis, present at admission, and were captured by the nurse navigators. Median age of the cohort was 68 years (interquartile range, 57-79 yr); 55.3% were male; 63.5% were White/Caucasian, 26.3% Black/African-American; was 16.7%, and 879 patients (71.3%) were presumed bacterial sepsis, nonviral etiology, and SEP-1 bundle eligible. Nurse navigator real-time classification of this group increased from 51.7% during the "surveillance only" period to 71.8% during the intervention period (p = 0.0002). Five hospital SEP-1 compliance for the period leading into the study period (July 1, 2020-August 31, 2020) was 62% (p < 0.0001), during the "surveillance only" period, it was 68.4% and during the intervention period it was 78.3% (p = 0.002).

CONCLUSIONS AND RELEVANCE

During an 11-week period of sepsis screening, monitoring, and teleconsultation in 5 EDs, SEP-1 compliance improved significantly compared with institutional SEP-1 reporting metrics and to a "surveillance only" training period.

Association Between Preexisting Heart Failure With Reduced Ejection Fraction and Fluid Administration Among Patients With Sepsis

Importance

Intravenous fluid administration is recommended to improve outcomes for patients with septic shock. However, there are few data on fluid administration for patients with preexisting heart failure with reduced ejection fraction (HFrEF).

Objective

To evaluate the association between preexisting HFrEF, guideline-recommended intravenous fluid resuscitation, and mortality among patients with community-acquired sepsis and septic shock.

Design, Setting, and Participants

A cohort study was conducted of adult patients hospitalized in an integrated health care system from January 1, 2013, to December 31, 2015, with community-acquired sepsis and preexisting assessment of cardiac function. Follow-up occurred through July 1, 2016. Data analyses were performed from November 1, 2020, to August 8, 2022.

Exposures

Preexisting heart failure with reduced ejection fraction (≤40%) measured by transthoracic echocardiogram within 1 year prior to hospitalization for sepsis.

Main Outcomes and Measures

Multivariable models were adjusted for patient factors and sepsis severity and clustered at the hospital level to generate adjusted odds ratios (aORs) and 95% CIs. The primary outcome was the administration of 30 mL/kg of intravenous fluid within 6 hours of sepsis onset. Secondary outcomes included in-hospital mortality, intensive care unit admission, rate of invasive mechanical ventilation, and administration of vasoactive medications.

Results

Of 5278 patients with sepsis (2673 men [51%]; median age, 70 years [IQR, 60-81 years]; 4349 White patients [82%]; median Sequential Organ Failure Assessment score, 4 [IQR, 3-5]), 884 (17%) had preexisting HFrEF, and 2291 (43%) met criteria for septic shock. Patients with septic shock and HFrEF were less likely to receive guideline-recommended intravenous fluid than those with septic shock without HFrEF (96 of 380 [25%] vs 699 of 1911 [37%]; P < .001), but in-hospital mortality was similar (47 of 380 [12%] vs 244 of 1911 [13%]; P = .83). In multivariable models, HFrEF was associated with a decreased risk-adjusted odds of receiving 30 mL/kg of intravenous fluid within the first 6 hours of sepsis onset (aOR, 0.63; 95% CI, 0.47-0.85; P = .002). The risk-adjusted mortality was not significantly different among patients with HFrEF (aOR, 0.92; 95% CI, 0.69-1.24; P = .59) compared with those without, and there was no interaction with intravenous fluid volume (aOR, 1.00; 95% CI, 0.98-1.03; P = .72).

Conclusions and Relevance

The results of this cohort study of patients with community-acquired septic shock suggest that preexisting HFrEF was common and was associated with reduced odds of receiving guideline-recommended intravenous fluids.

Antibiotics: it is all about timing, isn't it?

PURPOSE OF REVIEW

Sepsis guidelines and quality measures set aggressive deadlines for administering antibiotics to patients with possible sepsis or septic shock. However, the diagnosis of sepsis is often uncertain, particularly upon initial presentation, and pressure to treat more rapidly may harm some patients by exposing them to unnecessary or inappropriate broad-spectrum antibiotics.

RECENT FINDINGS

Observational studies that report that each hour until antibiotics increases mortality often fail to adequately adjust for comorbidities and severity of illness, fail to account for antibiotics given to uninfected patients, and inappropriately blend the effects of long delays with short delays. Accounting for these factors weakens or eliminates the association between time-to-antibiotics and mortality, especially for patients without shock. These findings are underscored by analyses of the Centers for Medicaid and Medicare Services SEP-1 measure: it has increased sepsis diagnoses and broad-spectrum antibiotic use but has not improved outcomes.

SUMMARY

Clinicians are advised to tailor the urgency of antibiotics to their certainty of infection and patients' severity of illness. Immediate antibiotics are warranted for patients with possible septic shock or high likelihood of infection. Antibiotics can safely be withheld to allow for more investigation, however, in most patients with less severe illnesses if the diagnosis of infection is uncertain.

Improving Compliance with the CMS SEP-1 Sepsis Bundle at a Community-Based Teaching Hospital Emergency Department

INTRODUCTION

The Centers for Medicare & Medicaid Services (CMS) designed Hospital Quality Initiatives (HQI) to assure delivery of quality health care for institutions receiving Medicare payments. Like many teaching institutions, the SEP-1 compliance rates at McLaren Oakland in Pontiac fluctuated monthly and were not achieving institutional target expectations.

METHODS

The project team designed a Sepsis Macro and a Sepsis Order Set in the electronic medical record system. The project team also implemented an educational initiative targeted at emergency medicine resident and attending physicians. The educational initiative instructed emergency medicine resident and attending physicians in the metrics measured in the SEP-1 bundle as well as how to properly use the newly designed Sepsis Macro and Sepsis Order Set.

RESULTS

After implementation of the Sepsis Macro and Sepsis Order Set, the overall compliance with the SEP-1 bundle improved from 57% to 62%, above national averages and at the institutional target expectations. However, there were not statistically significant differences (p = 0.562) between the compliance rate before and after program implementation (Pre = 57% (SD = 0.27); 95% CI: 0.29 - 0.85); Post= 62% (SD = 0.11); 95% CI: 0.55 - 0.70). After program implementation the SEP-1 compliance rate was met in 82% of the months in comparison with 50% of the months in the pre-intervention (p = 0.28).

CONCLUSIONS

Although not achieving statistical significance, this intervention demonstrated that simple, cost-effective measures of education and standardization in documentation and order entry in EMR’s can improve clinically significant compliance to CMS HQI metrics in community-based teaching institutions.

Implementation of an Electronic Health Record Integrated Clinical Pathway Improves Adherence to COVID-19 Hospital Care Guidelines

BACKGROUND

During the COVID-19 pandemic, frequently changing guidelines presented challenges to emergency department (ED) clinicians. The authors implemented an electronic health record (EHR)-integrated clinical pathway that could be accessed by clinicians within existing workflows when caring for patients under investigation (PUI) for COVID-19. The objective was to examine the association between clinical pathway utilization and adherence to institutional best practice treatment recommendations for COVID-19.

METHODS

The authors conducted an observational analysis of all ED patients seen in a health system inclusive of seven EDs between March 18, 2020, and April 20, 2021. They implemented the pathway as an interactive flow chart that allowed clinicians to place orders while viewing the most up-to-date institutional guidance. Primary outcomes were proportion of admitted PUIs receiving dexamethasone and aspirin in the ED, and secondary outcome was time to delivering treatment.

RESULTS

A total of 13 269 patients were admitted PUIs. The pathway was used by 40.6% of ED clinicians. When clinicians used the pathway, patients were more likely to be prescribed aspirin (OR, 7.15; 95% CI, 6.2-8.26) and dexamethasone (10.4; 8.85-12.2). For secondary outcomes, clinicians using the pathway had statistically significant ( P < 0.0001) improvement in timeliness of ordering medications and admission to the hospital. Aspirin, dexamethasone, and admission order time were improved by 103.89, 94.34, and 121.94 minutes, respectively.

CONCLUSIONS

The use of an EHR-integrated clinical pathway improved clinician adherence to changing COVID-19 treatment guidelines and timeliness to associated medication administration. As pathways continue to be implemented, their effects on improving patient outcomes and decreasing disparities in patient care should be further examined.

Intensive Care Unit Volume of Sepsis Patients Does Not Affect Mortality: Results of a Nationwide Retrospective Analysis

BACKGROUND

There is little research evaluating outcomes from sepsis in intensive care units (ICUs) with lower sepsis patient volumes as compared to ICUs with higher sepsis patient volumes. Our objective was to compare the outcomes of septic patients admitted to ICUs with different sepsis patient volumes.

MATERIALS AND METHODS

We included all patients from the eICU-CRD database admitted for the management of sepsis with blood lactate ≥ 2mmol/L within 24 hours of admission. Our primary outcome was ICU mortality. Secondary outcomes included hospital mortality, 30-day ventilator free days, and initiation of renal replacement therapy (RRT). ICUs were grouped in quartiles based on the number of septic patients treated at each unit.

RESULTS

10,716 patients were included in our analysis; 272 (2.5%) in low sepsis volume ICUs, 1,078 (10.1%) in medium-low sepsis volume ICUs, 2,608 (24.3%) in medium-high sepsis volume ICUs, and 6,758 (63.1%) in high sepsis volume ICUs. On multivariable analyses, no significant differences were documented regarding ICU and hospital mortality, and ventilator days in patients treated in lower versus higher sepsis volume ICUs. Patients treated at lower sepsis volume ICUs had lower rates of RRT initiation as compared to high volume units (medium-high vs. high: OR = 0.78, 95%CI = 0.66-0.91, P-value = 0.002 and medium-low vs. high: OR = 0.57, 95%CI = 0.44-0.73, P-value < 0.001).

CONCLUSION

The previously described volume-outcome association in septic patients was not identified in an intensive care setting.

Developing a shared sepsis data infrastructure: a systematic review and concept map to FHIR

The development of a shared data infrastructure across health systems could improve research, clinical care, and health policy across a spectrum of diseases, including sepsis. Awareness of the potential value of such infrastructure has been heightened by COVID-19, as the lack of a real-time, interoperable data network impaired disease identification, mitigation, and eradication. The Sepsis on FHIR collaboration establishes a dynamic, federated, and interoperable system of sepsis data from 55 hospitals using 2 distinct inpatient electronic health record systems. Here we report on phase 1, a systematic review to identify clinical variables required to define sepsis and its subtypes to produce a concept mapping of elements onto Fast Healthcare Interoperability Resources (FHIR). Relevant papers described consensus sepsis definitions, provided criteria for sepsis, severe sepsis, septic shock, or detailed sepsis subtypes. Studies not written in English, published prior to 1970, or “grey” literature were prospectively excluded. We analyzed 55 manuscripts yielding 151 unique clinical variables. We then mapped variables to their corresponding US Core FHIR resources and specific code values. This work establishes the framework to develop a flexible infrastructure for sharing sepsis data, highlighting how FHIR could enable the extension of this approach to other important conditions relevant to public health.

Impact of 1-hour and 3-hour sepsis time bundles on patient outcomes and antimicrobial use: A before and after cohort study

Background

Sepsis bundles, promulgated by Surviving Sepsis Campaign have not been widely adopted because of variability in sepsis identification strategies, implementation challenges, concerns about excess antimicrobial use, and limited evidence of benefit.

Methods

A 1-hour septic shock and a 3-hour sepsis bundle were implemented using a Breakthrough Series Collaborative in 14 public hospitals in Queensland, Australia. A before (baseline) and after (post-intervention) study evaluated its impact on outcomes and antimicrobial prescription in patients with confirmed bacteremia and sepsis.

Findings

Between 01 July 2017 to 31 March 2020, of 6976 adults presenting to the Emergency Departments and had a blood culture taken, 1802 patients (732 baseline, 1070 post-intervention) met inclusion criteria. Time to antibiotics in 1-hour 73.7% vs 85.1% (OR 1.9 [95%CI 1.1-3.6]) and the 3-hour bundle compliance (48.2% to 63.3%, OR 1.7, [95%CI 1.4 to 2.1]) improved post-intervention, accompanied by a significant reduction in Intensive Care Unit (ICU) admission rates (26.5% vs 17.5% (OR 0.5, [95%CI 0.4 to 0.7]). There were no significant differences in-hospital and 30-day post discharge mortality between the two phases. In a post-hoc analysis of the post-intervention phase, sepsis pathway compliance was associated with lower in-hospital mortality (9.7% vs 14.9%, OR 0.6, 95%CI 0.4 to 0.8). The proportions of appropriate antimicrobial prescription at baseline and post-intervention respectively were 55.4% vs 64.1%, (OR 1.4 [95%CI 0.9 to 2.1]).

Interpretation

Implementing 1-hour and 3-hour sepsis bundles for patients presenting with bacteremia resulted in improved bundle compliance and a reduced need for ICU admission without adversely influencing antimicrobial prescription.

Time-to-antibiotics and clinical outcomes in patients with sepsis and septic shock: a prospective nationwide multicenter cohort study

Background

Timely administration of antibiotics is one of the most important interventions in reducing mortality in sepsis. However, administering antibiotics within a strict time threshold in all patients suspected with sepsis will require huge amount of effort and resources and may increase the risk of unintentional exposure to broad-spectrum antibiotics in patients without infection with its consequences. Thus, controversy still exists on whether clinicians should target different time-to-antibiotics thresholds for patients with sepsis versus septic shock.

Methods

This study analyzed prospectively collected data from an ongoing multicenter cohort of patients with sepsis identified in the emergency department. Adjusted odds ratios (ORs) were compared for in-hospital mortality of patients who had received antibiotics within 1 h to that of those who did not. Spline regression models were used to assess the association of time-to-antibiotics as continuous variables and increasing risk of in-hospital mortality. The differences in the association between time-to-antibiotics and in-hospital mortality were assessed according to the presence of septic shock.

Results

Overall, 3035 patients were included in the analysis. Among them, 601 (19.8%) presented with septic shock, and 774 (25.5%) died. The adjusted OR for in-hospital mortality of patients whose time-to-antibiotics was within 1 h was 0.78 (95% confidence interval [CI] 0.61–0.99; p = 0.046). The adjusted OR for in-hospital mortality was 0.66 (95% CI 0.44–0.99; p = 0.049) and statistically significant in patients with septic shock, whereas it was 0.85 (95% CI 0.64–1.15; p = 0.300) in patients with sepsis but without shock. Among patients who received antibiotics within 3 h, those with septic shock showed 35% (p = 0.042) increased risk of mortality for every 1-h delay in antibiotics, but no such trend was observed in patients without shock.

Conclusion

Timely administration of antibiotics improved outcomes in patients with septic shock; however, the association between early antibiotic administration and outcome was not as clear in patients with sepsis without shock.

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

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.

Solumedrol Treatment for Severe Sepsis in Humans with a Blunted Adrenocorticotropic Hormone-Cortisol Response: A Prospective Randomized Double-Blind Placebo-Controlled Pilot Clinical Trial

PURPOSE

To test the benefits of Solumedrol treatment in sepsis patients with a blunted adrenocorticotropic hormone (ACTH)-cortisol response (delta <13 µg/dL) with regard to the number of days on ventilator, days on intravenous blood pressure support, length of time in an intensive care unit (ICU), 14-day mortality, and 28-day mortality. The trial was prospective, randomized, and double-blind. As part of a larger sepsis trial, 54 patients with sepsis had an intravenous ACTH stimulation test using 250 µg of ACTH, and serum cortisol was measured at times 0, 30, and 60 min. Eleven patients failed to increase their cortisol concentration above 19.9 µg/dL and were excluded from the clinical trial as they were considered to have adrenal insufficiency. The remaining 43 patients had a baseline cortisol of 32 ± 1 µg/dL increased to 38 ± 3 µg/dL at 30 min and 40 ± 3 at 60 min. All cortisol responses were <12.9 µg/dL between time 0 and time 60, which is defined as a blunted cortisol response to intravenous ACTH administration. Twenty-one were randomized to receive 20 mg of intravenous Solumedrol and 22 were randomized to receive a matching placebo every 8 h for 7-days. There was no significant difference between the two randomized groups. Data analysis was carried out bya two-tailed test and P < .05 as significant.

RESULTS

Results: The mean age was 51 ± 2 (mean ± SEM) with 61% female. Groups were well matched with regard to APACHE III score in Solumedrol versus placebo (59 ± 6 vs 59 ± 6), white blood cell count (18.8 ± 2.2 vs 18.6 ± 2.6), and incidence of bacteremia (29 vs 39%). The 28-day mortality rate was reduced in the Solumedrol treated arm (43 ± 11 vs 73 ± 10%; P < .05). There was no change in days in ICU, days on blood pressure agents, or days on ventilator. Seven days of high-dose intravenous Solumedrol treatment (20 mg every 8 h) in patients with a blunted cortisol response to ACTH was associated with an improved 28-day survival. This small study suggests that an inability to increase endogenous cortisol production in patients with sepsis who are then provided steroid treatment could improve survival.

Effects of Compliance with the Early Management Bundle (SEP-1) on Mortality Changes among Medicare Beneficiaries with Sepsis: A Propensity Score Matched Cohort Study

BACKGROUND

U.S. hospitals have reported compliance with the SEP-1 quality measure to Medicare since 2015. Finding an association between compliance and outcomes is essential to gauge measure effectiveness.

RESEARCH QUESTION

What is the association between compliance with SEP-1 and 30-day mortality among Medicare beneficiaries?

STUDY DESIGN AND METHODS

Studying patient-level data reported to Medicare by 3,241 hospitals from October 1, 2015 to March 31, 2017, we used propensity score matching and a hierarchical general linear model (HGLM) to estimate the treatment effects associated with compliance with SEP-1. Compliance was defined as completion of all qualifying SEP-1 elements including lactate measurements, blood culture collection, broad-spectrum antibiotic administration, 30 ml/kg crystalloid fluid administration, application of vasopressors, and patient reassessment. The primary outcome was a change in 30-day mortality. Secondary outcomes included changes in length-of-stay.

RESULTS

We completed two matches to evaluate population-level treatment effects. In "Standard-match" 122,870 patients whose care was compliant were matched with the same number whose care was non-compliant. Compliance was associated with a reduction in 30-day mortality: 21.81% versus 27.48% yielding an ARR of 5.67% (95% confidence interval [CI]: 5.33-6.00; P < 0.001). In "Stringent-match" 107,016 patients whose care was compliant were matched with the same number whose care was non-compliant. Compliance was associated with a reduction in 30-day mortality: 22.22% versus 26.28% yielding an ARR of 4.06% (95% CI: 3.70-4.41; P < 0.001). At the subject-level, our HGLM model found compliance associated with lower 30-day risk-adjusted mortality (adjusted conditional odds ratio = 0.829; 95% CI: 0.812-0.846; P < 0001). Multiple elements correlated with lower mortality. Median length-of-stay was shorter among cases whose care was compliant (5 vs. 6 days; IQR: 3-9 vs. 4-10; P < 0.001).

INTERPRETATION

Compliance with SEP-1 was associated with lower 30-day mortality. Rendering SEP-1 compliant care may reduce the incidence of avoidable deaths.