Implementation and evaluation of sepsis surveillance and decision support in medical ICU and emergency department

OBJECTIVE

To improve the timely diagnosis and treatment of sepsis many institutions implemented automated sepsis alerts. Poor specificity, time delays, and a lack of actionable information lead to limited adoption by bedside clinicians and no change in practice or clinical outcomes. We aimed to compare sepsis care compliance before and after a multi-year implementation of a sepsis surveillance coupled with decision support in a tertiary care center.

DESIGN

Single center before and after study.

SETTING

Large academic Medical Intensive Care Unit (MICU) and Emergency Department (ED).

POPULATION

Patients 18 years of age or older admitted to *** Hospital MICU and ED from 09/4/2011 to 05/01/2018 with severe sepsis or septic shock.

INTERVENTIONS

Electronic medical record-based sepsis surveillance system augmented by clinical decision support and completion feedback.

MEASUREMENTS AND MAIN RESULTS

There were 1950 patients admitted to the MICU with the diagnosis of severe sepsis or septic shock during the study period. The baseline characteristics were similar before (N = 854) and after (N = 1096) implementation of sepsis surveillance. The performance of the alert was modest with a sensitivity of 79.9%, specificity of 76.9%, positive predictive value (PPV) 27.9%, and negative predictive value (NPV) 97.2%. There were 3424 unique alerts and 1131 confirmed sepsis patients after the sniffer implementation. During the study period average care bundle compliance was higher; however after taking into account improvements in compliance leading up to the intervention, there was no association between intervention and improved care bundle compliance (Odds ratio: 1.16; 95% CI: 0.71 to 1.89; p-value 0.554). Similarly, the intervention was not associated with improvement in hospital mortality (Odds ratio: 1.55; 95% CI: 0.95 to 2.52; p-value: 0.078).

CONCLUSIONS

A sepsis surveillance system incorporating decision support or completion feedback was not associated with improved sepsis care and patient outcomes.

The Clinical Effect of an Early, Protocolized Approach to Mechanical Ventilation for Severe and Refractory Hypoxemia

BACKGROUND

ARDS remains a source of significant morbidity and mortality in the critically ill patient. The mainstay of therapy entails invasive mechanical ventilation utilizing a lung-protective strategy designed to limit lung injury associated with excessive stress and strain while the underlying etiology of respiratory failure is identified and treated. Less is understood about what to do once conventional ventilation parameters have been optimized but the patient's respiratory status remains unchanged or worsens. In 2015, a protocolized, stepwise approach to mechanical ventilation with partially automated and clearly defined thresholds for management changes was implemented at our institution. We hypothesized that, by identifying appropriate patients earlier, time-to-escalation and rescue therapy implementation would be shortened.

METHODS

Subjects with severe ARDS, treated with prone positioning based on our institution's protocolized approach from December 2013 to August 2016 were included. Their baseline characteristics, severity of illness scores, and mechanical ventilation parameters were collected and analyzed.

RESULTS

Baseline characteristics, tidal volumes, P_aO2 /F_IO2 , duration of ventilation after proning, and mortality were similar in both groups. Median (interquartile range [IQR]) PEEP at the time of proning was higher after the protocol implementation (12.5 cm H₂O [IQR 6.5-19.4] vs 18 cm H₂O [IQR 10-22], P = .386), and mean (IQR) respiratory system driving pressure was lower (16 cm H₂O [IQR 13-36.2] vs 12 cm H₂O [IQR 9-19.6], P = .029). Median (IQR) time from refractory hypoxemia identification to proning was shorter after protocol implementation (42.2 h [IQR 6.83-347.2] vs 16.3 h [IQR 1-99.7], I = .02), and P_aO2 /F_IO2 at 1 h after proning was higher. ICU and hospital LOS were shorter after the protocol implementation.

CONCLUSIONS

Following the implementation of an early, evidence-based, protocolized approach to optimizing mechanical ventilation, subjects with true refractory hypoxemia were identified earlier and time to proning was significantly shorter. Despite improvement in the evaluation and management of refractory hypoxemia as well as time to initiation of prone positioning, mortality was unchanged and there was variation in the duration of the position.

Multifaceted interventions to decrease mortality in patients with severe sepsis/septic shock-a quality improvement project

Despite knowledge that EGDT improves outcomes in septic patients, staff education on EGDT and compliance with the CPOE order set has been variable. Based on results of a resident survey to identify barriers to decrease severe sepsis/septic shock mortality in the medical intensive care unit (MICU), multifaceted interventions such as educational interventions to improve awareness to the importance of early goal-directed therapy (EGDT), and the use of the Computerized Physician Order Entry (CPOE) order set, were implemented in July 2013. CPOE order set was established to improve compliance with the EGDT resuscitation bundle elements. Orders were reviewed and compared for patients admitted to the MICU with severe sepsis/septic shock in July and August 2013 (controls) and 2014 (following the intervention). Similarly, educational slide sets were used as interventions for residents before the start of their ICU rotations in July and August 2013. While CPOE order set compliance did not significantly improve (78% vs. 76%, p = 0.74), overall EGDT adherence improved from 43% to 68% (p = 0.0295). Although there was a trend toward improved mortality, this did not reach statistical significance. This study shows that education interventions can be used to increase awareness of severe sepsis/septic shock and improve overall EGDT adherence.

Amblyopia screening in kindergartens with tno stereotest

One hundred and fifty children between 3 and 6 years old were screened for amblyopia with TNO stereotest in their kindergartens. Thirty screening positive children were found of whom 3 were amblyopic with strabismus and no stereopsis. Re-testing showed that 19 children were false screening positive. Three children with refractive errors and equally impaired vision in both eyes were not detected. The test was found suitable for screening of monocular amblyopia in kindergartens, as it was easy to administrate and indicated all children with monocular amblyopia.

Extended wear soft contact lenses in the treatment of strabismic amblyopia

17 amblyopic children between 4 and 9 years were fitted with high power plus extended wear soft contact lenses (Scanlens 24 h, Duragel 75) for optical occlusion of strabismic amblyopia. Amblyopia and eccentric fixation responded quickly to treatment between 2 to 13 weeks. Only one patient failed to reach 6/9, and 11 patients achieved equal visual acuity. Out of 10 patients with eccentric fixation only two remained eccentric after treatment. The contact lenses were tolerated by the children. Among the problems, concerning the use of extended wear soft contact lenses, should be mentioned fitting problems, deposits, loss of lenses (1 child needed 4 lenses) and occurrence of conjunctivitis (5 eyes). No major infections were seen. A one year follow-up showed that almost all the children needed renewed occlusion treatment. It is therefore recommended to continue with contact lens occlusion for at total period of 3 months.