Prevalence and Outcome of Sepsis: Mortality and Prolonged Intensive Care Unit Stay among Sepsis Patients Admitted to a Tertiary Centre in Malaysia

Background

Sepsis and septic shock are the leading causes of critical care-related mortality worldwide. This study aimed to determine the prevalence of sepsis, its intensive care unit (ICU) mortality rate and the factors associated with both ICU mortality and prolonged stay.

Methods

A prospective cohort study was conducted from January 2019 to December 2019 with adult patients presenting evidence of sepsis who were admitted to the ICU. Parameters were assessed in the ICU to determine the association with all-cause ICU mortality and prolonged stay.

Results

Out of 607 adults, 292 with sepsis were admitted to the ICU in 2019, with a mean age of 50.98 (standard deviation [SD] = 17.75) years old. There was, thus, a 48% incidence of sepsis. Mortality was observed in 78 patients (mortality rate = 26.7%) (95% confidence interval [CI]: 21.7, 32.2). Patients with higher Glasgow coma scale (GCS) scores had lower odds of ICU mortality (adjusted odds ratio [OR] = 0.90; 95% CI: 0.82, 0.98; P = 0.019), while patients with higher sequential organ failure assessment (SOFA) scores had higher odds (adjusted OR = 1.22; 95% CI: 1.11, 1.35; P < 0.001). Eighty patients (37.4%) who survived had prolonged ICU stays (95% CI: 30.9, 44.2). Patients with higher albumin levels had lower odds of a prolonged ICU stay (adjusted OR = 0.94; 95% CI: 0.90, 0.98; P = 0.006) and patients on renal replacement therapy had higher odds of a prolonged ICU stay (adjusted OR = 1.25; 95% CI: 1.74, 7.12; P < 0.001).

Conclusion

Our study identified a sepsis prevalence of 48% and an ICU mortality rate of 26.7% among adult patients admitted to the ICU. GCS and SOFA scores were the most important factors associated with ICU mortality.

24 Hours or Less Stay After Laparoscopic Minor Hepatectomy

BACKGROUND

Laparoscopic liver resections can result in decreased length of stay. We looked at our hospital experience with 24 hours or less stay after minor laparoscopic liver resections.

METHODS

Patients who underwent laparoscopic minor hepatectomy (less than 3 hepatic segments resection) and stayed 24 hours or less in the hospital were selected from prospectively kept hepatobiliary surgery database. All were managed according to the established enhanced recovery after surgery protocol.

RESULTS

14 cases were identified and included 3 bisegmentectomies and 11 segmental resections. Length of surgery was between 29 and 210 minutes (median 80.5 minutes), and median blood loss was 50 cc (range 20-400 cc). 4 patients were discharged home the same day with 10 staying overnight.

CONCLUSIONS

Selected group of patients undergoing minor laparoscopic hepatectomy can be discharged home the same day or less than 24 hours after surgery.

Implementing a Respiratory Therapist-Driven Continuous Albuterol Weaning Protocol in the Pediatric ICU

BACKGROUND

Status asthmaticus is one of the most frequent admission diagnoses in the pediatric ICU (PICU). Collaboration between respiratory therapists (RTs) and physicians may help efficiently deliver care to a patient in status asthmaticus. The Pediatric Asthma Severity Score (PASS) is a measure of severity of a patient's asthma exacerbation at a point in time. The aim of this quality improvement initiative was to establish an RT-driven continuous albuterol weaning protocol using the PASS score. We hypothesized that this would decrease the duration of continuous albuterol without increasing adverse events.

METHODS

This was a single-center implementation study in the PICU of a quaternary care children's hospital. Patients with a diagnosis of status asthmaticus who met criteria on continuous albuterol between September 2015 and September 2017 were included. An interdisciplinary team established the protocol, order sets, documentation, and education for involved staff. Qualifying subjects were assessed by an RT per protocol and assigned a PASS score, and the albuterol dose was adjusted on the basis of the PASS score.

RESULTS

We compared 104 subjects studied before the implementation of this protocol (September 2015 to August 2016) to 117 subjects after the implementation of this protocol (September 2016 to October 2017). Median (interquartile range) duration of continuous albuterol in the PICU post-implementation was unchanged compared to pre-implementation: 12.1 (7.2-21.0) h versus 11.1 (6-19) h (P = .22). Median PICU length of stay was also unchanged post-implementation compared to pre-implementation: 19.5 (14.3-29.7) h versus 23.2 (15.2-31.3) h (P = .16). Using control charts, these processes were stable. There was no difference in adverse events.

CONCLUSIONS

An interprofessionally-developed, RT-driven continuous albuterol weaning protocol can be implemented without negatively impacting duration of continuous albuterol or PICU length of stay and without increasing adverse events.

Clinical characteristics associated with days to discharge among patients admitted with a primary diagnosis of lower limb cellulitis

BACKGROUND

Clinicians have limited ability to classify risk of prolonged hospitalization among patients with lower limb cellulitis.

OBJECTIVE

We sought to identify characteristics associated with days to discharge and prolonged stay.

METHODS

We conducted retrospective cohort analysis including patients admitted with a primary diagnosis of lower limb cellulitis at community and tertiary hospitals.

RESULTS

There were 4224 admissions for lower limb cellulitis among 3692 patients. Mean age of the cohort was 64.4 years. Frequencies of tobacco smoking, obesity, and diabetes mellitus were 25.1%, 44.9%, and 19.3%, respectively. Patients having decreased likelihood of discharge included those with the following: 10-year age increments 0.90 (95% confidence interval [CI] 0.88-0.92), obesity 0.90 (95% CI 0.83-0.97), diabetes mellitus 0.90 (95% CI 0.82-0.98), tachycardia 0.76 (95% CI 0.67-0.85), hypotension 0.77 (95% CI 0.65-0.90), leukocytosis 0.86 (95% CI 0.79-0.93), neutrophilia 0.80 (95% CI 0.73-0.87), elevated serum creatinine 0.74 (95% CI 0.68-0.81), and low serum bicarbonate 0.84 (95% CI 0.75-0.95).

LIMITATIONS

This analysis is retrospective and based on coded data. Unknown confounding variables may also influence prolonged stay.

CONCLUSIONS

Patients with lower limb cellulitis and prolonged stay have a number of clinical characteristics which may be used to classify risk for prolonged stay.

A Preventative Respiratory Protocol to Identify Trauma Subjects at Risk for Respiratory Compromise on a General In-Patient Ward

BACKGROUND

Patients are at risk for respiratory complications after sustaining blunt chest trauma, yet contradictory evidence exists about the utility of prophylactic respiratory therapy to reduce respiratory complications in this population. This study assessed the effectiveness of a proactive respiratory protocol on an in-patient ward to identify trauma patients at risk for pulmonary complications, administer appropriate therapies, and prevent deterioration requiring transfer to the ICU.

METHODS

Trauma patients received a respiratory therapy evaluation at the time of admission to a general in-patient ward at a Level 1 trauma center. If subjects met protocol inclusion criteria, they received prophylactic respiratory treatments, primarily MetaNeb therapy, Vest therapy, or EzPAP. Multiple phases were included to evaluate the effectiveness of the protocol, with 50 subjects in each phase: a pre-protocol phase before adoption of the protocol; phase 1, which was found to have low physician adherence and overly broad inclusion criteria; and phase 2, with improved adherence and narrower inclusion criteria. Study inclusion criteria mirror the protocol criteria from phase 2: ≥3 rib fractures; pulmonary contusion; exacerbation of COPD, asthma, or other lung disease; or age ≥65 y with expected immobility of ≥48 h.

RESULTS

The respiratory protocol was associated with an elimination of unplanned admissions to the ICU. After controlling for injury severity and other important clinical factors, receiving the protocol significantly decreased hospital stay by approximately 1.5 d. More subjects were admitted from the emergency department directly to the ward, avoiding the ICU. Bronchodilator use also decreased, although the result did not reach statistical significance.

CONCLUSIONS

Study results suggest that a preventive respiratory protocol had a beneficial effect on patient outcomes; receiving the protocol reduced hospital days and eliminated unplanned admission to the ICU.

Predictors of Prolonged Hospitalization in Patients with Fever

Objective: The study was conducted to analyze the predictors of prolonged hospitalization in patients with fever.

Patients and Methods: This was a prospective cohort study conducted from July - December 2015 at Ayub Teaching Hospital, Pakistan. Convenience sampling was used to enroll the patients who visited the hospital during the study duration. A sample size of 115 patients was calculated. It included patients who presented with a new onset fever which started in the last month, and the cause of fever was undiagnosed at the time of admission. Critical patients were excluded. Data for more than 30 variables was collected on a pro forma. Univariate regression methods were used to analyze the data in the Statistical Package for Social Sciences (SPSS), version 23.

Results: A total of 115 patients were analyzed. Males constituted 66/115 (57.4%). The mean age for patients was 43.6 years (standard deviation (SD) = 20.2). On admission, low platelet counts (p = 0.001), high erythrocyte sedimentation rate (ESR) counts (p = 0.007), a high total leukocyte count (TLC) (p = 0.029), and involvement of nervous (p = 0.021), cardiovascular (p = 0.04), respiratory (p = 0.043), gastroenterological (p = 0.042), hematological (p = 0.028), or urogenital system (p = 0.016) were associated with a longer stay in the hospital.

Conclusion: Patients with an undiagnosed and new onset fever will have a longer hospital stay if, on admission, they have low platelet counts, a higher ESR, a high TLC, or involvement of nervous, cardiovascular, respiratory, gastrointestinal, hematological, or urogenital systems. An early identification of risk factors can lead to better treatment and may also lead to a decreased hospital stay.

Prognosis of critical surgical patients depending on the duration of stay in the ICU

Objective:

To analyze the epidemiological and prognostic differences between critical surgical patients admitted to intensive care unit (ICU) according to length of stay in the ICU.

Materials and Methods:

Retrospective observational study on patients with surgical pathology admitted to ICU of a tertiary hospital, during 7 years, with a stay ≥ 5 days. The variables analyzed were age, sex, Acute Physiology and Chronic Health Evaluation II (APACHE II), duration of stay, hospital and ICU mortality, original service, reason for admission, geographical place of residence, and the use of invasive techniques such as mechanical ventilation (MV), tracheotomy, and techniques of continuous renal replacement (CRR). Two groups were defined; one with intermediate stay, the one that exceeds the average of our population (> 5 days) and another with long stay patients (> 14 days). Readmissions were excluded. Firstly, the analysis of differential characteristics of patients was performed, this was according to the duration of their stay using either a contrast equal averages when the variable contrast between the two groups was quantitative or the Chi-square test when the variable analyzed was qualitative. For both tests, the existence of significant differences between groups was considered when the significance level was less than 5%. And, secondly, a model forecast ICU survival of these patients, regardless of length of stay in ICU, using a binary logistic regression analysis was performed.

Results:

Among the 540 patients analyzed, no significant differences were observed, depending on the length of stay in the ICU, except the need for invasive techniques such as MV or tracheotomy in those of longer stay (P = 0.000). However, ICU mortality was significantly higher for patients with intermediate stay (30 vs 17: 5%; P = 0.000), without observing differences in hospital mortality. ICU survival was influenced by age, APACHE II levels, admission to the ICU in a coma state, and the application of the three invasive techniques discussed.

Conclusion:

Surgical patients who survive in the ICU, regardless of the length of their stay in it, have the same odds of hospital survival. Found as predictors of mortality in ICU APACHE II, age, admission in a coma state, and application of invasive techniques.

Impact of a Dedicated Noninvasive Ventilation Team on Intubation and Mortality Rates in Severe COPD Exacerbations

BACKGROUND

Compared with usual care, noninvasive ventilation (NIV) lowers the risk of intubation and death for subjects with respiratory failure secondary to COPD exacerbations, but whether administration of NIV by a specialized, dedicated team improves its efficiency remains uncertain. Our aim was to test whether a dedicated team of respiratory therapists applying all acute NIV treatments would reduce the risk of intubation or death for subjects with COPD admitted for respiratory failure.

METHODS

We carried out a retrospective study comparing subjects with COPD admitted to the ICU before (2001-2003) and after (2010-2012) the creation of a dedicated NIV team in a regional acute care hospital. The primary outcome was the risk of intubation or death. The secondary outcomes were the individual components of the primary outcome and ICU/hospital stay.

RESULTS

A total of 126 subjects were included: 53 in the first cohort and 73 in the second. There was no significant difference in the demographic characteristics and severity of respiratory failure. Fifteen subjects (28.3%) died or had to undergo tracheal intubation in the first cohort, and only 10 subjects (13.7%) in the second cohort (odds ratio 0.40, 95% CI 0.16-0.99, P = .04). In-hospital mortality (15.1% vs 4.1%, P = .03) and median stay (ICU: 3.1 vs 1.9 d, P = .04; hospital: 11.5 vs 9.6 d, P = .04) were significantly lower in the second cohort, and a trend for a lower intubation risk was observed (20.8% vs 11% P = .13).

CONCLUSIONS

The delivery of NIV by a dedicated team was associated with a lower risk of death or intubation in subjects with respiratory failure secondary to COPD exacerbations. Therefore, the implementation of a team administering all NIV treatments on a 24-h basis should be considered in institutions admitting subjects with COPD exacerbations.

Comparison of Therapist-Directed and Physician-Directed Respiratory Care in COPD Subjects With Acute Pneumonia

BACKGROUND

The purpose of this retrospective medical record review was to compare the effects of therapist-directed (protocol RT) and physician-directed (non-protocol RT) respiratory therapy on hospital stay and 30-d post-discharge readmission in COPD subjects with acute bacterial pneumonia.

METHODS

We reviewed 320 medical records; 244 records were usable. Information gathered included gender, age, RT protocol type (protocol RT or non-protocol RT), hospital stay, 30-d post-discharge readmission, and disease severity score. A 3-way analysis of variance and post hoc analysis were performed to determine the possible effects of disease severity, age, and RT protocol type on hospital stay and the possible interaction effects among these independent variables. A chi-square test for independence was computed to determine whether there was an association between RT protocol type and 30-d readmission.

RESULTS

There were no significant interaction effects among RT protocol type, age, and disease severity on hospital stay. In addition, there were no significant effects of either RT protocol type (P=.41) or age (P=.85) on hospital stay in our subject sample. However, as expected, disease severity had a significant effect on hospital stay, increasing it by a mean of 2.6 d (95% CI 0.77-4.4, P=.005). The chi-square test for independence revealed that the frequency of 30-d readmission was significantly associated with RT protocol type (P=.02); fewer 30-d readmissions were associated with protocol RT.

CONCLUSIONS

We interpreted the finding of no difference in mean hospital stay between protocol and non-protocol RT to indicate that protocol RT did not confer a disadvantage to subjects in terms of hospital stay. Additionally, the results suggest that treatment efficacy is not sacrificed when RT is directed by respiratory therapists rather than by physicians regardless of disease severity and that therapist-directed protocols may have been of some benefit in reducing 30-d post-discharge readmission.