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An investigation of sepsis surveillance and emergency treatment on patient mortality outcomes: An observational cohort study.

ABSTRACT: Objective:To determine the prevalence of initiating the sepsis 3-h bundle of care and estimate effects of bundle completion on risk-adjusted mortality among emergency department (ED) patients screened-in by electronic surveillance. Materials and Methods:This was a multiple center observational cohort study conducted in 2016. The study population was comprised of patients screened-in by St. John Sepsis Surveillance Agent within 4 h of ED arrival, had a sepsis bundle initiated, and admitted to hospital. We built multivariable logistic regression models to estimate impact of a 3-h bundle completed within 3 h of arrival on mortality outcomes. Results:Approximately 3% ED patients were screened-in by electronic surveillance within 4 h of arrival and admitted to hospital. Nearly 7 in 10 (69%) patients had a bundle initiated, with most bundles completed within 3 h of arrival. The fully-adjusted risk model achieved good discrimination on mortality outcomes [area under the receiver operating characteristic 0.82, 95% confidence interval (CI) 0.79-0.85] and estimated 34% reduced mortality risk among patients with a bundle completed within 3 h of arrival compared to non-completers. Discussion:The sepsis bundle is an effective intervention for many vulnerable patients, and likely to be completed within 3 h after arrival when electronic surveillance with reliable alert notifications are integrated into clinical workflow. Beginning at triage, the platform and sepsis program enables identification and management of patients with greater precision, and increases the odds of good outcomes. Conclusion:Sepsis surveillance and clinical decision support accelerate accurate recognition and stratification of patients, and facilitate timely delivery of health care.

SUBMITTER: Amland RC

PROVIDER: S-EPMC6951936 | biostudies-literature | 2018 Jul

REPOSITORIES: biostudies-literature

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An investigation of sepsis surveillance and emergency treatment on patient mortality outcomes: An observational cohort study.

Amland Robert C RC Sutariya Bharat B BB

JAMIA open 20180515 1

<h4>Objective</h4>To determine the prevalence of initiating the sepsis 3-h bundle of care and estimate effects of bundle completion on risk-adjusted mortality among emergency department (ED) patients screened-in by electronic surveillance.<h4>Materials and methods</h4>This was a multiple center observational cohort study conducted in 2016. The study population was comprised of patients screened-in by St. John Sepsis Surveillance Agent within 4 h of ED arrival, had a sepsis bundle initiated, and ...[more]

PMID: 31984322

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Project description:PURPOSE:Sepsis is a common acute life-threatening condition that emergency physicians routinely face. Diagnostic options within the Emergency Department (ED) are limited due to lack of infrastructure, consequently limiting the use of invasive hemodynamic monitoring or imaging tests. The mortality rate due to sepsis can be assessed via multiple scoring systems, for example, mortality in emergency department sepsis (MEDS) score and sepsis patient evaluation in the emergency department (SPEED) score, both of which quantify the variation of mortality rates according to clinical findings, laboratory data, or therapeutic interventions. This study aims to improve the management processes of sepsis patients by comparing SPEED score and MEDS score for predicting the 28-day mortality in cases of emergency sepsis. METHODS:The study is a cross-sectional, prospective study including 61 sepsis patients in ED in Suez Canal University Hospital, Egypt, from August 2017 to June 2018. Patients were selected by two steps: (1) suspected septic patients presenting with at least one of the following abnormal clinical findings: (a) body temperature higher than 38 °C or lower than 36 °C, (b) heart rate higher than 90 beats/min, (c) hyperventilation evidenced by respiratory rate higher than 20 breaths/min or PaCO2 lower than 32 mmHg, and (d) white blood cell count higher than 12,000/?L or lower than 4000/?L; (2) confirmed septic patients with at least a 2-point increase from the baseline total sequential organ failure assessment (SOFA) score following infection. Other inclusion criteria included adult patients with an age ?18 years regardless of gender and those who had either systemic inflammatory response syndrome or suspected/confirmed infection. Patients were shortly follow-up for the 28-day mortality. Each patient was subject to SPEED score and MEDS score and then the results were compared to detect which of them was more effective in predicting outcome. The receiver operating characteristic curves were also done for MEDS and SPEED scores. RESULTS:Among the 61 patients, 41 died with the mortality rate of 67.2%. The mortality rate increased with a higher SPEED and MEDS scores. Both SPEED and MEDS scores revealed significant difference between the survivors and nonsurvivors (p = 0.004 and p < 0.001, respectively), indicating that both the two systems are effective in predicting the 28-day mortality of sepsis patients. Thereafter, the receiver operating characteristic curves were plotted, which showed that SPEED was better than the MEDS score when applied to the complete study population with an area under the curve being 0.87 (0.788-0.963) as compared with 0.75 (0.634-0.876) for MEDS. Logistic regression analysis revealed that the best fitting predictor of 28-day mortality for sepsis patients was the SPEED scoring system. For every one unit increase in SPEED score, the odds of 28-day mortality increased by 37%. CONCLUSION:SPEED score is more useful and accurate than MEDS score in predicting the 28-day mortality among sepsis patients. Therefore SPEED rather than MEDS should be more widely used in the ED for sepsis patients.

Project description:BackgroundMeasuring 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.MethodsThis 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.ResultsInfection 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.ConclusionsSOFA 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.

Project description:BACKGROUND:In 2013, New York began requiring hospitals to follow protocols for the early identification and treatment of sepsis. However, there is controversy about whether more rapid treatment of sepsis improves outcomes in patients. METHODS:We studied data from patients with sepsis and septic shock that were reported to the New York State Department of Health from April 1, 2014, to June 30, 2016. Patients had a sepsis protocol initiated within 6 hours after arrival in the emergency department and had all items in a 3-hour bundle of care for patients with sepsis (i.e., blood cultures, broad-spectrum antibiotic agents, and lactate measurement) completed within 12 hours. Multilevel models were used to assess the associations between the time until completion of the 3-hour bundle and risk-adjusted mortality. We also examined the times to the administration of antibiotics and to the completion of an initial bolus of intravenous fluid. RESULTS:Among 49,331 patients at 149 hospitals, 40,696 (82.5%) had the 3-hour bundle completed within 3 hours. The median time to completion of the 3-hour bundle was 1.30 hours (interquartile range, 0.65 to 2.35), the median time to the administration of antibiotics was 0.95 hours (interquartile range, 0.35 to 1.95), and the median time to completion of the fluid bolus was 2.56 hours (interquartile range, 1.33 to 4.20). Among patients who had the 3-hour bundle completed within 12 hours, a longer time to the completion of the bundle was associated with higher risk-adjusted in-hospital mortality (odds ratio, 1.04 per hour; 95% confidence interval [CI], 1.02 to 1.05; P<0.001), as was a longer time to the administration of antibiotics (odds ratio, 1.04 per hour; 95% CI, 1.03 to 1.06; P<0.001) but not a longer time to the completion of a bolus of intravenous fluids (odds ratio, 1.01 per hour; 95% CI, 0.99 to 1.02; P=0.21). CONCLUSIONS:More rapid completion of a 3-hour bundle of sepsis care and rapid administration of antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk-adjusted in-hospital mortality. (Funded by the National Institutes of Health and others.).

Project description:ContextFor patients with lumbar disk herniation, the Spine Patient Outcomes Research Trial (SPORT) randomized trial intent-to-treat analysis showed small but not statistically significant differences in favor of diskectomy compared with usual care. However, the large numbers of patients who crossed over between assigned groups precluded any conclusions about the comparative effectiveness of operative therapy vs usual care.ObjectiveTo compare the treatment effects of diskectomy and usual care.Design, setting, and patientsProspective observational cohort of surgical candidates with imaging-confirmed lumbar intervertebral disk herniation who were treated at 13 spine clinics in 11 US states and who met the SPORT eligibility criteria but declined randomization between March 2000 and March 2003.InterventionsStandard open diskectomy vs usual nonoperative care.Main outcome measuresChanges from baseline in the Medical Outcomes Study Short-Form Health Survey (SF-36) bodily pain and physical function scales and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons/MODEMS version).ResultsOf the 743 patients enrolled in the observational cohort, 528 patients received surgery and 191 received usual nonoperative care. At 3 months, patients who chose surgery had greater improvement in the primary outcome measures of bodily pain (mean change: surgery, 40.9 vs nonoperative care, 26.0; treatment effect, 14.8; 95% confidence interval, 10.8-18.9), physical function (mean change: surgery, 40.7 vs nonoperative care, 25.3; treatment effect, 15.4; 95% CI, 11.6-19.2), and Oswestry Disability Index (mean change: surgery, -36.1 vs nonoperative care, -20.9; treatment effect, -15.2; 95% CI, -18.5. to -11.8). These differences narrowed somewhat at 2 years: bodily pain (mean change: surgery, 42.6 vs nonoperative care, 32.4; treatment effect, 10.2; 95% CI, 5.9-14.5), physical function (mean change: surgery, 43.9 vs nonoperavtive care 31.9; treatment effect, 12.0; 95% CI; 7.9-16.1), and Oswestry Disability Index (mean change: surgery -37.6 vs nonoperative care -24.2; treatment effect, -13.4; 95% CI, -17.0 to -9.7).ConclusionsPatients with persistent sciatica from lumbar disk herniation improved in both operated and usual care groups. Those who chose operative intervention reported greater improvements than patients who elected nonoperative care. However, nonrandomized comparisons of self-reported outcomes are subject to potential confounding and must be interpreted cautiously.Trial registrationclinicaltrials.gov Identifier: NCT00000410.

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An investigation of sepsis surveillance and emergency treatment on patient mortality outcomes: An observational cohort study.

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An investigation of sepsis surveillance and emergency treatment on patient mortality outcomes: An observational cohort study.

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