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Garcia M, Al-Jaghbeer M, Morrison J, Boustany A, Ghimire B, Tapryal N, Mushtaq K, Orlosky K, Flowers-Surovi A, Murphy C, Rath P, Rahman M, Kickel C, Lee YC, Chang KY, Abi Fadel F. Multimodal Quality Initiatives in Sepsis Care: Assessing Impact on Core Measures and Outcomes. J Healthc Qual 2024; 46:245-250. [PMID: 38759142 DOI: 10.1097/jhq.0000000000000440] [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: 05/19/2024]
Abstract
ABSTRACT Providing timely and effective care for patients with sepsis is challenging due to delays in recognition and intervention. The Surviving Sepsis Campaign has developed bundles that have been shown to reduce sepsis mortality. However, hospitals have not consistently adhered to these bundles, resulting in suboptimal outcomes. To address this, a multimodal quality improvement sepsis program was implemented from 2017 to 2022 in a large urban tertiary hospital. The aim of this program was to enhance the Severe Sepsis and Septic Shock Management Bundle compliance and reduce sepsis mortality. At baseline, the Severe Sepsis and Septic Shock Management Bundle compliance rates were low, at 25%, with a sepsis observed/expected mortality ratio of 1.14. Our interventions included the formation of a multidisciplinary committee, the appointment of sepsis champions, the implementation of sepsis alerts and order sets, the formation of a Code Sepsis team, real-time audits, and peer-to-peer education. By 2022, compliance rose to 62%, and the observed/expected mortality ratio decreased to 0.73. Our approach led to improved outcomes and hospital rankings. These findings underscore the efficacy of a comprehensive sepsis care initiative, emphasizing the importance of interdisciplinary collaboration. A multimodal hospital-wide sepsis performance program is feasible and can contribute to improved outcomes. However, further research is necessary to determine the specific impact of individual strategies on sepsis outcomes.
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Townsend SR, Phillips GS, Duseja R, Tefera L, Cruikshank D, Dickerson R, Nguyen HB, Schorr CA, Levy MM, Dellinger RP, Conway WA, Browner WS, Rivers EP. Effects of Compliance with the Early Management Bundle (SEP-1) on Mortality Changes among Medicare Beneficiaries with Sepsis: A Propensity Score Matched Cohort Study. Chest 2021; 161:392-406. [PMID: 34364867 DOI: 10.1016/j.chest.2021.07.2167] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/06/2021] [Accepted: 07/19/2021] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Sean R Townsend
- Division of Pulmonary, Critical Care Medicine, California Pacific Medical Center, San Francisco, CA; Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA.
| | - Gary S Phillips
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH
| | - Reena Duseja
- Center for Clinical Standards and Quality, Centers for Medicare and Medicaid Services, Baltimore, MD
| | - Lemeneh Tefera
- Department of Emergency Medicine, Alameda Health System, Oakland, CA
| | | | | | - H Bryant Nguyen
- Division of Pulmonary, Critical Care, Hyperbaric, Allergy and Sleep Medicine, Loma Linda University, Loma Linda, CA
| | | | - Mitchell M Levy
- Division of Pulmonary, Critical Care and Sleep Medicine, Rhode Island Hospital, Providence, RI; Warren Alpert School of Medicine at Brown University, Providence, RI
| | | | - William A Conway
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI; Wayne State University, Detroit, MI
| | - Warren S Browner
- California Pacific Medical Center Research Institute, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | - Emanuel P Rivers
- Wayne State University, Detroit, MI; Department of Emergency Medicine and Surgery, Henry Ford Hospital, Detroit, MI
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Lee AHY, Aaronson E, Hibbert KA, Flynn MH, Rutkey H, Mort E, Sonis JD, Safavi KC. Design and Implementation of a Real-time Monitoring Platform for Optimal Sepsis Care in an Emergency Department: Observational Cohort Study. J Med Internet Res 2021; 23:e26946. [PMID: 34185009 PMCID: PMC8277370 DOI: 10.2196/26946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/14/2021] [Accepted: 04/30/2021] [Indexed: 11/19/2022] Open
Abstract
Background Sepsis is the leading cause of death in US hospitals. Compliance with bundled care, specifically serial lactates, blood cultures, and antibiotics, improves outcomes but is often delayed or missed altogether in a busy practice environment. Objective This study aims to design, implement, and validate a novel monitoring and alerting platform that provides real-time feedback to frontline emergency department (ED) providers regarding adherence to bundled care. Methods This single-center, prospective, observational study was conducted in three phases: the design and technical development phase to build an initial version of the platform; the pilot phase to test and refine the platform in the clinical setting; and the postpilot rollout phase to fully implement the study intervention. Results During the design and technical development, study team members and stakeholders identified the criteria for patient inclusion, selected bundle measures from the Center for Medicare and Medicaid Sepsis Core Measure for alerting, and defined alert thresholds, message content, delivery mechanisms, and recipients. Additional refinements were made based on 70 provider survey results during the pilot phase, including removing alerts for vasopressor initiation and modifying text in the pages to facilitate patient identification. During the 48 days of the postpilot rollout phase, 15,770 ED encounters were tracked and 711 patient encounters were included in the active monitoring cohort. In total, 634 pages were sent at a rate of 0.98 per attending physician shift. Overall, 38.3% (272/711) patients had at least one page. The missing bundle elements that triggered alerts included: antibiotics 41.6% (136/327), repeat lactate 32.4% (106/327), blood cultures 20.8% (68/327), and initial lactate 5.2% (17/327). Of the missing Sepsis Core Measures elements for which a page was sent, 38.2% (125/327) were successfully completed on time. Conclusions A real-time sepsis care monitoring and alerting platform was created for the ED environment. The high proportion of patients with at least one alert suggested the significant potential for such a platform to improve care, whereas the overall number of alerts per clinician suggested a low risk of alarm fatigue. The study intervention warrants a more rigorous evaluation to ensure that the added alerts lead to better outcomes for patients with sepsis.
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Affiliation(s)
- Andy Hung-Yi Lee
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Emily Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Kathryn A Hibbert
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Micah H Flynn
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Hayley Rutkey
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Elizabeth Mort
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Jonathan D Sonis
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Kyan C Safavi
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
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4
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Kaseer HS, Patel R, Tucker C, Elie MC, Staley BJ, Tran N, Lemon S. Comparison of fluid resuscitation weight-based dosing strategies in obese patients with severe sepsis. Am J Emerg Med 2021; 49:268-272. [PMID: 34171722 DOI: 10.1016/j.ajem.2021.06.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/08/2021] [Accepted: 06/14/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This study aims to compare the composite outcome of progression to septic shock between 30 mL/kg/ideal body weight (IBW) versus 30 mL/kg/non-IBW fluid resuscitation dosing strategies in obese patients with severe sepsis. METHODS We retrospectively evaluated obese patients admitted to an academic tertiary care center for the management of severe sepsis. Patients were included if they had a fluid bolus order placed using the sepsis order set between Oct 2018 and Sept 2019. The primary objective was the composite of progression to septic shock, defined as either persistent hypotension within 3 h after the conclusion of the 30 mL/kg fluid bolus administration or the initiation of vasopressor(s) within 6 h of the bolus administration. RESULTS Of 72 included patients, 49 (68%) were resuscitated using an IBW-based and 23 (32%) using a non-IBW-based dosing strategy. There were similar rates of progression to septic shock in the IBW and non-IBW groups (18% vs. 26%; p = 0.54). Median ICU and hospital LOS in the IBW group versus non-IBW group were (0 [IQR 0] vs. 0 [IQR 0 to 4] days; p = 0.13) and (6 [IQR 3 to 10] vs. 8 [IQR 5 to 12] days; p = 0.07), respectively. In-hospital mortality rates were similar between the groups. CONCLUSIONS Our study results suggest that in obese septic patients, fluid administration using an IBW-dosing strategy did not affect the progression to septic shock.
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Affiliation(s)
- Haya S Kaseer
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, United States of America.
| | - Rusha Patel
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, United States of America.
| | - Calvin Tucker
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, United States of America.
| | - Marie-Carmelle Elie
- Department of Emergency Medicine, University of Florida Health Shands Hospital, Gainesville, FL, United States of America.
| | - Benjamin J Staley
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, United States of America.
| | - Nicolas Tran
- University of Florida College of Pharmacy, Gainesville, FL, United States of America
| | - Steve Lemon
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, United States of America.
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5
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Rhee C, Chiotos K, Cosgrove SE, Heil EL, Kadri SS, Kalil AC, Gilbert DN, Masur H, Septimus EJ, Sweeney DA, Strich JR, Winslow DL, Klompas M. Infectious Diseases Society of America Position Paper: Recommended Revisions to the National Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) Sepsis Quality Measure. Clin Infect Dis 2021; 72:541-552. [PMID: 32374861 DOI: 10.1093/cid/ciaa059] [Citation(s) in RCA: 102] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/20/2020] [Indexed: 12/18/2022] Open
Abstract
The Centers for Medicare & Medicaid Services' Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) measure has appropriately established sepsis as a national priority. However, the Infectious Diseases Society of America (IDSA and five additional endorsing societies) is concerned about SEP-1's potential to drive antibiotic overuse because it does not account for the high rate of sepsis overdiagnosis and encourages aggressive antibiotics for all patients with possible sepsis, regardless of the certainty of diagnosis or severity of illness. IDSA is also concerned that SEP-1's complex "time zero" definition is not evidence-based and is prone to inter-observer variation. In this position paper, IDSA outlines several recommendations aimed at reducing the risk of unintended consequences of SEP-1 while maintaining focus on its evidence-based elements. IDSA's core recommendation is to limit SEP-1 to septic shock, for which the evidence supporting the benefit of immediate antibiotics is greatest. Prompt empiric antibiotics are often appropriate for suspected sepsis without shock, but IDSA believes there is too much heterogeneity and difficulty defining this population, uncertainty about the presence of infection, and insufficient data on the necessity of immediate antibiotics to support a mandatory treatment standard for all patients in this category. IDSA believes guidance on managing possible sepsis without shock is more appropriate for guidelines that can delineate the strengths and limitations of supporting evidence and allow clinicians discretion in applying specific recommendations to individual patients. Removing sepsis without shock from SEP-1 will mitigate the risk of unnecessary antibiotic prescribing for noninfectious syndromes, simplify data abstraction, increase measure reliability, and focus attention on the population most likely to benefit from immediate empiric broad-spectrum antibiotics.
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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
| | - 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
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, 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 & 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
| | - Jeffrey R Strich
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Dean L Winslow
- Division of Infectious Diseases, Department of Medicine, Stanford University School of Medicine, Stanford, California, 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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6
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Cortés-Puch I, Applefeld WN, Wang J, Danner RL, Eichacker PQ, Natanson C. Individualized Care Is Superior to Standardized Care for the Majority of Critically Ill Patients. Crit Care Med 2020; 48:1845-1847. [PMID: 32332282 PMCID: PMC10823796 DOI: 10.1097/ccm.0000000000004373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Tools for standardizing patient care can take many forms, including but not limited to, bundles, quality improvement and performance measures, guidelines, and protocols. Each is intended to improve compliance with interventions believed to be supported by the best available evidence, ensuring consistency of management across all patients with the ultimate goal of improving outcomes. However, in the ICU, patients typically present with complex acute illnesses and accompanying comorbidities, requiring careful tailoring of interventions and treatments for each individual patient. The rapidly changing nature of the underlying conditions also demands continuous reassessment and modification of each patient’s management on a frequent and sometimes moment-by-moment basis. Disrupting this individualized treatment approach by imposing prescriptive, overly restrictive, “one-size-fits-all” standardized treatments in the critical care setting may prevent the clinician from meeting individual patients’ needs and decrease care quality (1 ). This problem is compounded if the standardization tools adopted are not only inflexible but also have a poorly supported or entirely absent scientific basis. Importantly, identifiable patient subcategories often exist that fit poorly into the populations for which many interventions were developed and tested. Of equal concern, critical care trainees may become dependent on a standardized/cookbook approach to care and fail to recognize and learn how treatments must be tailored for the unique needs of each critically ill patient. Rather than rigidly standardizing critical care, approaches that recognize this complexity and are both scientifically sound and responsive to patient differences should be readily available to critical care clinicians without replacing sensible clinical judgment. Such strategies that acknowledge the limitations of available evidence hold more hope of improving, rather than inadvertently worsening, the outcome.
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Affiliation(s)
- Irene Cortés-Puch
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California Davis Medical Center, Sacramento, CA
| | - Willard N Applefeld
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Jeffrey Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Robert L Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Peter Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
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7
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A Multimodal Sepsis Quality-Improvement Initiative Including 24/7 Screening and a Dedicated Sepsis Response Team-Reduced Readmissions and Mortality. Crit Care Explor 2020; 2:e0251. [PMID: 33251514 PMCID: PMC7688252 DOI: 10.1097/cce.0000000000000251] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objectives To evaluate if a hospitalwide sepsis performance improvement initiative improves compliance with the Centers for Medicare and Medicaid Services-mandated sepsis bundle interventions and patient outcomes. Study Design Retrospective analysis comparing 6 months before and 14 months after intervention. Setting Tertiary teaching hospital in Washington, DC. Subjects Patients admitted with a diagnosis of sepsis to a tertiary hospital. Interventions Implementation of a multimodal quality-improvement initiative. Measurements and Main Results A total of 4,102 patients were diagnosed with sepsis, severe sepsis, or septic shock during the study period, 861 patients (21%) were diagnosed during a 6-month preintervention period, and 3,241 (79%) were diagnosed in a 13-month postintervention period. Adjusted for patient case-mix, the prevalence of simple sepsis increased by 12%, but it decreased for severe sepsis and septic shock by 5.3% and 6.9%, respectively. Compliance with all sepsis bundle interventions increased by 31.1 percentage points (p < 0.01). All-cause hospital readmission and readmission due to infection were both reduced by 1.6% and 1.7 percentage points (p < 0.05). Death from any sepsis diagnosis was reduced 4.5% (p < 0.01). Death from severe sepsis and septic shock both was reduced by 5% (p < 0.01) and 6.5% (p < 0.01), respectively. Conclusions After the implementation of multimodal sepsis performance initiatives, we observed a higher prevalence of sepsis secondary to screening but a lower prevalence of severe sepsis and septic shock, an improvement in compliance with the sepsis bundle interventions bundle, as well as reduction in hospital readmission and all- cause mortality rate.
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8
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Eby JC, Lane MA, Horberg M, Gentry CN, Coffin SE, Ray AJ, Sheridan KR, Bratzler DW, Wheeler D, Sarumi M, Barlam TF, Kim TJ, Rodriguez A, Nahass RG. How Do You Measure Up: Quality Measurement for Improving Patient Care and Establishing the Value of Infectious Diseases Specialists. Clin Infect Dis 2020; 68:1946-1951. [PMID: 30256911 DOI: 10.1093/cid/ciy814] [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] [Received: 05/09/2018] [Accepted: 09/18/2018] [Indexed: 12/30/2022] Open
Abstract
The shift from volume-based to value-based reimbursement has created a need for quantifying clinical performance of infectious diseases (ID) physicians. Nationally recognized ID specialty-specific quality measures will allow stakeholders, such as patients and payers, to determine the value of care provided by ID physicians and will promote clinical quality improvement. Few ID-specific measures have been developed; herein, we provide an overview of the importance of quality measurement for ID, discuss issues in quality measurement specific to ID, and describe standards by which candidate quality measures can be evaluated. If ID specialists recognize the need for quality measurement, then ID specialists can direct ID-related quality improvement, quantify the impact of ID physicians on patient outcomes, compare their performance to that of peers, and convey to stakeholders the value of the specialty.
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Affiliation(s)
- Joshua C Eby
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Michael A Lane
- Infectious Diseases Division, Washington University School of Medicine.,BJC HealthCare, St. Louis, Missouri
| | - Michael Horberg
- Research, Community Benefit, and Medical Strategy, Mid-Atlantic Permanente Medical Group, HIV/AIDS, Kaiser Permanente, Rockville, Maryland
| | | | - Susan E Coffin
- Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Pennsylvania
| | - Amy J Ray
- Department of Medicine, University Hospitals Cleveland Medical Center, Ohio
| | | | - Dale W Bratzler
- College of Public Health, University of Oklahoma Health Sciences Center
| | | | | | - Tamar F Barlam
- Division of Infectious Diseases, Boston University School of Medicine, Massachussetts
| | - Thomas J Kim
- Infectious Diseases Society of America, Arlington, Virginia
| | | | - Ronald G Nahass
- Department of Medicine, Rutgers University Robert Wood Johnson Medical School, Piscataway.,IDCare, Hillsborough Township, New Jersey
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9
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Seeking a balanced approach to implementing sepsis guidelines. JAAPA 2020; 33:13-17. [DOI: 10.1097/01.jaa.0000668788.10099.ff] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Rhee C, Kadri SS, Dekker JP, Danner RL, Chen HC, Fram D, Zhang F, Wang R, Klompas M. Prevalence of Antibiotic-Resistant Pathogens in Culture-Proven Sepsis and Outcomes Associated With Inadequate and Broad-Spectrum Empiric Antibiotic Use. JAMA Netw Open 2020; 3:e202899. [PMID: 32297949 PMCID: PMC7163409 DOI: 10.1001/jamanetworkopen.2020.2899] [Citation(s) in RCA: 159] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Broad-spectrum antibiotics are recommended for all patients with suspected sepsis to minimize the risk of undertreatment. However, little is known regarding the net prevalence of antibiotic-resistant pathogens across all patients with community-onset sepsis or the outcomes associated with unnecessarily broad empiric treatment. OBJECTIVE To elucidate the epidemiology of antibiotic-resistant pathogens and the outcomes associated with both undertreatment and overtreatment in patients with culture-positive community-onset sepsis. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 17 430 adults admitted to 104 US hospitals between January 2009 and December 2015 with sepsis and positive clinical cultures within 2 days of admission. Data analysis took place from January 2018 to December 2019. EXPOSURES Inadequate empiric antibiotic therapy (ie, ≥1 pathogen nonsusceptible to all antibiotics administered on the first or second day of treatment) and unnecessarily broad empiric therapy (ie, active against methicillin-resistant Staphylococcus aureus [MRSA]; vancomycin-resistant Enterococcus [VRE]; ceftriaxone-resistant gram-negative [CTX-RO] organisms, including Pseudomonas aeruginosa; or extended-spectrum β-lactamase [ESBL] gram-negative organisms when none of these were isolated). MAIN OUTCOMES AND MEASURES Prevalence and empiric treatment rates for antibiotic-resistant organisms and associations of inadequate and unnecessarily broad empiric therapy with in-hospital mortality were assessed, adjusting for baseline characteristics and severity of illness. RESULTS Of 17 430 patients with culture-positive community-onset sepsis (median [interquartile range] age, 69 [57-81] years; 9737 [55.9%] women), 2865 (16.4%) died in the hospital. The most common culture-positive sites were urine (9077 [52.1%]), blood (6968 [40.0%]), and the respiratory tract (2912 [16.7%]). The most common pathogens were Escherichia coli (5873 [33.7%]), S aureus (3706 [21.3%]), and Streptococcus species (2361 [13.5%]). Among 15 183 cases in which all antibiotic-pathogen susceptibility combinations could be calculated, most (12 398 [81.6%]) received adequate empiric antibiotics. Empiric therapy targeted resistant organisms in 11 683 of 17 430 cases (67.0%; primarily vancomycin and anti-Pseudomonal β-lactams), but resistant organisms were uncommon (MRSA, 2045 [11.7%]; CTX-RO, 2278 [13.1%]; VRE, 360 [2.1%]; ESBLs, 133 [0.8%]). The net prevalence for at least 1 resistant gram-positive organism (ie, MRSA or VRE) was 13.6% (2376 patients), and for at least 1 resistant gram-negative organism (ie, CTX-RO, ESBL, or CRE), it was 13.2% (2297 patients). Both inadequate and unnecessarily broad empiric antibiotics were associated with higher mortality after detailed risk adjustment (inadequate empiric antibiotics: odds ratio, 1.19; 95% CI, 1.03-1.37; P = .02; unnecessarily broad empiric antibiotics: odds ratio, 1.22; 95% CI, 1.06-1.40; P = .007). CONCLUSIONS AND RELEVANCE In this study, most patients with community-onset sepsis did not have resistant pathogens, yet broad-spectrum antibiotics were frequently administered. Both inadequate and unnecessarily broad empiric antibiotics were associated with higher mortality. These findings underscore the need for better tests to rapidly identify patients with resistant pathogens and for more judicious use of broad-spectrum antibiotics for empiric sepsis treatment.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Sameer S. Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - John P. Dekker
- Laboratory of Clinical Immunology and Microbiology, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Robert L. Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | | | - David Fram
- Commonwealth Informatics, Waltham, Massachusetts
| | - Fang Zhang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
| | - Rui Wang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
| | - Michael Klompas
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
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11
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Baghdadi JD, Wong MD, Uslan DZ, Bell D, Cunningham WE, Needleman J, Kerbel R, Brook R. Adherence to the SEP-1 Sepsis Bundle in Hospital-Onset v. Community-Onset Sepsis: a Multicenter Retrospective Cohort Study. J Gen Intern Med 2020; 35:1153-1160. [PMID: 32040837 PMCID: PMC7174506 DOI: 10.1007/s11606-020-05653-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 09/26/2019] [Accepted: 12/10/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Sepsis is the leading cause of in-hospital death. The SEP-1 sepsis bundle is a protocol for early sepsis care that requires providers to diagnose and treat sepsis quickly. Limited evidence suggests that adherence to the sepsis bundle is lower in cases of hospital-onset sepsis. OBJECTIVE To compare sepsis bundle adherence in hospital-onset vs. community-onset sepsis. DESIGN Retrospective cohort study using multivariable analysis of clinical data. PARTICIPANTS A total of 4658 inpatients age 18 or older were identified by diagnosis codes consistent with sepsis or disseminated infection. SETTING Four university hospitals in California between 2014 and 2016. MAIN OUTCOMES AND MEASURES The primary outcome was adherence to key components of the sepsis bundle defined by the Centers for Medicare and Medicaid Services in their core measure, SEP-1. Covariates included clinical characteristics related to the patient, infection, and pathogen. KEY RESULTS Compared with community-onset, cases of hospital-onset sepsis were less likely to receive SEP-1 adherent care (relative risk 0.33, 95% confidence interval 0.29-0.38, p < 0.001). With the exception of vasopressors (RR 1.11, p = 0.002), each component of SEP-1 evaluated-blood cultures (RR 0.76, p < 0.001), serum lactate (RR 0.51, p < 0001), broad-spectrum antibiotics (RR 0.62, p < 0.001), intravenous fluids (0.47, p < 0.001), and follow-up lactate (RR 0.71, p < 0.001)-was less likely to be performed within the recommended time frame in hospital-onset sepsis. Within the hospital, cases of hospital-onset sepsis arising on the ward were less likely to receive SEP-1-adherent care than were cases arising in the intensive care unit (RR 0.68, p = 0.004). CONCLUSIONS Inpatients with hospital-onset sepsis receive different management than individuals with community-onset sepsis. It remains to be determined whether system-level factors, provider-level factors, or factors related to measurement explain the observed variation in care or whether variation in care affects outcomes.
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Affiliation(s)
- Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Mitchell D Wong
- UCLA Division of General Internal Medicine, Los Angeles, CA, USA
| | - Daniel Z Uslan
- UCLA Division of Infectious Diseases, Los Angeles, CA, USA
| | - Douglas Bell
- UCLA Division of General Internal Medicine, Los Angeles, CA, USA
| | - William E Cunningham
- UCLA Fielding School of Public Health, Department of Health Policy and Management, Los Angeles, CA, USA
| | - Jack Needleman
- UCLA Fielding School of Public Health, Department of Health Policy and Management, Los Angeles, CA, USA
| | | | - Robert Brook
- UCLA Department of Medicine, Los Angeles, CA, USA
- RAND Corporation, Santa Monica, CA, USA
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, USA
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12
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Wang J, Strich JR, Applefeld WN, Sun J, Cui X, Natanson C, Eichacker PQ. Driving blind: instituting SEP-1 without high quality outcomes data. J Thorac Dis 2020; 12:S22-S36. [PMID: 32148923 DOI: 10.21037/jtd.2019.12.100] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In 2015, the Centers for Medicare and Medicaid Services (CMS) instituted an all-or-none sepsis performance measure bundle (SEP-1) to promote high-quality, cost-effective care. Systematic reviews demonstrated only low-quality evidence supporting most of SEP-1's interventions. CMS has removed some but not all of these unproven components. The current SEP-1 version requires patients with suspected sepsis have a lactate level, blood cultures, broad-spectrum antibiotics and, if hypotensive, a fixed 30 mL/kg fluid infusion within 3 hours, and a repeat lactate if initially elevated within 6 hours. Experts have continued to raise concerns that SEP-1 remains overly prescriptive, lacks a sound scientific basis and presents risks (overuse of antibiotics and inappropriate fluids not titrated to need). To incentivize compliance with SEP-1, CMS now publicly publishes how often hospitals complete all interventions in individual patients. However, compliance measured across hospitals (5 studies, 48-2,851 hospitals) or patients (three studies, 110-851 patients) has been low (approximately 50%) which is not surprising given SEP-1's lack of scientific basis. The largest observational study (1,738 patients) reporting survival rates employing SEP-1 found they were not significantly improved with the measure (P=0.53) as did the next largest study (851 patients, adjusted survival odds ratio 1.36, 95% CI, 0.85 to 2.18). Two smaller observational studies (158 and 450 patients) reported SEP-1 improved unadjusted survival (P≤0.05) but were confounded either by baseline imbalances or by simultaneous introduction of a code sepsis protocol to improve compliance. Regardless, retrospective studies have well known biases related to non-randomized designs, uncontrolled data collection and failure to adjust for unrecognized influential variables. Such low-quality science should not be the basis for a national mandate compelling care for a rapidly lethal disease with a high mortality rate. Instead, SEP-1 should be based on high quality reproducible evidence from randomized controlled trials (RCT) demonstrating its benefit and thereby safety. Otherwise we risk not only doing harm but standardizing it.
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Affiliation(s)
- Jeffrey Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Jeffrey R Strich
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Willard N Applefeld
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Xizhong Cui
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Peter Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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13
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Pepper DJ, Sun J, Cui X, Welsh J, Natanson C, Eichacker PQ. Antibiotic- and Fluid-Focused Bundles Potentially Improve Sepsis Management, but High-Quality Evidence Is Lacking for the Specificity Required in the Centers for Medicare and Medicaid Service's Sepsis Bundle (SEP-1). Crit Care Med 2019; 47:1290-1300. [PMID: 31369426 PMCID: PMC10802116 DOI: 10.1097/ccm.0000000000003892] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To address three controversial components in the Centers for Medicare and Medicaid Service's sepsis bundle for performance measure (SEP-1): antibiotics within 3 hours, a 30 mL/kg fluid infusion for all hypotensive patients, and repeat lactate measurements within 6 hours if initially elevated. We hypothesized that antibiotic- and fluid-focused bundles like SEP-1 would probably show benefit, but evidence supporting specific antibiotic timing, fluid dosing, or serial lactate requirements would not be concordant. Therefore, we performed a meta-analysis of studies of sepsis bundles like SEP-1. DATA SOURCES PubMed, Embase, ClinicalTrials.gov through March 15, 2018. STUDY SELECTION Studies comparing survival in septic adults receiving versus not receiving antibiotic- and fluid-focused bundles. DATA EXTRACTION Two investigators (D.J.P., P.Q.E.). DATA SYNTHESIS Seventeen observational studies (11,303 controls and 4,977 bundle subjects) met inclusion criteria. Bundles were associated with increased odds ratios of survival (odds ratio [95% CI]) in 15 studies with substantial heterogeneity (I = 61%; p < 0.01). Survival benefits were consistent in the five largest (1,697-12,486 patients per study) (1.20 [1.11-1.30]; I = 0%) and six medium-sized studies (167-1,029) (2.03 [1.52-2.71]; I = 8%) but not the six smallest (64-137) (1.25 [0.42-3.66]; I = 57%). Bundles were associated with similarly increased survival benefits whether requiring antibiotics within 1 hour (n = 7 studies) versus 3 hours (n = 8) versus no specified time (n = 2); or 30 mL/kg fluid (n = 7) versus another volume (≥ 2 L, n = 1; ≥ 20 mL/kg, n = 2; 1.5-2 L or 500 mL, n = 1 each; none specified, n = 4) (p = 0.19 for each comparison). In the only study employing serial lactate measurements, survival was not increased versus others. No study had a low risk of bias or assessed potential adverse bundle effects. CONCLUSIONS Available studies support the notion that antibiotic- and fluid-focused sepsis bundles like SEP-1 improve survival but do not demonstrate the superiority of any specific antibiotic time or fluid volume or of serial lactate measurements. Until strong reproducible evidence demonstrates the safety and benefit of any fixed requirement for these interventions, the present findings support the revision of SEP-1 to allow flexibility in treatment according to physician judgment.
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Affiliation(s)
- Dominique J Pepper
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Xizhong Cui
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Judith Welsh
- NIH Library, National Institutes of Health, Bethesda, MD
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Peter Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
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14
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Does the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) Improve Survival in Septic Adults? Ann Emerg Med 2019; 73:363-365. [DOI: 10.1016/j.annemergmed.2018.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Indexed: 01/11/2023]
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15
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Adherence to fluid resuscitation guidelines and outcomes in patients with septic shock: Reassessing the "one-size-fits-all" approach. J Crit Care 2019; 51:94-98. [PMID: 30784983 DOI: 10.1016/j.jcrc.2019.02.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/16/2019] [Accepted: 02/02/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The Surviving Sepsis Campaign and Centers for Medicare and Medicaid Services (CMS) Severe Sepsis and Septic Shock Management Bundle (SEP-1) recommend rapid crystalloid infusion (≥30 mL/kg) for patients with sepsis-induced hypoperfusion or septic shock. We aimed to assess compliance with this recommendation, factors associated with non-compliance, and how compliance relates to mortality. DESIGN Retrospective, observational study. SETTING 1136-bed academic and 235-bed community hospital (January 2015-June 2016). PATIENTS Patients with septic shock. INTERVENTIONS Crystalloid infusion (≥30 mL/kg) within 6 h of identification of septic shock as required by CMS. MEASUREMENTS Associations with compliance and how compliance associates with mortality; odds ratios (OR) and 95% confidence intervals (CI) reported. MAIN RESULTS Overall, 1027 septic shock patients were included. Of these, 486 (47.3%) met the 6-hour 30 ml/kg fluid requirement. Compliance was lower in patients with congestive heart failure (CHF) (40.9%), chronic kidney disease (CKD) (42.3%) or chronic liver disease (38.5%) and among those that were identified in the inpatient setting (35.4%) rather than in the emergency department (51.7%). When adjusting for relevant covariates, compliance (compared to non-compliance) was not associated with in-hospital mortality: OR 1.03 CI 0.76-1.41. CONCLUSIONS These findings question a "one-size-fits-all" approach to fluid administration and performance measures for patients with sepsis.
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Abstract
Despite numerous advances in understanding the pathophysiology of sepsis and its treatment, sepsis morbidity and mortality remain high. The 2016 Surviving Sepsis Campaign guidelines incorporated the latest research to formulate new sepsis diagnoses and updated treatment recommendations. This article reviews how to manage patients with sepsis and provides insight into the 2016 guidelines, updates, and suggestions.
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Rhee C, Filbin M, Massaro AF, Bulger A, McEachern D, Tobin KA, Kitch B, Thurlo-Walsh B, Kadar A, Koffman A, Pande A, Hamad Y, Warren DK, Jones T, O’Brien C, Anderson DJ, Wang R, Klompas M. Compliance With the National SEP-1 Quality Measure and Association With Sepsis Outcomes: A Multicenter Retrospective Cohort Study. Crit Care Med 2018; 46:1585-1591. [PMID: 30015667 PMCID: PMC6138564 DOI: 10.1097/ccm.0000000000003261] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Many septic patients receive care that fails the Centers for Medicare and Medicaid Services' SEP-1 measure, but it is unclear whether this reflects meaningful lapses in care, differences in clinical characteristics, or excessive rigidity of the "all-or-nothing" measure. We compared outcomes in cases that passed versus failed SEP-1 during the first 2 years after the measure was implemented. DESIGN Retrospective cohort study. SETTING Seven U.S. hospitals. PATIENTS Adult patients included in SEP-1 reporting between October 2015 and September 2017. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 851 sepsis cases in the cohort, 281 (33%) passed SEP-1 and 570 (67%) failed. SEP-1 failures had higher rates of septic shock (20% vs 9%; p < 0.001), hospital-onset sepsis (11% vs 4%; p = 0.001), and vague presenting symptoms (46% vs 30%; p < 0.001). The most common reasons for failure were omission of 3- and 6-hour lactate measurements (228/570 failures, 40%). Only 86 of 570 failures (15.1%) had greater than 3-hour delays until broad-spectrum antibiotics. Cases that failed SEP-1 had higher in-hospital mortality rates (18.4% vs 11.0%; odds ratio, 1.82; 95% CI, 1.19-2.80; p = 0.006), but this association was no longer significant after adjusting for differences in clinical characteristics and severity of illness (adjusted odds ratio, 1.36; 95% CI, 0.85-2.18; p = 0.205). Delays of greater than 3 hours until antibiotics were significantly associated with death (adjusted odds ratio, 1.94; 95% CI, 1.04-3.62; p = 0.038), whereas failing SEP-1 for any other reason was not (adjusted odds ratio, 1.10; 95% CI, 0.70-1.72; p = 0.674). CONCLUSIONS Crude mortality rates were higher in sepsis cases that failed versus passed SEP-1, but there was no difference after adjusting for clinical characteristics and severity of illness. Delays in antibiotic administration were associated with higher mortality but only accounted for a small fraction of SEP-1 failures. SEP-1 may not clearly differentiate between high- and low-quality care, and detailed risk adjustment is necessary to properly interpret associations between SEP-1 compliance and mortality.
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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
| | - Michael Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Amy Bulger
- Department of Quality and Safety, Brigham and Women’s Hospital, Boston, MA
| | - Donna McEachern
- Department of Quality and Safety, Brigham and Women’s Hospital, Boston, MA
| | - Kathleen A. Tobin
- Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, MA
| | - Barrett Kitch
- Department of Medicine, North Shore Medical Center, Salem, MA
| | - Bert Thurlo-Walsh
- Office of Quality, Patient Safety & Experience, Newton-Wellesley Hospital, Newton, MA
| | - Aran Kadar
- Department of Medicine, Newton-Wellesley Hospital, Newton, MA
| | - Alexandra Koffman
- Department of Quality, Brigham and Women’s Faulkner Hospital, Boston, MA
| | - Anupam Pande
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Yasir Hamad
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - David K. Warren
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Travis Jones
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Cara O’Brien
- Department of Medicine, Duke University Medical Center, Durham, NC
| | | | - Rui Wang
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston MA
| | - 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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18
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Filbin MR, Thorsen JE, Lynch J, Gillingham TD, Pasakarnis CL, Capp R, Shapiro NI, Mooncai T, Hou PC, Heldt T, Reisner AT. Challenges and Opportunities for Emergency Department Sepsis Screening at Triage. Sci Rep 2018; 8:11059. [PMID: 30038408 PMCID: PMC6056466 DOI: 10.1038/s41598-018-29427-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 07/10/2018] [Indexed: 12/20/2022] Open
Abstract
Feasibility of ED triage sepsis screening, before diagnostic testing has been performed, has not been established. In a retrospective, outcome-blinded chart review of a one-year cohort of ED adult septic shock patients ("derivation cohort") and three additional, non-consecutive months of all adult ED visits ("validation cohort"), we evaluated the qSOFA score, the Shock Precautions on Triage (SPoT) vital-signs criterion, and a triage concern-for-infection (tCFI) criterion based on risk factors and symptoms, to screen for sepsis. There were 19,670 ED patients in the validation cohort; 50 developed ED septic shock, of whom 60% presented without triage hypotension, and 56% presented with non-specific symptoms. The tCFI criterion improved specificity without substantial reduction of sensitivity. At triage, sepsis screens (positive qSOFA vital-signs and tCFI, or positive SPoT vital-signs and tCFI) were 28% (95% CI: 16-43%) and 56% (95% CI: 41-70%) sensitive, respectively, p < 0.01. By the conclusion of the ED stay, sensitivities were 80% (95% CI: 66-90%) and 90% (95% CI: 78-97%), p > 0.05, and specificities were 97% (95% CI: 96-97%) and 95% (95% CI: 95-96%), p < 0.001. ED patients who developed septic shock requiring vasopressors often presented normotensive with non-specific complaints, necessitating a low threshold for clinical concern-for-infection at triage.
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Affiliation(s)
- Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, United States.
| | - Jill E Thorsen
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, United States
| | - James Lynch
- Department of Electrical and Biomedical Engineering, Massachusetts Institute of Technology, 45 Carleton Street, E25-330, Cambridge, MA, 02139, United States
| | - Trent D Gillingham
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, United States
| | - Corey L Pasakarnis
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, United States
| | - Roberta Capp
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Leprino Building, 12401 East 17th Avenue, Aurora, CO, 80045, United States
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Center, 330 Brookline Avenue, Boston, MA, 02215, United States
| | - Theodore Mooncai
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, United States
| | - Peter C Hou
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, United States
| | - Thomas Heldt
- Department of Electrical and Biomedical Engineering, Massachusetts Institute of Technology, 45 Carleton Street, E25-330, Cambridge, MA, 02139, United States
| | - Andrew T Reisner
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, United States
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19
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Variability in determining sepsis time zero and bundle compliance rates for the centers for medicare and medicaid services SEP-1 measure. Infect Control Hosp Epidemiol 2018; 39:994-996. [PMID: 29932042 DOI: 10.1017/ice.2018.134] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We compared sepsis "time zero" and Centers for Medicare and Medicaid Services (CMS) SEP-1 pass rates among 3 abstractors in 3 hospitals. Abstractors agreed on time zero in 29 of 80 (36%) cases. Perceived pass rates ranged from 9 of 80 cases (11%) to 19 of 80 cases (23%). Variability in time zero and perceived pass rates limits the utility of SEP-1 for measuring quality.
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20
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Venkatesh AK, Slesinger T, Whittle J, Osborn T, Aaronson E, Rothenberg C, Tarrant N, Goyal P, Yealy DM, Schuur JD. Preliminary Performance on the New CMS Sepsis-1 National Quality Measure: Early Insights From the Emergency Quality Network (E-QUAL). Ann Emerg Med 2018; 71:10-15.e1. [DOI: 10.1016/j.annemergmed.2017.06.032] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 05/30/2017] [Accepted: 06/27/2017] [Indexed: 10/19/2022]
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21
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Perner A, Gordon AC, Angus DC, Lamontagne F, Machado F, Russell JA, Timsit JF, Marshall JC, Myburgh J, Shankar-Hari M, Singer M. The intensive care medicine research agenda on septic shock. Intensive Care Med 2017; 43:1294-1305. [DOI: 10.1007/s00134-017-4821-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 04/25/2017] [Indexed: 12/15/2022]
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