Community-acquired septic shock: early management and outcome in a nationwide study in Finland

Door-to-antibiotic time and mortality in patients with sepsis: Systematic review and meta-analysis

OBJECTIVES

To evaluate whether the timing of initial antibiotic administration in patients with sepsis in hospital affects mortality.

METHODS

This systematic review and meta-analysis included studies from inception up to 19 May 2022. Interventional and observational studies including adult human patients with suspected or confirmed sepsis and reported time of antibiotic administration with mortality were included. Data were extracted by two independent reviewers. Summary estimates were calculated by using random-effects model. The primary outcome was mortality.

RESULTS

We included 42 studies comprising 190,896 patients with sepsis. Pooled data showed that the OR for patient mortality who received antibiotics ≤1 hr was 0.83 (95 %CI: 0.67 to 1.04) when compared with patients who received antibiotics >1hr. Significant reductions in the risk of death in patients with earlier antibiotic administration were observed in patients ≤3 hrs versus >3 hrs (OR: 0.80, 95 %CI: 0.68 to 0.94) and ≤6 hrs vs 6 hrs (OR: 0.57, 95 %CI: 0.39 to 0.82).

CONCLUSIONS

Our findings show an improvement in mortality in sepsis patients with early administration of antibiotics at <3 and <6 hrs. Thus, these results suggest that antibiotics should be administered within 3 hrs of sepsis recognition or ED arrival regardless of the presence or absence of shock.

Mortality in Community-Acquired Sepsis and Infections in the Faroe Islands-A Prospective Observational Study

The aim of this study was to collect data and analyze mortality among patients hospitalized with community-acquired infections in the Faroe Islands. A prospective observational study was conducted in the Medical Department of the National Hospital of the Faroe Islands from October 2013 to April 2015. Cumulative all-cause, in-hospital, short-term, intermediate-term and long-term mortality rates were calculated. Kaplan-Meier survival curves comparing infection-free patients with infected patients of all severities and different age groups are presented. A log-rank test was used to compare groups. Mortality hazard ratios were calculated for subgroups using Cox regression multivariable models. There were 1309 patients without infection and 755 patients with infection. There were 51% female and 49% male patients. Mean age was 62.73 ± 19.71. Cumulative all-cause mortality and in-hospital mortality were highest in more severe forms of infection. This pattern remained the same for short-term mortality in the model adjusted for sex and age, while there were no significant differences among the various infection groups in regard to intermediate- or long-term survival after adjustment. Overall and short-term mortality rates were highest among those with severe manifestations of infection and those with infection compared to infection-free patients.

Nurses' and Physicians' Experiences After Implementation of a Quality Improvement Project to Improve Sepsis Awareness in Hospitals

Purpose

Previous research has explored nurses´ experience with the implementation of early detection alert systems, and nurses and physicians' perceptions of sepsis management and use of sepsis triage. As one of the first, this study aims to investigate the perceived usefulness of an interdisciplinary quality improvement project including standardized sepsis patient pathway to improve the early identification and treatment of sepsis patients.

Participants and Methods

This study was a qualitative study that employed semi-structured interviews with thirteen ward nurses and five ward physicians recruited by convenience and respondent-driven sampling, respectively. The interviews explored the perceived usefulness of mutual training in sepsis care in medical hospital wards. We applied Systematic Text Condensation to analyze the experiences and knowledge of professional identification and cooperation in early identification of sepsis patients.

Results

The results revealed three main themes: Awareness of sepsis, collaboration between nurses and physicians, and clinical assessment and judgement. The findings highlighted the positive impact of the project in terms of raising awareness, improving communication, and enhancing the ability to detect and treat sepsis. The study also identified the importance of repetition and reminders to maintain awareness, the need for ongoing training for new healthcare professionals, and the challenges of collaboration and decision-making processes.

Conclusion

The sepsis intervention seemed successful in improving awareness of sepsis and enhancing interprofessional collaboration between nurses and physicians. Health professionals continued to rely on their clinical judgment but increased the use of objective measurements and communication of vital signs. Continuous repetition and education for new colleagues were identified as important factors for the sustainability of the intervention. Overall, the study highlights the importance of standardized protocols and training for early detection and management of sepsis in healthcare settings.

Sepsis Performance Improvement Programs: From Evidence Toward Clinical Implementation

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2022. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2022. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901.

Antibiotic Timing in Pediatric Septic Shock

BACKGROUND AND OBJECTIVES

National guidelines advocate for the administration of antibiotics within 1 hour to children with septic shock, although there is variance in the pediatric evidence-based literature supporting this benchmark. Our objective for this study was to describe the association of target time to antibiotic administration (TTAA) with outcomes of children treated for suspected septic shock in a pediatric emergency department. Septic shock is suspected when signs of perfusion and/or hypotension are present. The primary outcome was mortality. Secondary outcomes included PICU admission, hospital and PICU length of stay, and organ dysfunction resolution by hospital day 2.

METHODS

We conducted a retrospective study of children <18 years of age admitted from the pediatric emergency department and treated for suspected septic shock between February 1, 2007, and December 31, 2015. Associations between TTAA and outcomes were evaluated by using multivariable linear and logistic regression models obtained from stepwise selection.

RESULTS

Of 1377 patients, 47% were boys with a median age of 4.0 (interquartile range 1.4-11.6) years, 1.5% (20) died, 90% were compliant with TTAA goals, 40% required PICU admission, 38% had ≥2 unique complex chronic conditions, 71% received antibiotics in ≤2 hours, and 30% had a culture-positive bacterial etiology. There were no significant associations between TTAA and outcomes.

CONCLUSIONS

We found no association with TTAA and any clinical outcomes, adding to the growing body of literature questioning the timing benchmark of antibiotic administration. Although the importance of antibiotics is not in question, elucidating the target TTAA may improve resource use and decrease inappropriate or unnecessary antibiotic exposure.

Epidemiology of community-acquired sepsis in the Faroe Islands - a prospective observational study

INTRODUCTION

The aim of the study was to gather nation-wide epidemiological and clinical data in order to characterize community-acquired sepsis in the Faroe Islands, and to compare these data with epidemiological studies performed in other geographical areas.

METHODS

A prospective, observational study conducted from October 2013 until April 2015 to characterize sepsis, and to calculate incidence rates for community-acquired sepsis of any severity, community-acquired severe sepsis, community-acquired septic shock and community-acquired sepsis without community-acquired severe sepsis or community-acquired septic shock.

RESULTS

Of 5279 admissions, 583 cases fulfilled the criteria for community-acquired sepsis of any severity. The mean age of all cases was 67.6 ± 18.3 years. Men accounted for 298 (51.5%) admissions. Charlson comorbidity index was greater than 2 in 247 (42.4%) cases. The incidence of community-acquired sepsis of any severity was 1414/100,000 person-years at risk (95% CI, 1374-1440). The incidence rate for community-acquired sepsis without community-acquired severe sepsis and community-acquired septic shock was 719/100,000 person-years at risk (95% CI, 695-742), for community-acquired severe sepsis 644/100,000 person-years at risk (95% CI, 623-668), for community-acquired septic shock 51/100,000 person-years at risk (95% CI, 45-58). The highest incidence was seen in elderly patients.

CONCLUSION

The incidence rates were slightly higher in men and increased with age, especially in those older than 85 years. Incidence rates of sepsis of any severity were higher than previously published from other countries.

An electronic warning system helps reduce the time to diagnosis of sepsis

OBJECTIVE

To describe the improvements of an early warning system for the identification of septic patients on the time to diagnosis, antibiotic delivery, and mortality.

METHODS

This was an observational cohort study that describes the successive improvements made over a period of 10 years using an early warning system to detect sepsis, including systematic active manual surveillance, electronic alerts via a telephonist, and alerts sent directly to the mobile devices of nurses. For all periods, after an alert was triggered, early treatment was instituted according to the institutional sepsis guidelines.

RESULTS

In total, 637 patients with sepsis were detected over the study period. The median triage-to-diagnosis time was reduced from 19:20 (9:10 - 38:15) hours to 12:40 (2:50 - 23:45) hours when the manual surveillance method was used (p = 0.14), to 2:10 (1:25 - 2:20) hours when the alert was sent automatically to the hospital telephone service (p = 0.014), and to 1:00 (0:30 - 1:10) hour when the alert was sent directly to the nurse's mobile phone (p = 0.016). The diagnosis-to-antibiotic time was reduced to 1:00 (0:55 - 1:30) hours when the alert was sent to the telephonist and to 0:45 (0:30 - 1:00) minutes when the alert was sent directly to the nurse's mobile phone (p = 0.02), with the maintenance of similar values over the following years. There was no difference in the time of treatment between survivors and non-survivors.

CONCLUSION

Electronic systems help reduce the triage-to-diagnosis time and diagnosis-to-antibiotic time in patients with sepsis.

Infectious Diseases Team for the Early Management of Severe Sepsis and Septic Shock in the Emergency Department

Background

The impact on patient survival of an infectious disease (ID) team dedicated to the early management of severe sepsis/septic shock (SS/SS) in Emergency Department (ED) has yet to be assessed.

Methods

A quasiexperimental pre-post study was performed at the general ED of our hospital. During the pre phase (June 2013-July 2014), all consecutive adult patients with SS/SS were managed according to the standard of care, data were prospectively collected. During the post phase (August 2014-October 2015), patients were managed in collaboration with a dedicated ID team performing a bedside patient evaluation within 1 hour of ED arrival.

Results

Overall, 382 patients were included, 195 in the pre phase and 187 in the post phase. Median age was 82 years (interquartile range, 70-88). The most common infection sources were lung (43%) and urinary tract (17%); in 22% of cases, infection source remained unknown. During the post phase, overall compliance with the Surviving Sepsis Campaign (SSC) bundle and appropriateness of initial antibiotic therapy improved from 4.6% to 32% (P < .001) and from 30% to 79% (P < .001), respectively. Multivariate analysis showed that predictors of all-cause 14-day mortality were quick sepsis-related organ failure assessment ≥2 (hazard ratio [HR], 1.68; 95% confidence interval [CI], 1.15-2.45; P = .007), serum lactate ≥2 mmol/L (HR, 2.13; 95% CI, 1.39-3.25; P < .001), and unknown infection source (HR, 2.07; 95% CI, 1.42-3.02; P < .001); being attended during the post phase was a protective factor (HR, 0.64; 95% CI, 0.43-0.94; P = .026).

Conclusion

Implementation of an ID team for the early management of SS/SS in the ED improved the adherence to SSC recommendations and patient survival.

Association of Delayed Antimicrobial Therapy with One-Year Mortality in Pediatric Sepsis

OBJECTIVE

Delayed antimicrobial therapy in sepsis is associated with increased hospital mortality, but the impact of antimicrobial timing on long-term outcomes is unknown. We tested the hypothesis that hourly delays to antimicrobial therapy are associated with 1-year mortality in pediatric severe sepsis.

DESIGN

Retrospective observational study.

SETTING

Quaternary academic pediatric intensive care unit (PICU) from February 1, 2012 to June 30, 2013.

PATIENTS

One hundred sixty patients aged ≤21 years treated for severe sepsis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We tested the association of hourly delays from sepsis recognition to antimicrobial administration with 1-year mortality using multivariable Cox and logistic regression. Overall 1-year mortality was 24% (39 patients), of whom 46% died after index PICU discharge. Median time from sepsis recognition to antimicrobial therapy was 137 min (IQR 65-287). After adjusting for severity of illness and comorbid conditions, hourly delays up to 3 h were not associated with 1-year mortality. However, increased 1-year mortality was evident in patients who received antimicrobials ≤1 h (aOR 3.8, 95% CI 1.2, 11.7) or >3 h (aOR 3.5, 95% CI 1.3, 9.8) compared with patients who received antimicrobials within 1 to 3 h from sepsis recognition. For the subset of patients who survived index PICU admission, antimicrobial therapy ≤1 h was also associated with increased 1-year mortality (aOR 5.5, 95% CI 1.1, 27.4), while antimicrobial therapy >3 h was not associated with 1-year mortality (aOR 2.2, 95% CI 0.5, 11.0).

CONCLUSIONS

Hourly delays to antimicrobial therapy, up to 3 h, were not associated with 1-year mortality in pediatric severe sepsis in this study. The finding that antimicrobial therapy ≤1 h from sepsis recognition was associated with increased 1-year mortality should be regarded as hypothesis-generating for future studies.

Point-of-care lactate testing for sepsis at presentation to health care: a systematic review of patient outcomes

BACKGROUND

Lactate is measured in hospital settings to identify patients with sepsis and severe infections, and to guide initiation of early treatment. Point-of-care technology could facilitate measurement of lactate by clinicians in the community. However, there has been little research into its utility in these environments.

AIM

To investigate the effect of using point-of-care lactate at presentation to health care on mortality and other clinical outcomes, in patients presenting with acute infections.

DESIGN AND SETTING

Studies comparing the use of point-of-care lactate to usual care in initial patient assessment at presentation to health care were identified using a maximally sensitive search strategy of six electronic databases.

METHOD

Two independent authors screened 3063 records for eligibility, and extracted data from eligible studies. Quality assessment for observational studies was performed using the ROBINS-I tool.

RESULTS

Eight studies were eligible for inclusion (3063 patients). Seven studies were recruited from emergency departments, and one from a pre-hospital aeromedical setting. Five studies demonstrated a trend towards reduced mortality with point-of-care lactate; three studies achieved statistical significance. One study demonstrated a significant reduction in length of hospital stay, although another did not find any significant difference. Two studies demonstrated a significant reduction in time to treatment for antibiotics and intravenous fluids.

CONCLUSION

This review identifies an evidence gap - there is no high-quality evidence to support the use of point-of-care lactate in community settings. There are no randomised controlled trials (RCTs) and no studies in primary care. RCT evidence from community settings is needed to evaluate this potentially beneficial diagnostic technology.

Neutrophil CD64, C-reactive protein, and procalcitonin in the identification of sepsis in the ICU - Post-test probabilities

PURPOSE

We were interested in whether C-reactive protein (CRP) and procalcitonin (PCT) distinguish sepsis from non-septic controls and whether a combination of CRP, PCT, and neutrophil CD64 improves identification of sepsis in the intensive care unit (ICU).

MATERIALS AND METHODS

We analyzed the CRP and PCT concentrations from 27 patients with sepsis and 15 ICU controls. In addition, CD64 on neutrophils was measured using quantitative flow cytometry. We present a multiple marker analysis for sepsis diagnostics combining neutrophil CD64, CRP, and PCT using post-test analysis.

RESULTS

The CRP and PCT values separated sepsis and non-septic ICU patients. In post-test analysis, CRP provided a positive probability of 0.48 and a negative probability of 0.053 for sepsis in the ICU; while, the corresponding values were 0.35 and 0.0059, respectively, for PCT and 0.62 and 0.0013, respectively, for neutrophil CD64. When neutrophil CD64 was analyzed with PCT and CRP, the probabilities were 0.98 and <0.001, respectively.

CONCLUSIONS

Neutrophil CD64 expression was superior to PCT and CRP for the identification of sepsis in ICU. Positive post-test probability for any combinations of simultaneously analyzed CRP, PCT and CD64 showed improved diagnostic accuracy for sepsis. This approach may be useful for guiding antibiotic treatment in ICU.

Infectious Etiologies and Patient Outcomes in Pediatric Septic Shock

BACKGROUND

Septic shock remains an important cause of death and disability in children. Optimal care requires early recognition and treatment.

METHODS

We evaluated a retrospective cohort of children (age <19) treated in our emergency department (ED) for septic shock during 2008-2012 to investigate the association between timing of antibiotic therapy and outcomes. The exposures were (1) receipt of empiric antibiotics in ≤1 hour and (2) receipt of appropriate antibiotics in ≤1 hour. The primary outcome was development of new or progressive multiple system organ dysfunction syndrome (NP-MODS). The secondary outcome was mortality.

RESULTS

Among 321 patients admitted to intensive care, 48% (n = 153) received empiric antibiotics in ≤1 hour. These patients were more ill at presentation with significantly greater median pediatric index of mortality 2 (PIM2) scores and were more likely to receive recommended resuscitation in the ED (61% vs 14%); however, rates of NP-MODS (9% vs 12%) and hospital mortality (7% vs 4%) were similar to those treated later. Early, appropriate antibiotics were administered to 33% (n = 67) of patients with identified or suspected bacterial infection. These patients had significantly greater PIM2 scores but similar rates of NP-MODS (15% vs 15%) and hospital mortality (10% vs 6%) to those treated later.

CONCLUSIONS

Critically ill children with septic shock treated in a children's hospital ED who received antibiotics in ≤1 hour were significantly more severely ill than those treated later, but they did not have increased risk of NP-MODS or death.

Impact of a Multidisciplinary Bundle on Time to Antibiotic Administration in Septic SICU Patients

PURPOSE

The goal of this study was to investigate barriers to timely antibiotic administration in septic surgical intensive care unit (SICU) patients and examine the impact of a multidisciplinary bundle on the time from prescription to antibiotic administration.

METHODS

This was a pre- and postintervention study that consisted of 3 phases: (1) preintervention phase, retrospective evaluation of data, (2) intervention implementation, and (3) a postintervention phase. A nurse survey was conducted to identify barriers to rapid antibiotic administration during phase 1. Based on this survey, multidisciplinary interventions included adding antibiotics to the automatic dispensing cabinet, educating monthly staff, and providing an antibiotic dosing table to all prescribers, which is attached to the computer workstations. Our multidisciplinary team consisted of the ICU medical directors, nurse managers, nurses, a critical care fellow, and ICU pharmacists.

RESULTS

The percentage of antibiotics that were received within 60 minutes was 26.3% in the pregroup versus 84.0% in the postgroup ( P < .001). The mean total prescriber to patient time was 110 minutes in the pregroup versus 58.4 minutes in the postgroup ( P < .001).

CONCLUSION

We achieved a higher rate of timely antibiotic administration among septic SICU patients by implementing process changes based on barriers identified by the nurses.

Severe Sepsis in Elderly Patients Undergoing Gastrointestinal Surgery-a Prospective Multicenter Follow-up Study of Finnish Intensive Care Units

BACKGROUND

We aimed to evaluate the outcome of elderly patients with severe sepsis after alimentary tract surgery.

METHODS

A prospective study was conducted in 24 intensive care units (ICU) in Finland. Four thousand five hundred consecutive patients were admitted to ICUs and 470 patients fulfilled the criteria for severe sepsis. All patients who had undergone gastrointestinal surgery were included. The outcomes of elderly (≥65 years) and younger patients were compared. The key factor under analysis was death from any cause during the hospitalization or within 1 year after the surgery.

RESULTS

A total of 73 elderly patients (and 81 younger patients) were found to have severe alimentary tract surgery-related sepsis. The mean age of the elderly patients was 76.4 years, and 56.2 % were female. The most common indication for surgery was acute cholecystitis (21.9 %), followed by acute diverticulitis (13.7 %), and gastroduodenal ulcer (13.7 %). The anatomic site of the infection was intra-abdominal in 86.3 % of cases, the second most common being pulmonary (13.7 %). In-hospital mortality was 47.9 % and 1-year mortality 64.4 %. Of the discharged patients, 31.6 % died within 1 year. Patients who died were older and more frequently had concomitant conditions. The ICU scoring systems (APACHE, SAPS, and SOFA) and elevated lactate levels were predictive of increased mortality.

CONCLUSION

Severe sepsis among the elderly is a rare but often-fatal infectious event. In addition to high in-hospital mortality, it is also associated with significant 1-year mortality.

Patient survival, predictive factors and disease course of severe sepsis in Czech intensive care units: A multicentre, retrospective, observational study

BACKGROUND

Severe sepsis/septic shock is associated with high mortality. In Central Europe, there is a dearth of information on the prevalence and treatment of severe sepsis. The EPOSS (Data-based Evaluation and Prediction of Outcome in Severe Sepsis) project launched in 2011 was aimed at collecting data on patients with severe sepsis/septic shock.

METHODS

The EPOSS study processes data from the EPOSS project database, and is a retrospective, multicentre, observational study. This included all consecutive patients aged 18 and over who were admitted to participating ICUs from 1 January 2011 to 5 November 2013 and met the inclusion criteria of severe sepsis/septic shock. The primary endpoint was to analyse the relationship between in-hospital mortality (either in ICU or after discharge from ICU) and the type and number of fulfilled diagnostic and treatment interventions during the first 6 h after the diagnosis of severe sepsis/septic shock.

RESULTS

The collected dataset involved 1082 patients meeting the criteria of severe sepsis/septic shock. Following data validation, a final dataset of 897 patients was obtained. The average age of the patient group was 64.7 years; mortality at discharge from EPOSS ICUs was 35.5% and from hospital 40.7%. Of the 10 evaluated diagnostic and treatment interventions within the initial 6 hours of identifying severe sepsis/septic shock (i.e. fulfilment of SSC bundles), four or five diagnostic and treatment interventions were administered to 58.4% patients. Combined diagnostic and treatment interventions associated with the lowest in-hospital mortality were: CVP of ≥8-12 mm Hg & MAP of ≥65 mm Hg & Urine output at ≥0.5 mL/kg/h & Lactate of ≤4.0 mmol/L & Initial lactate measured & Antibiotics in the first hour. Lactate at <4 mmol/L and MAP of ≥65 mm Hg remained statistically significant even after adjustment for patient age and APACHE II score. Statistically significantly increased in-hospital mortality was found in patients admitted from general departments (45.7%) or from other ICUs (41.6%), compared to a lower in-hospital mortality of patients transferred from outpatient clinics (26.5%) or Emergency (38.0%). Severe sepsis/septic shock patients transferred from the department of internal medicine were associated with a higher in-hospital mortality (45.1%) than surgical patients (35.5%).

CONCLUSIONS

The most effective measures associated with the lowest in-hospital mortality in septic shock patients were CVP of ≥8-12 mm Hg, MAP of ≥65 mm Hg, urine output at ≥0.5 mL/kg/h, initial lactate level of ≤4.0 mmol/L and administration of antibiotics within the first hour.

Kinetics of leukocyte CD11b and CD64 expression in severe sepsis and non-infectious critical care patients

BACKGROUND

Leukocyte surface molecules may improve sepsis diagnostics. Our aim was to study whether monocyte and neutrophil CD11b and CD64 expression differs between patients with severe sepsis (including septic shock) and intensive care unit (ICU) controls, and also to investigate the expression kinetics in patient groups.

METHODS

Monocyte and neutrophil CD11b and CD64 expression was analyzed in 27 patients with severe sepsis, 7 off-pump coronary artery bypass (OPCAB) patients, and 8 ICU patients without systemic inflammation in the beginning of the treatment using quantitative flow cytometry. Blood samples were collected within 48 h of the beginning of severe sepsis, at admission to the ICU for non-systemic inflammatory response syndrome patients, and on the day of surgery before the skin incision for OPCAB patients, and on 2 consecutive days for all patients. Ten healthy individuals served as controls.

RESULTS

Monocyte and neutrophil CD11b and neutrophil CD64 expression was higher in severe sepsis patients compared with the other groups (P < 0.05). In severe sepsis, the expression decreased over time (P < 0.05). In OPCAB patients, the monocyte and neutrophil CD64 expression increased after surgery (P < 0.05). Neutrophil CD64 expression had the highest and statistically significant area under curves (AUC) values for identification of severe sepsis during 3 consecutive days, the highest AUC being 0.990 on D0.

CONCLUSION

Neutrophil CD64 as well as neutrophil and monocyte CD11b expressions were highest in severe sepsis compared with non-infectious conditions, and thus analyses of their expression may be promising approach for sepsis diagnosis in ICU population.

Empiric antimicrobial therapy in severe sepsis and septic shock: optimizing pathogen clearance

Mortality and morbidity in severe sepsis and septic shock remain high despite significant advances in critical care. Efforts to improve outcome in septic conditions have focused on targeted, quantitative resuscitation strategies utilizing intravenous fluids, vasopressors, inotropes, and blood transfusions to correct disease-associated circulatory dysfunction driven by immune-mediated systemic inflammation. This review explores an alternate paradigm of septic shock in which microbial burden is identified as the key driver of mortality and progression to irreversible shock. We propose that clinical outcomes in severe sepsis and septic shock hinge upon the optimized selection, dosing, and delivery of highly potent antimicrobial therapy.

Delayed antimicrobial therapy increases mortality and organ dysfunction duration in pediatric sepsis

OBJECTIVES

Delayed antimicrobials are associated with poor outcomes in adult sepsis, but data relating antimicrobial timing to mortality and organ dysfunction in pediatric sepsis are limited. We sought to determine the impact of antimicrobial timing on mortality and organ dysfunction in pediatric patients with severe sepsis or septic shock.

DESIGN

Retrospective observational study.

SETTING

PICU at an academic medical center.

PATIENTS

One hundred thirty patients treated for severe sepsis or septic shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We determined if hourly delays from sepsis recognition to initial and first appropriate antimicrobial administration were associated with PICU mortality (primary outcome); ventilator-free, vasoactive-free, and organ failure-free days; and length of stay. Median time from sepsis recognition to initial antimicrobial administration was 140 minutes (interquartile range, 74-277 min) and to first appropriate antimicrobial was 177 minutes (90-550 min). An escalating risk of mortality was observed with each hour delay from sepsis recognition to antimicrobial administration, although this did not achieve significance until 3 hours. For patients with more than 3-hour delay to initial and first appropriate antimicrobials, the odds ratio for PICU mortality was 3.92 (95% CI, 1.27-12.06) and 3.59 (95% CI, 1.09-11.76), respectively. These associations persisted after adjustment for individual confounders and a propensity score analysis. After controlling for severity of illness, the odds ratio for PICU mortality increased to 4.84 (95% CI, 1.45-16.2) and 4.92 (95% CI, 1.30-18.58) for more than 3-hour delay to initial and first appropriate antimicrobials, respectively. Initial antimicrobial administration more than 3 hours was also associated with fewer organ failure-free days (16 [interquartile range, 1-23] vs 20 [interquartile range, 6-26]; p = 0.04).

CONCLUSIONS

Delayed antimicrobial therapy was an independent risk factor for mortality and prolonged organ dysfunction in pediatric sepsis.

Implementing a collaborative sepsis protocol on the time to antibiotics in an emergency department of a saudi hospital: quasi randomized study

Background. The objective of this study is to evaluate the impact of an ED sepsis protocol on the time to antibiotics for emergency department (ED) patients with severe sepsis. Methods. Quasiexperimental prospective study was conducted at the emergency department. Consecutive patients with severe sepsis were included before and after the implementation of a sepsis protocol. The outcome measures were time from recognition of severe sepsis/septic shock to first antibiotic dose delivery and the appropriateness of initial choice of antibiotics based on the presumed source of infection. Results. There were 47 patients in preintervention group and 112 patients in postintervention group. Before implementation, mean time from severe sepsis recognition to delivery of antibiotics was 140 ± 97 minutes. During the intervention period, the mean time was 68 ± 67 minutes, with an overall reduction of 72 minutes. The protocol resulted in an overall improvement of 37% in the compliance, as 62% received appropriate initial antibiotics for the presumed source of infection as compared to 25% before the start of protocol. Conclusion. Implementation of ED sepsis protocol improved the time from recognition of severe sepsis/septic shock to first antibiotic dose delivery as well as the appropriateness of initial antibiotic therapy.

Aetiology, antimicrobial therapy and outcome of patients with community acquired severe sepsis: a prospective study in a Norwegian university hospital

Background

Severe sepsis is recognized as an inflammatory response causing organ dysfunction in patients with infection. Antimicrobial therapy is the mainstay of treatment. There is an ongoing demand for local surveillance of sepsis aetiology and monitoring of empirical treatment recommendations. The present study was established to describe the characteristics, quality of handling and outcome of patients with severe sepsis admitted to a Norwegian university hospital.

Methods

A one year prospective, observational study of adult community acquired case-defined severe sepsis was undertaken. Demographics, focus of infection, microbiological findings, timing and adequacy of empirical antimicrobial agents were recorded. Clinical diagnostic practice was evaluated. Differences between categorical groups were analysed with Pearson’s chi-squared test. Predictors of in-hospital mortality were identified in a multivariate stepwise backward logistic regression model.

Results

In total 220 patients were identified, yielding an estimated annual incidence of 0.5/1000 inhabitants. The focus of infection was established at admission in 69%. Respiratory tract infection was present in 52%, while genitourinary, soft tissue and abdominal infections each were found in 12-14%. Microbiological aetiology was identified in 61%; most prevalent were Streptococcus pneumoniae, Escherichia coli and Staphylococcus aureus. Independent predictors of in-hospital mortality were malignancy, cardiovascular disease, endocarditis, abdominal infections, undefined microbiological aetiology, delay in administration of empirical antimicrobial agents ≥ 6 hours and use of inadequate antimicrobial agents. In patients ≥ 75 years, antimicrobial therapy was less in compliance with current recommendations and more delayed.

Conclusions

Community acquired severe sepsis is common. Initial clinical aetiology is often revised. Compliance with recommendations for empirical antimicrobial treatment is lowest in elderly patients. Our results emphasizes that quick identification of correct source of infection, proper sampling for microbiological analyses, and fast administration of adequate antimicrobial agents are crucial points in the management of severe sepsis.

Short- and long-term mortality in severe sepsis/septic shock in a setting with low antibiotic resistance: a prospective observational study in a Swedish university hospital

Background: There is little epidemiologic data on sepsis, particularly in areas of low antibiotic resistance. Here we report a prospective observational study of severe sepsis and septic shock in patients admitted to the Intensive Care Unit (ICU) at Karolinska University Hospital, Sweden. We aimed to evaluate short- and long-term mortality, and risk factors for sepsis-related death. A second aim was to investigate patient care in relation to gender.

Methods: One hundred and one patients with severe sepsis and septic shock, admitted to the ICU between 2005 and 2009, were prospectively enrolled in the study. Defined primary endpoints were day 28, hospital, and 1-year mortality. Risk factors for sepsis-related death was evaluated with a multivariate analysis in a pooled analysis with two previous sepsis cohorts. In the subset of patient admitted to the ICU through the emergency department (ED), time to clinician evaluation and time to antibiotics were assessed in relation to gender.

Results: In the septic cohort, the day 28, hospital, and 1-year mortality rates were 19, 29, and 34%, respectively. Ninety-three percent of the patients received adequate antibiotics from the beginning. Multi-resistant bacteria were only found in three cases. Among the 43 patients admitted to the ICU through the ED, the median time to antibiotics was 86 min (interquartile range 52–165), and overall 77% received appropriate antibiotics within 2 h. Female patients received antibiotics significantly later compared to male patients (p = 0.047).

Conclusion: The results demonstrate relatively low mortality rates among ICU patients with severe sepsis/septic shock, as compared to reports from outside Scandinavia. Early adequate antibiotic treatment and the low incidence of resistant isolates may partly explain these findings. Importantly, a gender difference in time to antibiotic therapy was seen.

An alternate pathophysiologic paradigm of sepsis and septic shock: implications for optimizing antimicrobial therapy

The advent of modern antimicrobial therapy following the discovery of penicillin during the 1940s yielded remarkable improvements in case fatality rate of serious infections including septic shock. Since then, pathogens have continuously evolved under selective antimicrobial pressure resulting in a lack of significant improvement in clinical effectiveness in the antimicrobial therapy of septic shock despite ever more broad-spectrum and potent drugs. In addition, although substantial effort and money has been expended on the development novel non-antimicrobial therapies of sepsis in the past 30 years, clinical progress in this regard has been limited. This review explores the possibility that the current pathophysiologic paradigm of septic shock fails to appropriately consider the primacy of the microbial burden of infection as the primary driver of septic organ dysfunction. An alternate paradigm is offered that suggests that has substantial implications for optimizing antimicrobial therapy in septic shock. This model of disease progression suggests the key to significant improvement in the outcome of septic shock may lie, in great part, with improvements in delivery of existing antimicrobials and other anti-infectious strategies. Recognition of the role of delays in administration of antimicrobial therapy in the poor outcomes of septic shock is central to this effort. However, therapeutic strategies that improve the degree of antimicrobial cidality likely also have a crucial role.

Acute Normovolemic Hemodilution in the Pig Is Associated with Renal Tissue Edema, Impaired Renal Microvascular Oxygenation, and Functional Loss

Background:

The authors investigated the impact of acute normovolemic hemodilution (ANH) on intrarenal oxygenation and its functional short-term consequences in pigs.

Methods:

Renal microvascular oxygenation (µPo2) was measured in cortex, outer and inner medulla via three implanted optical fibers by oxygen-dependent quenching of phosphorescence. Besides systemic hemodynamics, renal function, histopathology, and hypoxia-inducible factor-1α expression were determined. ANH was performed in n = 18 pigs with either colloids (hydroxyethyl starch 6% 130/0.4) or crystalloids (full electrolyte solution), in three steps from a hematocrit of 30% at baseline to a hematocrit of 15% (H3).

Results:

ANH with crystalloids decreased µPo2 in cortex and outer medulla approximately by 65% (P &lt; 0.05) and in inner medulla by 30% (P &lt; 0.05) from baseline to H3. In contrast, µPo2 remained unaltered during ANH with colloids. Furthermore, renal function decreased by approximately 45% from baseline to H3 (P &lt; 0.05) only in the crystalloid group. Three times more volume of crystalloids was administered compared with the colloid group. Alterations in systemic and renal regional hemodynamics, oxygen delivery and oxygen consumption during ANH, gave no obvious explanation for the deterioration of µPo2 in the crystalloid group. However, ANH with crystalloids was associated with the highest formation of renal tissue edema and the highest expression of hypoxia-inducible factor-1α, which was mainly localized in distal convoluted tubules.

Conclusions:

ANH to a hematocrit of 15% statistically significantly impaired µPo2 and renal function in the crystalloid group. Less tissue edema formation and an unimpaired renal µPo2 in the colloid group might account for a preserved renal function.

Association between inotrope treatment and 90-day mortality in patients with septic shock

BACKGROUND

Administration of inotropes in septic patients with low cardiac output or low central/mixed venous saturation is recommended in current guidelines. However, the impact of inotrope use on the outcome of these patients is controversial. We aimed to analyse the association of inotrope treatment with 90-day mortality.

METHODS

Data from 420 consecutive patients with septic shock were retrospectively collected from the intensive care unit (ICU) data management system. Factors associated with inotrope treatment were assessed. The association of 90-day mortality with inotrope treatment was first analysed using logistic regression analysis, and second including propensity score based on observed variables for selection to inotrope treatment. A subgroup analysis was performed for the 252 patients with pulmonary artery catheter.

RESULTS

One hundred eighty-six (44.3%) patients received inotrope treatment during the first 24 h in ICU. Of those, 168 (90.3%) received dobutamine, 29 (15.6%) levosimendan, and 23 (12.4%) epinephrine. Blood lactate (P < 0.001), central venous pressure, (P < 0.001), and norepinephrine dose (P = 0.03) were independently associated with inotrope treatment. Patients with inotrope treatment had a higher 90-day mortality (42.5% vs. 23.9%, P < 0.001). Age (P < 0.001), Acute Physiology and Chronic Health Evaluation II score (P < 0.001), and inotrope treatment (P = 0.003) were independently associated with 90-day mortality also after adjustment with propensity score.

CONCLUSION

The use of inotrope treatment in septic shock was associated with increased 90-day mortality without and after adjustment with propensity to receive inotrope. To differentiate between non-observed biases of severity of septic shock and an unfavourable effect of inotropes, prospective studies are needed.

[Prognostic value of procalcitonin, C-reactive protein and leukocytes in septic shock]

OBJECTIVES

This study evaluates the potential prognostic value of serial measurements of different biomarkers (procalcitonin [PCT], C-reactive protein and leukocytes [CRP]) in septic shock patients.

DESIGN

Prospective observational study.

SETTING

Intensive care unit of a third-level University Hospital.

PATIENTS

The study comprised a total of 88 septic shock patients defined using the 2001 Consensus Conference SCCM/ESICM/ACCP/ATS/SIS criteria. The PCT, CRP and leukocytes were recorded on admission to the ICU and again 72 hours after admission.

INTERVENTIONS

None.

RESULTS

Those patients with increasing procalcitonin levels showed higher hospital mortality than those with a decreasing levels (58.8% vs. 15.4%, P<0.01). No such effect was observed in relation to C-reactive protein or leukocytes. The best area under the curve for prognosis was for procalcitonin clearance (0.79). A procalcitonin clearance of 70% or higher offered a sensitivity and specificity of 94.7% and 53%, respectively.

CONCLUSIONS

Serial procalcitonin measurements are more predictive of the prognosis of septic shock patients than single measurements of this parameter. The prognostic reliability of the latter is also better than in the case of C-reactive protein and leukocytes. The application of serial procalcitonin measurements may allow the identification of those septic patients at increased mortality risk, and help improve their treatment.

Early antimicrobial therapy in severe sepsis and septic shock

The advent of modern antimicrobial therapy following the discovery of penicillin during the 1940s yielded remarkable improvements in the case fatality rates of serious infections, including septic shock. Since then, pathogens have continuously evolved under selective antimicrobial pressure, resulting in a lack of additional significant improvement in clinical effectiveness of antimicrobial therapy of septic shock despite ever more broad-spectrum and potent drugs. In addition, although substantial effort and money were expended on the development of novel nonantimicrobial therapies of sepsis in the past 30 years, clinical progress in this regard has been limited. This article explores the possibility that the key to significant improvement in the outcome of septic shock may lie, in great part, with improvements in delivery of existing antimicrobials. Recognizing the role of delays in administration of antimicrobial therapy in the poor outcomes of septic shock is central to this effort.

Improving door-to-antibiotic time in severely septic emergency department patients

BACKGROUND

The Surviving Sepsis Campaign (SSC) guidelines recommend that broad-spectrum antibiotics be administered to severely septic patients within 3 h of emergency department (ED) admission. Despite the well-established evidence regarding the benefit of timely antibiotics, adoption of the SSC recommendation into daily clinical practice has been slow and sporadic.

STUDY OBJECTIVE

To study the impact of storing broad-spectrum antibiotics in an ED automated dispensing cabinet (ADC) on the timeliness of antibiotic administration in severely septic patients presenting to the ED.

METHODS

Retrospective observational study of timeliness of antibiotic administration in severely septic patients presenting to a community ED before and after adding broad-spectrum antibiotics to the ED ADC. Data on 56 patients before and 54 patients after the intervention were analyzed. The primary outcome measure was mean order-to-antibiotic time. Secondary outcome measures included mean door-to-antibiotic time and percentage of patients receiving antibiotics within 3 h.

RESULTS

The final analysis was on 110 patients. Order-to-antibiotic administration time was reduced by 29 min post-intervention (55 min vs. 26 min, 95% confidence interval [CI] 12.5-45.19). Mean door-to-antibiotic time was also reduced by 70 min (167 min vs. 97 min, 95% CI 37.53-102.29). The percentage of severely septic patients receiving antibiotics within 3h of arrival to the ED increased from 65% pre-intervention to 93% post-intervention (95% CI 0.12-0.42).

CONCLUSION

Storing key antibiotics in an institution's severe sepsis antibiogram in the ED ADC can significantly reduce order-to-antibiotic times and increase the percentage of patients receiving antibiotics within the recommended 3 h of ED arrival.

Circulating high sensitivity troponin T in severe sepsis and septic shock: distribution, associated factors, and relation to outcome

PURPOSE

To assess the clinical utility of a recently developed highly sensitive cardiac troponin T (hs-cTnT) assay for providing prognostic information on patients with sepsis.

METHODS

cTnT levels were measured by the novel hs-cTnT assay at two time points (inclusion and 72 h thereafter) in a subgroup of patients from the FINNSEPSIS study and associations with clinical outcomes were examined. Results for the hs-cTnT assay were compared to those of the established fourth-generation cTnT assay.

RESULTS

cTnT measured by the fourth-generation and hs-cTnT assay was detectable in 124 (60%) and 207 (100%) patients, respectively, on inclusion in this study. hs-cTnT levels on inclusion correlated with several indices of risk in sepsis, including the simplified acute physiology score (SAPS) II and sequential organ failure assessment (SOFA) scores. The level of hs-cTnT on inclusion was higher in hospital non-survivors (n = 47) than survivors (n = 160) (median 0.054 [Q1-3, 0.022-0.227] versus 0.035 [0.015-0.111] μg/L, P = 0.047), but hs-cTnT level was not an independent predictor of in-hospital mortality. hs-cTnT levels on inclusion were also higher in patients with septic shock during the hospitalization (0.044 [0.024-0.171] versus 0.033 [0.012-0.103] μg/L, P = 0.03), while this was not the case for the fourth-generation cTnT assay or NT-proBNP levels.

CONCLUSIONS

Circulating hs-cTnT is present in patients with severe sepsis and septic shock, associates with disease severity and survival, but does not add to SAPS II score for prediction of mortality. hs-cTnT measurement could still have a role in sepsis as an early marker of shock.

Factors associated with nonadherence to early goal-directed therapy in the ED

BACKGROUND

Protocol-driven early goal-directed therapy (EGDT) has been shown to reduce mortality in patients with severe sepsis and septic shock in the ED. EGDT appears to be underused, even in centers with formalized protocols. The aim of our study was to identify factors associated with not initiating EGDT in the ED.

METHODS

This was a cohort study of 340 EGDT-eligible patients presenting to a single center ED from 2005 to 2007. EGDT eligibility was defined as a serum lactate >or= 4 mmol/L or systolic BP< 90 mm Hg after volume resuscitation. EGDT initiation was defined as the measurement of central venous oxygen saturation via central venous catheter. Multivariable logistic regression was used to adjust for potential confounding.

RESULTS

EGDT was not initiated in 142 eligible patients (42%). EGDT was not completed in 43% of patients in whom EGDT was initiated. Compliance with the protocol varied significantly at the physician level, ranging from 0% to 100%. Four risk factors were found to be associated independently with decreased odds of initiating EGDT: female sex of the patient (P = .001), female sex of the clinician (P = .041), serum lactate (rather than hemodynamic) criterion for EGDT (P = .018), and nonconsultation to the Severe Sepsis Service (P < .001).

CONCLUSIONS

Despite a formalized protocol, we found that EGDT was underused. We identified potential barriers to the effective implementation of EGDT at the patient, clinician, and organizational level. The use of a consultation service to facilitate the implementation of EGDT may be an effective strategy to improve protocol adherence.

Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and mortality in septic shock patients: results of a three-year follow-up quasi-experimental study

OBJECTIVES

To describe the effectiveness of the Surviving Sepsis Campaign bundles with regard to both implementation and outcome in patients with septic shock and to determine the contribution of the various elements of the bundles to the outcome.

DESIGN

Quasi-experimental study with a historical comparison group.

SETTING

The three medical-surgical intensive care units of an academic tertiary care center.

PATIENTS

A total of 384 adult patients in septic shock were enrolled after the educational intervention (September 2005-August 2008) and 96 patients in the historical group (June 2004-May 2005).

INTERVENTION

A hospital-wide quality improvement program based on the implementation of the Surviving Sepsis Campaign guidelines performed between June 2005 and August 2005.

MEASUREMENTS AND RESULTS

In-hospital mortality was reduced from 57.3% in the historical group to 37.5% in the intervention group (p = .001). This difference remained significant after controlling for confounding factors (odds ratio, 0.50; 95% confidence interval, 0.28-0.89). The intervention group had also lower length of stay for survivors in the hospital (36.2 +/- 34.8 days vs. 41.0 +/- 26.3 days; p = .043) and in the intensive care units (8.4 +/- 9.8 days vs. 11.0 +/- 9.5 days; p = .004). Improvements in survival were related to the number of bundle interventions completed (p for trend <.001). Compliance with six or more interventions of the 6-hr resuscitation bundle was an independent predictor of survival (adjusted odds ratio, 0.30; 95% confidence interval, 0.17-0.53; p <.001). The only single intervention with impact on mortality was the achievement of ScvO2 > or =70% (adjusted odds ratio, 0.62; 95% confidence interval, 0.38-0.99; p = .048).

CONCLUSIONS

The implementation of the Surviving Sepsis Campaign guidelines was associated with a significant decrease in mortality. The benefits depend on the number of interventions accomplished within the time limits. The 6-hr resuscitation bundle showed greater compliance and effectiveness than the 24-hr management bundle.

Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department

OBJECTIVE

To study the association between time to antibiotic administration and survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department.

DESIGN

Single-center cohort study.

SETTING

The emergency department of an academic tertiary care center from 2005 through 2006.

PATIENTS

Two hundred sixty-one patients undergoing early goal-directed therapy.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Effects of different time cutoffs from triage to antibiotic administration, qualification for early goal-directed therapy to antibiotic administration, triage to appropriate antibiotic administration, and qualification for early goal-directed therapy to appropriate antibiotic administration on in-hospital mortality were examined. The mean age of the 261 patients was 59 +/- 16 yrs; 41% were female. In-hospital mortality was 31%. Median time from triage to antibiotics was 119 mins (interquartile range, 76-192 mins) and from qualification to antibiotics was 42 mins (interquartile range, 0-93 mins). There was no significant association between time from triage or time from qualification for early goal-directed therapy to antibiotics and mortality when assessed at different hourly cutoffs. When analyzed for time from triage to appropriate antibiotics, there was a significant association at the <1 hr (mortality 19.5 vs. 33.2%; odds ratio, 0.30 [95% confidence interval, 0.11-0.83]; p = .02) time cutoff; similarly, for time from qualification for early goal-directed therapy to appropriate antibiotics, a significant association was seen at the < or =1 hr (mortality 25.0 vs. 38.5%; odds ratio, 0.50 [95% confidence interval, 0.27-0.92]; p = .03) time cutoff.

CONCLUSIONS

Elapsed times from triage and qualification for early goal-directed therapy to administration of appropriate antimicrobials are primary determinants of mortality in patients with severe sepsis and septic shock treated with early goal-directed therapy.

Australasian resuscitation of sepsis evaluation (ARISE): A multi-centre, prospective, inception cohort study

AIM

Determine current resuscitation practices and outcomes in patients presenting to the emergency department (ED) with sepsis and hypoperfusion or septic shock in Australia and New Zealand (ANZ).

METHODS

Three-month prospective, multi-centre, observational study of all adult patients with sepsis and hypoperfusion or septic shock in the ED of 32 ANZ tertiary-referral, metropolitan and rural hospitals.

RESULTS

324 patients were enrolled (mean [SD] age 63.4 [19.2] years, APACHE II score 19.0 [8.2], 52.5% male). Pneumonia (n=138/324, 42.6%) and urinary tract infection (n=98/324, 30.2%) were the commonest sources of sepsis. Between ED presentation and 6hours post-enrolment (T6hrs), 44.4% (n=144/324) of patients received an intra-arterial catheter, 37% (n=120/324) a central venous catheter and 0% (n=0/324) a continuous central venous oxygen saturation (ScvO(2)) catheter. Between enrolment and T6hrs, 32.1% (n=104/324) received a vasopressor infusion, 7.4% (n=24/324) a red blood cell transfusion, 2.5% (n=8/324) a dobutamine infusion and 18.5% (n=60/324) invasive mechanical ventilation. Twenty patients (6.2%) were transferred from ED directly to the operating theatre, 36.4% (n=118/324) were admitted directly to ICU, 1.2% (n=4/324) died in the ED and 56.2% (n=182/324) were transferred to the hospital floor. Overall ICU admission rate was 52.4% (n=170/324). ICU and overall in-hospital mortality were 18.8% (n=32/170) and 23.1% (n=75/324) respectively. In-hospital mortality was not different between patients admitted to ICU (24.7%, n=42/170) and the hospital floor (21.4%, n=33/154).

CONCLUSIONS

Management of ANZ patients presenting to ED with sepsis does not routinely include protocolised, ScvO(2)-directed resuscitation. In-hospital mortality compares favourably with reported mortality in international sepsis trials and nationwide surveys of resuscitation practices.

Shock settico

Lo shock settico corrisponde all’associazione di un’infezione e di un’insufficienza emodinamica, eventualmente associata ad altri deficit viscerali. Le definizioni assimilano spesso lo shock settico alla sepsi grave, la cui insufficienza emodinamica è considerata reversibile. I fondamenti del trattamento si basano su misure che si devono applicare in tempi brevi: il trattamento specifico, che corrisponde alla lotta contro l’agente infettivo, e il trattamento sintomatico, in particolare mediante il ripristino di un’emodinamica efficace. L’aumento del numero delle infezioni gravi e degli shock settici nei paesi industrializzati è stato all’origine di sforzi considerevoli allo scopo di migliorarne la gestione. In particolare, il frutto delle riflessioni congiunte di diverse società scientifiche è stato formalizzato in raccomandazioni, riassunte in procedure. In effetti, la strategia che mira a un miglioramento delle pratiche sembra ridurre la mortalità legata alle infezioni. Alcuni ostacoli compromettono tuttavia il loro uso, dal riconoscimento del problema all’organizzazione delle cure.