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SARTINI MARINA, PATRONE CARLOTTA, SPAGNOLO ANNAMARIA, SCHINCA ELISA, OTTRIA GIANLUCA, DUPONT CHIARA, ALESSIO-MAZZOLA MATTIA, BRAGAZZI NICOLALUIGI, CRISTINA MARIALUISA. The management of healthcare-related infections through lean methodology: systematic review and meta-analysis of observational studies. JOURNAL OF PREVENTIVE MEDICINE AND HYGIENE 2022; 63:E464-E475. [PMID: 36415303 PMCID: PMC9648549 DOI: 10.15167/2421-4248/jpmh2022.63.3.2661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/13/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Lean is largely applied to the health sector and on the healthcare-associated infections (HAI). However, a few results on the improvement of the outcome have been reported in literature. The purpose of this study is to analyze if the lean application can reduce the HAI rate. METHODS A comprehensive search was performed on PubMed/Medline, Scopus, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the following keywords: "lean" and "infection". Inclusion criteria were: 1) research articles with quantitative data and relevant information on lean methodology and its impact on healthcare infections; 2) prospective studies. The risk of bias and the study quality was independently assessed by two researchers using the "The National Institutes of Health (NIH) quality assessment tool for before-after (Pre-Post) study with no control group". The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines has been used. 22 studies were included in the present meta-analysis. RESULTS Lean application demonstrated a significant protective role on healthcare-associated infections rate (RR 0.50; 95% C.I.: 0.38-0.66) with significant impact on central line-associated bloodstream infections (CLABSIs) (RR 0.47; 95% C.I.: 0.28-0.82). CONCLUSIONS Lean has a positive impact on the decreasing of HAIs and on the improvement of compliance and satisfaction of the staff.
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Affiliation(s)
- MARINA SARTINI
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- S.S.D. U.O. Hospital Hygiene, E.O. Ospedali Galliera, Genoa, Italy
| | - CARLOTTA PATRONE
- Department of Directorate, Office Innovation, Development and Lean Application, E.O. Ospedali Galliera, Genoa, Italy
| | - ANNA MARIA SPAGNOLO
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- S.S.D. U.O. Hospital Hygiene, E.O. Ospedali Galliera, Genoa, Italy
| | - ELISA SCHINCA
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- S.S.D. U.O. Hospital Hygiene, E.O. Ospedali Galliera, Genoa, Italy
| | - GIANLUCA OTTRIA
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- S.S.D. U.O. Hospital Hygiene, E.O. Ospedali Galliera, Genoa, Italy
| | - CHIARA DUPONT
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | | | - NICOLA LUIGI BRAGAZZI
- Laboratory for Industrial and Applied Mathematics (LIAM), Department of Mathematics and Statistics, York University, Toronto, ON, Canada
| | - MARIA LUISA CRISTINA
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- S.S.D. U.O. Hospital Hygiene, E.O. Ospedali Galliera, Genoa, Italy
- Correspondence: Maria-Luisa Cristina, Dep. Health Sciences, University of Genoa, Via A. Pastore 1 – 16132 Genova. Phone +39 010 3538883 - E-mail ;
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Warstadt NM, Caldwell JR, Tang N, Mandola S, Jamin C, Dahn C. Quality initiative to improve emergency department sepsis bundle compliance through utilisation of an electronic health record tool. BMJ Open Qual 2022; 11:bmjoq-2021-001624. [PMID: 34992053 PMCID: PMC8739442 DOI: 10.1136/bmjoq-2021-001624] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 12/10/2021] [Indexed: 12/23/2022] Open
Abstract
Introduction Sepsis is a common cause of emergency department (ED) presentation and hospital admission, accounting for a disproportionate number of deaths each year relative to its incidence. Sepsis outcomes have improved with increased recognition and treatment standards promoted by the Surviving Sepsis Campaign. Due to delay in recognition and other barriers, sepsis bundle compliance remains low nationally. We hypothesised that a targeted education intervention regarding use of an electronic health record (EHR) tool for identification and management of sepsis would lead to increased EHR tool utilisation and increased sepsis bundle compliance. Methods We created a multidisciplinary quality improvement team to provide training and feedback on EHR tool utilisation within our ED. A prospective evaluation of the rate of EHR tool utilisation was monitored from June through December 2020. Simultaneously, we conducted two retrospective cohort studies comparing overall sepsis bundle compliance for patients when EHR tool was used versus not used. The first cohort was all patients with intention-to-treat for any sepsis severity. The second cohort of patients included adult patients with time of recognition of sepsis in the ED admitted with a diagnosis of severe sepsis or septic shock. Results EHR tool utilisation increased from 23.3% baseline prior to intervention to 87.2% during the study. In the intention-to-treat cohort, there was a statistically significant difference in compliance between EHR tool utilisation versus no utilisation in overall bundle compliance (p<0.001) and for several individual components: initial lactate (p=0.009), repeat lactate (p=0.001), timely antibiotics (p=0.031), blood cultures before antibiotics (p=0.001), initial fluid bolus (p<0.001) and fluid reassessment (p<0.001). In the severe sepsis and septic shock cohort, EHR tool use increased from 71.2% pre-intervention to 85.0% post-intervention (p=0.008). Conclusion With training, feedback and EHR optimisation, an EHR tool can be successfully integrated into current workflows and appears to increase sepsis bundle compliance.
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Affiliation(s)
- Nicholus Michael Warstadt
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - J Reed Caldwell
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Nicole Tang
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Staci Mandola
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Catherine Jamin
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA.,Divison of Critical Care Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Cassidy Dahn
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA .,Divison of Critical Care Medicine, New York University Grossman School of Medicine, New York, New York, USA
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Warren J, Plunkett E, Rudge J, Stamoulis C, Torlinski T, Tarrant C, Mullhi R. Trainee doctors' experiences of learning and well-being while working in intensive care during the COVID-19 pandemic: a qualitative study using appreciative inquiry. BMJ Open 2021; 11:e049437. [PMID: 34035110 PMCID: PMC8154293 DOI: 10.1136/bmjopen-2021-049437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Concern about trainee work-related well-being has been raised in recent years and is the subject of several reviews, reports and research studies. This study aimed to understand the experiences of trainees working in a large intensive care unit during the first surge of the COVID-19 pandemic from an educational and operational perspective in order to highlight what worked and what could be improved. DESIGN A qualitative study using peer-to-peer semistructured interviews, developed using appreciative inquiry methodology, was conducted during July 2020. Responses were analysed using a thematic analysis technique. SETTING A large, tertiary intensive care unit in the UK. PARTICIPANTS All trainees in anaesthesia and intensive care working on the intensive care unit during the first surge were invited to participate. RESULTS Forty interviews were conducted and four over-arching themes were identified. These were: feeling safe and supported; physical demands; the emotional burden of caring; and a sense of fulfilment, value and personal development. Positive aspects of the organisational response to the pandemic included communication, personal protective equipment supply, team working and well-being support. Suggestions for improvement focused on rest facilities, rota patterns and hierarchies, creating opportunities for reflection and ensuring continued educational and training opportunities despite operational demands. CONCLUSIONS Trainees described opportunities for learning and fulfilment, as well as challenges, in working through a pandemic. Trainees described their needs and how well these were met during the pandemic. Ideas for improvement most frequently related to basic needs including safety and fatigue, but suggestions also related to supporting learning and development. The appreciative inquiry methodology of the project facilitated effective reflection on positive aspects of trainee experiences.
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Affiliation(s)
- Jennifer Warren
- Anaesthesia and Critical Care Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Emma Plunkett
- Anaesthesia and Critical Care Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - James Rudge
- Anaesthesia and Critical Care Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Christina Stamoulis
- Anaesthesia and Critical Care Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Tomasz Torlinski
- Anaesthesia and Critical Care Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Carolyn Tarrant
- Social Science Applied to Healthcare Improvement Research (SAPPHIRE) Group, Health Sciences, University of Leicester, Leicester, Leicestershire, UK
| | - Randeep Mullhi
- Anaesthesia and Critical Care Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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von Itzstein MS, Gupta A, Kernstine KH, Mara KC, Khanna S, Gerber DE. Increased reporting but decreased mortality associated with adverse events in patients undergoing lung cancer surgery: Competing forces in an era of heightened focus on care quality? PLoS One 2020; 15:e0231258. [PMID: 32271810 PMCID: PMC7145007 DOI: 10.1371/journal.pone.0231258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 03/19/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Advances in surgical techniques have improved clinical outcomes and decreased complications. At the same time, heightened attention to care quality has resulted in increased identification of hospital-acquired adverse events. We evaluated these divergent effects on the reported safety of lung cancer resection. METHODS AND MATERIALS We analyzed hospital-acquired adverse events in patients undergoing lung cancer resection using the National Hospital Discharge Survey (NHDS) database from 2001-2010. Demographics, diagnoses, and procedures data were abstracted using ICD-9 codes. We used the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI) to identify hospital-acquired adverse events. Weighted analyses were performed using t-tests and chi-square. RESULTS A total of 302,444 hospitalizations for lung cancer resection and were included in the analysis. Incidence of PSI increased over time (28% in 2001-2002 vs 34% in 2009-2010; P<0.001). Those with one or more PSI had increased in-hospital mortality (aOR = 11.1; 95% CI, 4.7-26.1; P<0.001) and prolonged hospitalization (12.5 vs 7.8 days; P<0.001). However, among those with PSI, in-hospital mortality decreased over time, from 17% in 2001-2002 to 2% in 2009-2010. CONCLUSIONS In a recent ten-year period, documented rates of adverse events associated with lung cancer resection increased. Despite this increase in safety events, we observed that mortality decreased. Because such metrics may be incorporated into hospital rankings and reimbursement considerations, adverse event coding consistency and content merit further evaluation.
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Affiliation(s)
- Mitchell S. von Itzstein
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Arjun Gupta
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Kemp H. Kernstine
- Department of Cardiothoracic Surgery, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Kristin C. Mara
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States of America
| | - Sahil Khanna
- Division of Gastroenterology, Mayo Clinic, Rochester, MN, United States of America
| | - David E. Gerber
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States of America
- Department of Population & Data Sciences, UT Southwestern Medical Center, Dallas, TX, United States of America
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center Dallas, TX, United States of America
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Jackson Chornenki N, Liaw P, Bagshaw S, Burns K, Dodek P, English S, Fan E, Ferrari N, Fowler R, Fox-Robichaud A, Garland A, Green R, Hebert P, Kho M, Martin C, Maslove D, McDonald E, Menon K, Murthy S, Muscedere J, Scales D, Stelfox HT, Wang HT, Weiss M. Data initiatives supporting critical care research and quality improvement in Canada: an environmental scan and narrative review. Can J Anaesth 2020; 67:475-484. [PMID: 31970619 DOI: 10.1007/s12630-020-01571-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 11/11/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022] Open
Abstract
PURPOSE Collection and analysis of health data are crucial to achieving high-quality clinical care, research, and quality improvement. This review explores existing hospital, regional, provincial and national data platforms in Canada to identify gaps and barriers, and recommend improvements for data science. SOURCE The Canadian Critical Care Trials Group and the Canadian Critical Care Translational Biology Group undertook an environmental survey using list-identified names and keywords in PubMed and the grey literature, from the Canadian context. Findings were grouped into sections, corresponding to geography, purpose, and patient sub-group initiatives, using a narrative qualitative approach. Emerging themes, impressions, and recommendations towards improving data initiatives were generated. PRINCIPAL FINDINGS In Canada, the Canadian Institute for Health Information Discharge Abstract Database contains high-level clinical data on every adult and child discharged from acute care facilities; however, it does not contain data from Quebec, critical care-specific severity of illness risk-adjustment scores, physiologic data, or data pertaining to medication use. Provincially mandated critical care platforms in four provinces contain more granular data, and can be used to risk adjust and link to within-province data sets; however, no inter-provincial collaborative mechanism exists. There is very limited infrastructure to collect and link biological samples from critically ill patients nationally. Comprehensive international clinical data sets may inform future Canadian initiatives. CONCLUSION Clinical and biological data collection among critically ill patients in Canada is not sufficiently coordinated, and lags behind other jurisdictions. An integrated and inclusive critical care data platform is a key clinical and scientific priority in Canada.
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Affiliation(s)
| | | | | | | | - Peter Dodek
- University of British Columbia, Vancouver, BC, Canada
| | | | - Eddy Fan
- University of Toronto, Toronto, ON, Canada
| | - Nicolay Ferrari
- Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Robert Fowler
- University of Toronto, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, Sunnybrook Hospital, University of Toronto, 2075 Bayview Avenue, Room D478, Toronto, ON, M4N 3M5, Canada.
| | | | | | | | - Paul Hebert
- Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | | | | | | | | | | | | | | | | | | | | | - Matthew Weiss
- Centre hospitalier universitaire de Québec, Quebec City, QC, Canada
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Schmutz JB, Meier LL, Manser T. How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis. BMJ Open 2019; 9:e028280. [PMID: 31515415 PMCID: PMC6747874 DOI: 10.1136/bmjopen-2018-028280] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES To investigate the relationship between teamwork and clinical performance and potential moderating variables of this relationship. DESIGN Systematic review and meta-analysis. DATA SOURCE PubMed was searched in June 2018 without a limit on the date of publication. Additional literature was selected through a manual backward search of relevant reviews, manual backward and forward search of studies included in the meta-analysis and contacting of selected authors via email. ELIGIBILITY CRITERIA Studies were included if they reported a relationship between a teamwork process (eg, coordination, non-technical skills) and a performance measure (eg, checklist based expert rating, errors) in an acute care setting. DATA EXTRACTION AND SYNTHESIS Moderator variables (ie, professional composition, team familiarity, average team size, task type, patient realism and type of performance measure) were coded and random-effect models were estimated. Two investigators independently extracted information on study characteristics in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS The review identified 2002 articles of which 31 were included in the meta-analysis comprising 1390 teams. The sample-sized weighted mean correlation was r=0.28 (corresponding to an OR of 2.8), indicating that teamwork is positively related to performance. The test of moderators was not significant, suggesting that the examined factors did not influence the average effect of teamwork on performance. CONCLUSION Teamwork has a medium-sized effect on performance. The analysis of moderators illustrated that teamwork relates to performance regardless of characteristics of the team or task. Therefore, healthcare organisations should recognise the value of teamwork and emphasise approaches that maintain and improve teamwork for the benefit of their patients.
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Affiliation(s)
- Jan B Schmutz
- Department of Communication Studies, Northwestern University, Evanston, Illinois, USA
| | - Laurenz L Meier
- Department of Work and Organizational Psychology, University of Neuchâtel, Neuchâtel, Switzerland
| | - Tanja Manser
- FHNW School of Applied Psychology, University of Applied Sciences and Arts Northwestern Switzerland, Olten, Switzerland
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Janssens S, Simon R, Barwick S, Beckmann M, Marshall S. Leadership sharing in maternity emergency teams: a retrospective cohort study in simulation. BMJ SIMULATION & TECHNOLOGY ENHANCED LEARNING 2019; 6:135-139. [DOI: 10.1136/bmjstel-2018-000409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/10/2019] [Indexed: 11/03/2022]
Abstract
BackgroundShared leadership is associated with improved team performance in many domains, but little is understood about how leadership is shared spontaneously in maternity emergency teams, and if it is associated with improved team performance.MethodsA video analysis study of multidisciplinary teams attending a maternity emergency management course was performed at a simulation centre colocated with a tertiary maternity hospital. Sixteen teams responding to a simulated postpartum haemorrhage were analysed between November 2016 and November 2017. Videos were transcribed, and utterances coded for leadership type using a coding system developed a priori. Distribution of leadership utterances between team members was calculated using the Gini coefficient. Teamwork was assessed using validated tools and clinical performance was assessed by time to perform a critical intervention and a checklist of required tasks.ResultsThere was a significant sharing of leadership functions across the team despite the traditional recommendation for a singular leader, with the dominant leader only accounting for 58% of leadership utterances. There was no significant difference in Auckland Team Assessment Tool scores between high and low leadership sharing teams (5.02 vs 4.96, p=0.574). Time to critical intervention was shorter in low leadership sharing teams (193 s vs 312 s, p=0.018) but checklist completion did not differ significantly. Teams with better clinical performance had fewer leadership utterances beyond the dominant two leaders compared with poorer performing teams.ConclusionsLeadership is spontaneously shared in maternity emergency teams despite the recommendation for singular leadership. Spontaneous leadership emerging from multiple team members does not appear to be associated with the improvements in team performance seen in other domains.
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Zhang Z, Hong Y, Smischney NJ, Kuo HP, Tsirigotis P, Rello J, Kuan WS, Jung C, Robba C, Taccone FS, Leone M, Spapen H, Grimaldi D, Van Poucke S, Simpson SQ, Honore PM, Hofer S, Caironi P. Early management of sepsis with emphasis on early goal directed therapy: AME evidence series 002. J Thorac Dis 2017; 9:392-405. [PMID: 28275488 PMCID: PMC5334094 DOI: 10.21037/jtd.2017.02.10] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Severe sepsis and septic shock are major causes of morbidity and mortality in patients entering the emergency department (ED) or intensive care unit (ICU). Despite substantial efforts to improve patient outcome, treatment of sepsis remains challenging to clinicians. In this context, early goal directed therapy (EGDT) represents an important concept emphasizing both early recognition of sepsis and prompt initiation of a structured treatment algorithm. As part of the AME evidence series on sepsis, we conducted a systematic review of all randomized controlled EGDT trials. Focus was laid on the setting (emergency department versus ICU) where EGDT was carried out. Early recognition of sepsis, through clinical or automated systems for early alert, together with well-timed initiation of the recommended therapy bundles may improve patients' outcome. However, the original "EGDT" protocol by Rivers and coworkers has been largely modified in subsequent trials. Currently, many investigators opt for an "expanded" EGDT (as suggested by the Surviving Sepsis Campaign). Evidence is also presented on the effectiveness of automated systems for early sepsis alert. Early recognition of sepsis and well-timed initiation of the SSC bundle may improve patient outcome.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | | | - Han-Pin Kuo
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan
| | - Panagiotis Tsirigotis
- 2nd Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Jordi Rello
- CIBERES, Vall d’Hebron Institute of Research, Universitat Autonoma de Barcelona, Spain
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore and the Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Christian Jung
- University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Division of Cardiology, Pulmonology and Vascular Medicine, Düsseldorf, Germany
| | - Chiara Robba
- Neurosciences Critical Care Unit, Box 1, Addenbrooke’s Hospital, Cambridge, UK
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Marc Leone
- Service d’anesthésie et de réanimation, Hôpital Nord, Assistance Publique – Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Herbert Spapen
- Intensive Care Department, University Hospital, Vrije Universiteit, Brussels, Belgium
| | - David Grimaldi
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Sven Van Poucke
- Department of Anesthesiology, Emergency Medicine, Critical Care and Pain Therapy, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Steven Q. Simpson
- Division of Pulmonary and Critical Care Medicine, University of Kansas, Kansas, USA
| | - Patrick M. Honore
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel Brussels, Brussels, Belgium
| | - Stefan Hofer
- Department of Anesthesiology, University of Heidelberg, Heidelberg, Germany
| | - Pietro Caironi
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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Lee WK, Kim HY, Lee J, Koh SO, Kim JM, Na S. Protocol-Based Resuscitation for Septic Shock: A Meta-Analysis of Randomized Trials and Observational Studies. Yonsei Med J 2016; 57:1260-70. [PMID: 27401660 PMCID: PMC4960395 DOI: 10.3349/ymj.2016.57.5.1260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 12/31/2015] [Accepted: 01/06/2016] [Indexed: 01/20/2023] Open
Abstract
PURPOSE Owing to the recommendations of the Surviving Sepsis Campaign guidelines, protocol-based resuscitation or goal-directed therapy (GDT) is broadly advocated for the treatment of septic shock. However, the most recently published trials showed no survival benefit from protocol-based resuscitation in septic shock patients. Hence, we aimed to assess the effect of GDT on clinical outcomes in such patients. MATERIALS AND METHODS We performed a systematic review that included a meta-analysis. We used electronic search engines including PubMed, Embase, and the Cochrane database to find studies comparing protocol-based GDT to common or standard care in patients with septic shock and severe sepsis. RESULTS A total of 13269 septic shock patients in 24 studies were included [12 randomized controlled trials (RCTs) and 12 observational studies]. The overall mortality odds ratio (OR) [95% confidence interval (CI)] for GDT versus conventional care was 0.746 (0.631-0.883). In RCTs only, the mortality OR (95% CI) for GDT versus conventional care in the meta-analysis was 0.93 (0.75-1.16). The beneficial effect of GDT decreased as more recent studies were added in an alternative, cumulative meta-analysis. No significant publication bias was found. CONCLUSION The result of this meta-analysis suggests that GDT reduces mortality in patients with severe sepsis or septic shock. However, our cumulative meta-analysis revealed that the reduction of mortality risk was diminished as more recent studies were added.
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Affiliation(s)
- Woo Kyung Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Yeon Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jinae Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Shin Ok Koh
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Jeong Min Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sungwon Na
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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Nguyen HB, Jaehne AK, Jayaprakash N, Semler MW, Hegab S, Yataco AC, Tatem G, Salem D, Moore S, Boka K, Gill JK, Gardner-Gray J, Pflaum J, Domecq JP, Hurst G, Belsky JB, Fowkes R, Elkin RB, Simpson SQ, Falk JL, Singer DJ, Rivers EP. Early goal-directed therapy in severe sepsis and septic shock: insights and comparisons to ProCESS, ProMISe, and ARISE. Crit Care 2016; 20:160. [PMID: 27364620 PMCID: PMC4929762 DOI: 10.1186/s13054-016-1288-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Prior to 2001 there was no standard for early management of severe sepsis and septic shock in the emergency department. In the presence of standard or usual care, the prevailing mortality was over 40-50 %. In response, a systems-based approach, similar to that in acute myocardial infarction, stroke and trauma, called early goal-directed therapy was compared to standard care and this clinical trial resulted in a significant mortality reduction. Since the publication of that trial, similar outcome benefits have been reported in over 70 observational and randomized controlled studies comprising over 70,000 patients. As a result, early goal-directed therapy was largely incorporated into the first 6 hours of sepsis management (resuscitation bundle) adopted by the Surviving Sepsis Campaign and disseminated internationally as the standard of care for early sepsis management. Recently a trio of trials (ProCESS, ARISE, and ProMISe), while reporting an all-time low sepsis mortality, question the continued need for all of the elements of early goal-directed therapy or the need for protocolized care for patients with severe and septic shock. A review of the early hemodynamic pathogenesis, historical development, and definition of early goal-directed therapy, comparing trial conduction methodology and the changing landscape of sepsis mortality, are essential for an appropriate interpretation of these trials and their conclusions.
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Affiliation(s)
- H. Bryant Nguyen
- />Department of Medicine, Pulmonary and Critical Care Medicine, Loma Linda University, Loma Linda, CA USA
- />Department of Emergency Medicine, Loma Linda University, Loma Linda, CA USA
| | - Anja Kathrin Jaehne
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Quality Assurance, Aspirus Hospital, Iron River, MI USA
| | - Namita Jayaprakash
- />Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN USA
| | - Matthew W. Semler
- />Department of Medicine, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN USA
| | - Sara Hegab
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Angel Coz Yataco
- />Department of Medicine, Pulmonary and Critical Care Medicine, University of Kentucky, Lexington, KY USA
| | - Geneva Tatem
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Dhafer Salem
- />Department of Internal Medicine, Mercy Hospital Medical Center, Chicago, IL USA
| | - Steven Moore
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Kamran Boka
- />Department of Internal Medicine, Division of Critical Care Medicine, University of Texas Health Science Center at Houston, Houston, TX USA
| | - Jasreen Kaur Gill
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Jayna Gardner-Gray
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Jacqueline Pflaum
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Juan Pablo Domecq
- />Department of Internal Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />CONEVID, Conocimiento y Evidencia Research Unit, Universidad Peruana Cayetano Heredia, Lima, PERU
| | - Gina Hurst
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Justin B. Belsky
- />Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Raymond Fowkes
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Ronald B. Elkin
- />Pulmonary and Critical Care Medicine, California Pacific Medical Center, San Francisco, CA USA
| | - Steven Q. Simpson
- />Pulmonary and Critical Care Medicine, University of Kansas, Kansas City, Kansas USA
| | - Jay L. Falk
- />Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida USA
- />University of Central Florida College of Medicine, Orlando, Florida USA
- />University of Florida College of Medicine, Orlando, Florida USA
- />University of South Florida College of Medicine, Orlando, Florida USA
- />Florida State University College of Medicine, Orlando, Florida USA
| | - Daniel J. Singer
- />Department of Surgery, Division of Surgical Critical Care, Icahn School of Medicine, Mount Sinai Hospital,, New York, NY USA
| | - Emanuel P. Rivers
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Surgery, Henry Ford Hospital, Wayne State University, Detroit, MI USA
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11
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Wira CR, Dodge K, Sather J, Dziura J. Meta-analysis of protocolized goal-directed hemodynamic optimization for the management of severe sepsis and septic shock in the Emergency Department. West J Emerg Med 2015; 15:51-9. [PMID: 24696750 PMCID: PMC3952890 DOI: 10.5811/westjem.2013.7.6828] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 02/14/2012] [Accepted: 07/07/2013] [Indexed: 12/25/2022] Open
Abstract
Introduction: To perform a meta-analysis identifying studies instituting protocolized hemodynamic optimization in the emergency department (ED) for patients with severe sepsis and septic shock. Methods: We modeled the structure of this analysis after the QUORUM and MOOSE published recommendations for scientific reviews. A computer search to identify articles was performed from 1980 to present. Studies included for analysis were adult controlled trials implementing protocolized hemodynamic optimization in the ED for patients with severe sepsis and septic shock. Primary outcome data was extracted and analyzed by 2 reviewers with the primary endpoint being short-term mortality reported either as 28-day or in-hospital mortality. Results: We identified 1,323 articles with 65 retrieved for review. After application of inclusion and exclusion criteria 25 studies (15 manuscripts, 10 abstracts) were included for analysis (n=9597). The mortality rate for patients receiving protocolized hemodynamic optimization (n=6031) was 25.8% contrasted to 41.6% in control groups (n=3566, p<0.0001). Conclusion: Protocolized hemodynamic optimization in the ED for patients with severe sepsis and septic shock appears to reduce mortality.
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Affiliation(s)
- Charles R Wira
- Yale University, Department of Emergency Medicine, New Haven, Connecticut
| | - Kelly Dodge
- Yale University, Department of Emergency Medicine, New Haven, Connecticut
| | - John Sather
- Yale University, Department of Emergency Medicine and Surgical Critical Care, New Haven, Connecticut
| | - James Dziura
- Yale University, Department of Emergency Medicine, New Haven, Connecticut
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12
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An Electronic Tool for the Evaluation and Treatment of Sepsis in the ICU: A Randomized Controlled Trial. Crit Care Med 2015; 43:1595-602. [PMID: 25867906 DOI: 10.1097/ccm.0000000000001020] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To determine whether addition of an electronic sepsis evaluation and management tool to electronic sepsis alerting improves compliance with treatment guidelines and clinical outcomes in septic ICU patients. DESIGN A pragmatic randomized trial. SETTING Medical and surgical ICUs of an academic, tertiary care medical center. PATIENTS Four hundred and seven patients admitted during a 4-month period to the medical or surgical ICU with a diagnosis of sepsis established at the time of admission or in response to an electronic sepsis alert. INTERVENTIONS Patients were randomized to usual care or the availability of an electronic tool capable of importing, synthesizing, and displaying sepsis-related data from the medical record, using logic rules to offer individualized evaluations of sepsis severity and response to therapy, informing users about evidence-based guidelines, and facilitating rapid order entry. MEASUREMENTS AND MAIN RESULTS There was no difference between the electronic tool (218 patients) and usual care (189 patients) with regard to the primary outcome of time to completion of all indicated Surviving Sepsis Campaign 6-hour Sepsis Resuscitation Bundle elements (hazard ratio, 1.98; 95% CI, 0.75-5.20; p = 0.159) or time to completion of each element individually. ICU mortality, ICU-free days, and ventilator-free days did not differ between intervention and control. Providers used the tool to enter orders in only 28% of available cases. CONCLUSIONS A comprehensive electronic sepsis evaluation and management tool is feasible and safe but did not influence guideline compliance or clinical outcomes, perhaps due to low utilization.
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13
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Damiani E, Donati A, Serafini G, Rinaldi L, Adrario E, Pelaia P, Busani S, Girardis M. Effect of performance improvement programs on compliance with sepsis bundles and mortality: a systematic review and meta-analysis of observational studies. PLoS One 2015; 10:e0125827. [PMID: 25946168 PMCID: PMC4422717 DOI: 10.1371/journal.pone.0125827] [Citation(s) in RCA: 162] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 03/26/2015] [Indexed: 02/08/2023] Open
Abstract
Background Several reports suggest that implementation of the Surviving Sepsis Campaign (SSC) guidelines is associated with mortality reduction in sepsis. However, adherence to the guideline-based resuscitation and management sepsis bundles is still poor. Objective To perform a systematic review of studies evaluating the impact of performance improvement programs on compliance with Surviving Sepsis Campaign (SSC) guideline-based bundles and/or mortality. Data Sources Medline (PubMed), Scopus and Intercollegiate Studies Institute Web of Knowledge databases from 2004 (first publication of the SSC guidelines) to October 2014. Study Selection Studies on adult patients with sepsis, severe sepsis or septic shock that evaluated changes in compliance to individual/combined bundle targets and/or mortality following the implementation of performance improvement programs. Interventions may consist of educational programs, process changes or both. Data Extraction Data from the included studies were extracted independently by two authors. Unadjusted binary data were collected in order to calculate odds ratios (OR) for compliance to individual/combined bundle targets. Adjusted (if available) or unadjusted data of mortality were collected. Random-effects models were used for the data synthesis. Results Fifty observational studies were selected. Despite high inconsistency across studies, performance improvement programs were associated with increased compliance with the complete 6-hour bundle (OR = 4.12 [95% confidence interval 2.95-5.76], I2 = 87.72%, k = 25, N = 50,081) and the complete 24-hour bundle (OR = 2.57 [1.74-3.77], I2 = 85.22%, k = 11, N = 45,846) and with a reduction in mortality (OR = 0.66 [0.61-0.72], I2 = 87.93%, k = 48, N = 434,447). Funnel plots showed asymmetry. Conclusions Performance improvement programs are associated with increased adherence to resuscitation and management sepsis bundles and with reduced mortality in patients with sepsis, severe sepsis or septic shock.
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Affiliation(s)
- Elisa Damiani
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Via Tronto 10, 60126 Torrette di Ancona, Italy
- * E-mail:
| | - Abele Donati
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Via Tronto 10, 60126 Torrette di Ancona, Italy
| | - Giulia Serafini
- Department of Anesthesiology and Intensive Care, Modena University Hospital, L.go del Pozzo 71, 41100 Modena, Italy
| | - Laura Rinaldi
- Department of Anesthesiology and Intensive Care, Modena University Hospital, L.go del Pozzo 71, 41100 Modena, Italy
| | - Erica Adrario
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Via Tronto 10, 60126 Torrette di Ancona, Italy
| | - Paolo Pelaia
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Via Tronto 10, 60126 Torrette di Ancona, Italy
| | - Stefano Busani
- Department of Anesthesiology and Intensive Care, Modena University Hospital, L.go del Pozzo 71, 41100 Modena, Italy
| | - Massimo Girardis
- Department of Anesthesiology and Intensive Care, Modena University Hospital, L.go del Pozzo 71, 41100 Modena, Italy
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14
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Physiological changes after fluid bolus therapy in sepsis: a systematic review of contemporary data. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:696. [PMID: 25673138 PMCID: PMC4331149 DOI: 10.1186/s13054-014-0696-5] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Fluid bolus therapy (FBT) is a standard of care in the management of the septic, hypotensive, tachycardic and/or oliguric patient. However, contemporary evidence for FBT improving patient-centred outcomes is scant. Moreover, its physiological effects in contemporary ICU environments and populations are poorly understood. Using three electronic databases, we identified all studies describing FBT between January 2010 and December 2013. We found 33 studies describing 41 boluses. No randomised controlled trials compared FBT with alternative interventions, such as vasopressors. The median fluid bolus was 500 ml (range 100 to 1,000 ml) administered over 30 minutes (range 10 to 60 minutes) and the most commonly administered fluid was 0.9% sodium chloride solution. In 19 studies, a predetermined physiological trigger initiated FBT. Although 17 studies describe the temporal course of physiological changes after FBT in 31 patient groups, only three studies describe the physiological changes at 60 minutes, and only one study beyond this point. No studies related the physiological changes after FBT with clinically relevant outcomes. There is a clear need for at least obtaining randomised controlled evidence for the physiological effects of FBT in patients with severe sepsis and septic shock beyond the period immediately after its administration. ‘Just as water retains no shape, so in warfare there are no constant conditions’ Sun Tzu (‘The Art of War’)
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15
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Herlitz J, Bång A, Wireklint-Sundström B, Axelsson C, Bremer A, Hagiwara M, Jonsson A, Lundberg L, Suserud BO, Ljungström L. Suspicion and treatment of severe sepsis. An overview of the prehospital chain of care. Scand J Trauma Resusc Emerg Med 2012; 20:42. [PMID: 22738027 PMCID: PMC3441306 DOI: 10.1186/1757-7241-20-42] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 04/25/2012] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Sepsis is a life-threatening condition where the risk of death has been reported to be even higher than that associated with the major complications of atherosclerosis, i.e. myocardial infarction and stroke. In all three conditions, early treatment could limit organ dysfunction and thereby improve the prognosis. AIM To describe what has been published in the literature a/ with regard to the association between delay until start of treatment and outcome in sepsis with the emphasis on the pre-hospital phase and b/ to present published data and the opportunity to improve various links in the pre-hospital chain of care in sepsis. METHODS A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases. RESULTS In overall terms, we found a small number of articles (n = 12 of 1,162 unique hits) which addressed the prehospital phase. For each hour of delay until the start of antibiotics, the prognosis appeared to become worse. However, there was no evidence that prehospital treatment improved the prognosis.Studies indicated that about half of the patients with severe sepsis used the emergency medical service (EMS) for transport to hospital. Patients who used the EMS experienced a shorter delay to treatment with antibiotics and the start of early goal-directed therapy (EGDT). Among EMS-transported patients, those in whom the EMS staff already suspected sepsis at the scene had a shorter delay to treatment with antibiotics and the start of EGDT.There are insufficient data on other links in the prehospital chain of care, i.e. patients, bystanders and dispatchers. CONCLUSION Severe sepsis is a life-threatening condition. Previous studies suggest that, with every hour of delay until the start of antibiotics, the prognosis deteriorates. About half of the patients use the EMS. We need to know more about the present situation with regard to the different links in the prehospital chain of care in sepsis.
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Affiliation(s)
- Johan Herlitz
- School of Health Sciences, Research Centre PreHospen, University of Borås, The Prehospital Research Centre of Western Sweden, SE 501 90, Borås, Sweden
- Sahlgrenska University Hospital, SE 413 45, Göteborg, Sweden
| | - Angela Bång
- School of Health Sciences, Research Centre PreHospen, University of Borås, The Prehospital Research Centre of Western Sweden, SE 501 90, Borås, Sweden
| | - Birgitta Wireklint-Sundström
- School of Health Sciences, Research Centre PreHospen, University of Borås, The Prehospital Research Centre of Western Sweden, SE 501 90, Borås, Sweden
| | - Christer Axelsson
- School of Health Sciences, Research Centre PreHospen, University of Borås, The Prehospital Research Centre of Western Sweden, SE 501 90, Borås, Sweden
| | - Anders Bremer
- School of Health Sciences, Research Centre PreHospen, University of Borås, The Prehospital Research Centre of Western Sweden, SE 501 90, Borås, Sweden
| | - Magnus Hagiwara
- School of Health Sciences, Research Centre PreHospen, University of Borås, The Prehospital Research Centre of Western Sweden, SE 501 90, Borås, Sweden
| | - Anders Jonsson
- School of Health Sciences, Research Centre PreHospen, University of Borås, The Prehospital Research Centre of Western Sweden, SE 501 90, Borås, Sweden
| | - Lars Lundberg
- School of Health Sciences, Research Centre PreHospen, University of Borås, The Prehospital Research Centre of Western Sweden, SE 501 90, Borås, Sweden
| | - Björn-Ove Suserud
- School of Health Sciences, Research Centre PreHospen, University of Borås, The Prehospital Research Centre of Western Sweden, SE 501 90, Borås, Sweden
| | - Lars Ljungström
- Department of Infectious Diseases, Skövde Central Hospital, Skövde, Sweden
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