ICU Admission Source as a Predictor of Mortality for Patients With Sepsis

Purpose: Sepsis is the leading noncardiac cause of intensive care unit (ICU) death. Pre-ICU admission site may be associated with mortality of ICU patients with sepsis. This study quantifies mortality differences among patients with sepsis admitted to an ICU from a hospital ward, emergency department (ED), or an operating room (OR). Methods: We conducted a retrospective cohort study of 1762 adults with sepsis using ICU record data obtained from a clinical database of an academic medical center. Survival analysis provided crude and adjusted hazard rate ratio (HRR) estimates comparing hospital mortality among patients from hospital wards, EDs, and ORs, adjusted for age, sex, and severity of illness. Results: Mortality of patients with sepsis differed based on the pre-ICU admission site. Compared to patients admitted from an ED, patients admitted from hospital wards had higher mortality (HRR: 1.35; 95% confidence interval [CI]: 1.09-1.68) and those admitted from an OR had lower mortality (HRR: 0.37; 95% CI: 0.23-0.58). Conclusion: Patients with sepsis admitted to an ICU from a hospital ward experienced greater mortality than patients with sepsis admitted to an ICU from an ED. These findings indicate that there may be systematic differences in the selection of patient care locations, recognition, and management of patients with sepsis that warrant further investigation.

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Implementation of a pharmacist-provided pharmacogenomics service in an executive health program

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxab137 ◽

2021 ◽

Author(s):

Ina Liko ◽

Lisa Corbin ◽

Eric Tobin ◽

Christina L Aquilante ◽

Yee Ming Lee

Keyword(s):

Health Program ◽

Medical Center ◽

Academic Medical Center ◽

Test Results ◽

Sample Collection ◽

Team Members ◽

University Of Colorado ◽

Academic Medical ◽

Previous Medication ◽

Selection Of

Abstract Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose We describe the implementation of a pharmacist-provided pharmacogenomics (PGx) service in an executive health program (EHP) at an academic medical center. Summary As interest in genomic testing grows, pharmacists have the opportunity to advance the use of PGx in EHPs, in collaboration with other healthcare professionals. In November 2018, a pharmacist-provided PGx service was established in the EHP at the University of Colorado Hospital. The team members included 3 physicians, a pharmacist trained in PGx, a registered dietitian/exercise physiologist, a nurse, and 2 medical assistants. We conducted 4 preimplementation steps: (1) assessment of the patient population, (2) selection of a PGx test, (3) establishment of a visit structure, and (4) selection of a billing model. The PGx consultations involved two 1-hour visits. The first visit encompassed pretest PGx education, review of the patient’s current medications and previous medication intolerances, and DNA sample collection for genotyping. After this visit, the pharmacist developed a therapeutic plan based on the PGx test results, discussed the results and plan with the physician, and created a personalized PGx report. At the second visit, the pharmacist reviewed the PGx test results, personalized the PGx report, and discussed the PGx-guided therapeutic plan with the patient. Overall, the strategy worked well; minor challenges included evaluation of gene-drug pairs with limited PGx evidence, communication of information to non-EHP providers, scheduling issues, and reimbursement. Conclusion The addition of a PGx service within an EHP was feasible and provided pharmacists the opportunity to lead PGx efforts and collaborate with physicians to expand the precision medicine footprint at an academic medical center.

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Sympathetic stimulation increases serum lactate concentrations in patients admitted with sepsis: implications for resuscitation strategies

Annals of Intensive Care ◽

10.1186/s13613-021-00805-9 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Nikhil Jagan ◽

Lee E. Morrow ◽

Ryan W. Walters ◽

Robert W. Plambeck ◽

Tej M. Patel ◽

...

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Surrogate Marker ◽

Lactate Production ◽

Severity Of Illness ◽

Serum Lactate ◽

Sympathetic Stimulation ◽

Arterial Blood ◽

Academic Medical ◽

Lactate Levels

Abstract Background Diametrically opposed positions exist regarding the deleterious effects of elevated lactate. There are data suggesting that it is a detrimental proxy for tissue hypoperfusion and anaerobic metabolism in sepsis and an alternative viewpoint is that some of the hyperlactatemia produced maybe adaptive. This study was conducted to explore the relationship between serum lactate levels, mean arterial blood pressure (MAP), and sympathetic stimulation in patients with sepsis. Methods Retrospective analysis of prospectively collected clinical data from four community-based hospitals and one academic medical center. 8173 adults were included. Heart rate (HR) was used as a surrogate marker of sympathetic stimulation. HR, MAP, and lactate levels were measured upon presentation. Results MAP and HR interacted to affect lactate levels with the highest levels observed in patients with low MAP and high HR (3.6 mmol/L) and the lowest in patients with high MAP and low HR (2.2 mmol/L). The overall mortality rate was 12.4%. Each 10 beats/min increase in HR increased the odds of death 6.0% (95% CI 2.6% to 9.4%), each 1 mmol/L increase in lactate increased the odds of death 20.8% (95% CI 17.4% to 24.2%), whereas each 10 mmHg increase in MAP reduced the odds of death 12.3% (95% CI 9.2% to 15.4%). However, HR did not moderate or mediate the association between lactate and death. Conclusions In septic patients, lactate production was associated with increased sympathetic activity (HR ≥ 90) and hypotension (MAP < 65 mmHg) and was a significant predictor of mortality. Because HR, lactate, and MAP were associated with mortality, our data support the present strategy of using these measurements to gauge severity of illness upon presentation. Since HR did not moderate or mediate the association between lactate and death, criticisms alleging that lactate caused by sympathetic stimulation is adaptive (i.e., less harmful) do not appear substantiated.

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A Neutrophil Subset Defined by Intracellular Olfactomedin 4 is Associated with Mortality in Sepsis

AJP Lung Cellular and Molecular Physiology ◽

10.1152/ajplung.00090.2020 ◽

2020 ◽

Author(s):

Kirsten Neudoerffer Kangelaris ◽

Regina Clemens ◽

Xiaohui Fang ◽

Alejandra Jauregui ◽

Tom Liu ◽

...

Keyword(s):

Host Response ◽

Medical Center ◽

Academic Medical Center ◽

Severity Of Illness ◽

Youden Index ◽

Prognostic Information ◽

Suspected Sepsis ◽

Neutrophil Percentage ◽

Academic Medical ◽

Poor Outcomes

Sepsis is a heterogeneous syndrome clinically and biologically but biomarkers of distinct host response pathways for early prognostic information and testing targeted treatments are lacking. We hypothesized that Olfactomedin 4 (OLFM4), a matrix glycoprotein of neutrophil specific granules defines a distinct neutrophil subset that may be an independent risk factor for poor outcomes in sepsis. In a single-center, prospective cohort study, we enrolled adults admitted to an academic medical center from the Emergency Department (ED) with suspected sepsis (identified by 2 or greater Systemic Inflammatory Response Syndrome [SIRS] criteria and antibiotic receipt) from March 2016 through December 2017, followed by sepsis adjudication according to Sepsis-3. We collected 200mL of whole blood within 24 hours of admission and stained for the neutrophil surface marker CD66b followed by intracellular staining for OLFM4 quantitated by flow cytometry. The predictor for 60-day mortality was the percentage of OLFM4+ neutrophils and at a cut-point of OLFM4+ ≥37.6% determined by the Youden Index. Of 120 enrolled patients with suspected sepsis, 97 had sepsis and 23 had non-sepsis SIRS. The mean percentage of OLFM4+ neutrophils was significantly increased in both sepsis and non-sepsis SIRS patients who died (P ≤ 0.01). Among sepsis patients with elevated OLFM4+(≥37.6%), 56% died compared to 18% with OLFM4+ <37.6% (P=0.001).The association between OLFM4+ and mortality withstood adjustment for demographics, co-morbidities and measures of severity of illness (P<0.03). In sepsis, OLFM4+ neutrophil percentage is independently associated with 60-day mortality and may represent a novel measure of the heterogeneity of host response to sepsis.

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Maximum Norepinephrine Dosage Within 24 Hours as an Indicator of Refractory Septic Shock: A Retrospective Study

Journal of Intensive Care Medicine ◽

10.1177/0885066619860736 ◽

2019 ◽

Vol 35 (11) ◽

pp. 1285-1289

Author(s):

Daisuke Kasugai ◽

Akihiko Hirakawa ◽

Masuyuki Ozaki ◽

Kazuki Nishida ◽

Takao Ikeda ◽

...

Keyword(s):

Septic Shock ◽

Medical Center ◽

Characteristic Curve ◽

Academic Medical Center ◽

Do Not Resuscitate ◽

Weighting Method ◽

Icu Admission ◽

Academic Medical ◽

Refractory Septic Shock ◽

Multivariable Regression

Background: The management of refractory septic shock remains a major challenge in critical care and its early indicators are not fully understood. We hypothesized that the maximum norepinephrine dosage within 24 hours of intensive care unit (ICU) admission may be a useful indicator of early mortality in patients with septic shock. Methods: In this retrospective single-center observational study, patients with septic shock admitted to the emergency ICU of an academic medical center between April 2011 and March 2017 were included. Individuals with cardiac arrest and those with do-not-resuscitate orders before admission were excluded. We analyzed if the maximum norepinephrine dosage within 24 hours of ICU admission (MD24) was associated with 7-day mortality. Results: Among 152 patients with septic shock, 20 (15%) did not survive by day 7. The receiver operating characteristic curve analysis for predicting 7-day mortality revealed a cutoff of MD24 of 0.6 μg/kg/min (sensitivity 47%, specificity 93%). In the multivariable regression analysis, a higher MD24 was significantly associated with 7-day mortality (odds ratio: 7.20; 95% confidence interval [CI]: 2.02-25.7; P = .002) but not with 30-day mortality. Using the inverse probability of treatment weighting method in a propensity scoring analysis, a higher MD24 was significantly associated with 7-day (hazard ratio [HR]: 8.9; 95% CI: 3.2-25.0; P < .001) and 30-day mortality (HR: 2.7; 95% CI: 1.2-5.8; P = .012). Conclusions: An MD24 ≥0.6 μg/kg/min was significantly associated with 7-day mortality in patients with septic shock and may therefore be a useful indicator of refractory septic shock.

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Evaluation of Subepithelial Abnormalities of the Appendix by Endoscopic Ultrasound

Diagnostic and Therapeutic Endoscopy ◽

10.1155/2009/295379 ◽

2009 ◽

Vol 2009 ◽

pp. 1-5 ◽

Cited By ~ 3

Author(s):

Lance T. Uradomo ◽

Peter E. Darwin

Keyword(s):

Endoscopic Ultrasound ◽

Medical Center ◽

Academic Medical Center ◽

Case Series ◽

Proximal Colon ◽

Retrospective Case ◽

Academic Medical ◽

Subepithelial Lesions ◽

Selection Of Patients ◽

Selection Of

Background. The use of through-the-scope (TTS) miniprobe catheter endoscopic ultrasound is a valuable technique for evaluating subepithelial lesions in the proximal colon. Few reports include the evaluation of the appendix by EUS. Objective. To describe endoscopic and endosonographic characteristics of subepithelial lesions of the appendix. Methods. Retrospective case series in a single academic medical center. Adult patients referred for evaluation of subepithelial lesions of the appendix identified by colonoscopy between April 1, 2003 to February 29, 2008. Data were abstracted from an electronic endoscopic database for all patients undergoing miniprobe endoscopic ultrasound examination of the appendix. Medical records were reviewed for patient followup and outcomes. Results. Nine cases were identified. Seven (78%) patients were female. Seven (78%) utilized the 12 MHz miniprobe device and two (22%) used the 20 MHz device. Three mucoceles were described and confirmed by surgical resection. Cases also included one inverted appendix, one gastrointestinal stromal tumor, and one lipoma. In three cases, no abnormality was found. Conclusions. EUS evaluation of the appendix is feasible with standard miniprobe devices and may assist in the selection of patients who may benefit from surgical management.

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A Phenome-Wide Association Study (PheWAS) of COVID-19 Outcomes by Race Using the Electronic Health Records Data in Michigan Medicine

Journal of Clinical Medicine ◽

10.3390/jcm10071351 ◽

2021 ◽

Vol 10 (7) ◽

pp. 1351

Author(s):

Maxwell Salvatore ◽

Tian Gu ◽

Jasmine A. Mack ◽

Swaraaj Prabhu Sankar ◽

Snehal Patil ◽

...

Keyword(s):

Association Study ◽

Medical Center ◽

Academic Medical Center ◽

Healthcare Delivery ◽

Circulatory System ◽

Health Records ◽

Icu Admission ◽

Academic Medical ◽

Targeted Screening ◽

Clinical Diagnoses

Background: We performed a phenome-wide association study to identify pre-existing conditions related to Coronavirus disease 2019 (COVID-19) prognosis across the medical phenome and how they vary by race. Methods: The study is comprised of 53,853 patients who were tested/diagnosed for COVID-19 between 10 March and 2 September 2020 at a large academic medical center. Results: Pre-existing conditions strongly associated with hospitalization were renal failure, pulmonary heart disease, and respiratory failure. Hematopoietic conditions were associated with intensive care unit (ICU) admission/mortality and mental disorders were associated with mortality in non-Hispanic Whites. Circulatory system and genitourinary conditions were associated with ICU admission/mortality in non-Hispanic Blacks. Conclusions: Understanding pre-existing clinical diagnoses related to COVID-19 outcomes informs the need for targeted screening to support specific vulnerable populations to improve disease prevention and healthcare delivery.

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Communication failure: analysis of prescribers’ use of an internal free-text field on electronic prescriptions

Journal of the American Medical Informatics Association ◽

10.1093/jamia/ocy003 ◽

2018 ◽

Vol 25 (6) ◽

pp. 709-714 ◽

Cited By ~ 2

Author(s):

Angela Ai ◽

Adrian Wong ◽

Mary Amato ◽

Adam Wright

Keyword(s):

Safety Concern ◽

Medical Center ◽

Academic Medical Center ◽

Electronic Prescribing ◽

Free Text ◽

Potential Harm ◽

Administrative Personnel ◽

Academic Medical ◽

Record Data ◽

Electronic Prescriptions

Abstract Importance Electronic prescribing promises to improve the safety and clarity of prescriptions. However, it also can introduce miscommunication between prescribers and pharmacists. There are situations where information that is meant to be sent to pharmacists is not sent to them, which has the potential for dangerous errors. Objective To examine how frequently prescribers or administrative personnel put information intended for pharmacists in a field not sent to pharmacists, classify the type of information included, and assess the potential harm associated with these missed messages. Design, Setting, Participants Medication record data from our legacy electronic health record were requested for ambulatory care patients seen at an academic medical center from January 1, 2000, to May 31, 2015 (20 123 881 records). From this database, 6 060 272 medication orders met our inclusion criteria. We analyzed a random sample of 10 000 medication orders with internal comments. Main Outcomes and Measures Reviewers classified internal comments for intent. Comments intended for pharmacists were also sorted into descriptive categories and analyzed for the potential for patient harm. Results We found that 11.7% of the prescriptions in our sample contained comments that were intended to be sent to pharmacists. Many comments contained information about the dose, route, or duration of the prescription (38.0%). Approximately a third of the comments intended for pharmacists contained information that had the potential for significant or severe harm if not communicated. Conclusion We found undelivered comments that were clearly intended for pharmacists and contained important information for either pharmacists or patients. This poses a legitimate safety concern, as a portion of comments contained information that could have prevented severe or significant harm.

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The use of anti-factor Xa monitoring in a selection of patients receiving enoxaparin at a large academic medical center

Journal of Thrombosis and Thrombolysis ◽

10.1007/s11239-016-1384-x ◽

2016 ◽

Vol 42 (4) ◽

pp. 479-485 ◽

Cited By ~ 8

Author(s):

Gretchen L. Sacha ◽

Katie M. Greenlee ◽

Jeffrey M. Ketz

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Factor Xa ◽

Academic Medical ◽

Selection Of Patients ◽

Selection Of

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Survival in critically ill admissions with and without COVID-19 at an academic medical center during the height of the pandemic

Journal of Hospital Administration ◽

10.5430/jha.v10n2p29 ◽

2021 ◽

Vol 10 (2) ◽

pp. 29

Author(s):

Caroline A. Ricard ◽

Janelle O'keeffe Poyant ◽

Sharon L. Holewinski ◽

Stanley A. Nasraway Jr

Keyword(s):

Intensive Care ◽

Hospital Mortality ◽

Critically Ill ◽

Medical Center ◽

Academic Medical Center ◽

Severity Of Illness ◽

Mortality Rates ◽

Academic Medical ◽

Crude Mortality ◽

Significant Difference

Objective: Early reports demonstrate that patients with Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection have high rates of hospitalization, intensive care unit (ICU) admission, and death. We sought to examine characteristics of ICU admissions with and without Coronavirus 2019 (COVID-19) and to compare outcomes between these two critically ill cohorts.Methods: A retrospective analysis of 600 unique adult ICU admissions was conducted at an academic medical center in Boston, MA from March 22 to May 31, 2020.Results: Of 600 ICU admissions, 170 (28.3%) tested positive for COVID-19. Those with COVID-19 had greater severity of illness and were more likely to require mechanical ventilation (MV). Hospital and ICU mortality rates were greater in the COVID-19 group (22.4% vs. 9.5%; 18.2% vs. 7.2%, respectively), but lower than previous reports. Unadjusted odds ratio (OR) for COVID-19 as a predictor of hospital mortality was 2.73 (95% CI 1.68 to 4.43), but when accounting for clinical characteristics and severity of illness, adjusted OR for hospital mortality was no different (1.09 [95% CI 0.50 to 2.41]) among those with and without COVID-19.Conclusions: COVID-19 admissions had greater severity of illness and suffered higher crude mortality rates compared to the non-COVID-19 cohort. However, there was no significant difference in the adjusted OR for hospital mortality between patients with and without COVID-19. This novel finding may be attributed to the “learning curve” from other healthcare system experiences, early hospital-wide preparation, and dedicated intensive care.

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