Additional Telemedicine Rounds as a Successful Performance-Improvement Strategy for Sepsis Management: Observational Multicenter Study (Preprint)

BACKGROUND Sepsis is a major health care problem with high morbidity and mortality rates and affects millions of patients. Telemedicine, defined as the exchange of medical information via electronic communication, improves the outcome of patients with sepsis and decreases the mortality rate and length of stay in the intensive care unit (ICU). Additional telemedicine rounds could be an effective component of performance-improvement programs for sepsis, especially in underserved rural areas and hospitals without ready access to critical care physicians. OBJECTIVE Our aim was to evaluate the impact of additional daily telemedicine rounds on adherence to sepsis bundles. We hypothesized that additional telemedicine support may increase adherence to sepsis guidelines and improve the detection rates of sepsis and septic shock. METHODS We conducted a retrospective, observational, multicenter study between January 2014 and July 2015 with one tele-ICU center and three ICUs in Germany. We implemented telemedicine as part of standard care and collected data continuously during the study. During the daily telemedicine rounds, routine screening for sepsis was conducted and adherence to the Surviving Sepsis Campaign’s 3-hour and 6-hour sepsis bundles were evaluated. RESULTS In total, 1168 patients were included in this study, of which 196 were positive for severe sepsis and septic shock. We found that additional telemedicine rounds improved adherence to the 3-hour (Quarter 1, 35% vs Quarter 6, 76.2%; P=.01) and 6-hour (Quarter 1, 50% vs Quarter 6, 95.2%; P=.001) sepsis bundles. In addition, we noted an increase in adherence to the item “Administration of fluids when hypotension” (Quarter 1, 80% vs Quarter 6, 100%; P=.049) of the 3-hour bundle and the item “Remeasurement of lactate” (Quarter 1, 65% vs Quarter 6, 100%, P=.003) of the 6-hour bundle. The ICU length of stay after diagnosis of severe sepsis and septic shock remained unchanged over the observation period. Due to a higher number of patients with sepsis in Quarter 5 (N=60) than in other quarters, we observed stronger effects of the additional rounds on mortality in this quarter (Quarter 1, 50% vs Quarter 5, 23.33%, P=.046). CONCLUSIONS Additional telemedicine rounds are an effective component of and should be included in performance-improvement programs for sepsis management.

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770. Multimodal Sepsis Performance Improvement Initiative Improves Early and Appropriate Treatment, Reduces Sepsis-related Readmissions, and Reduces Overall Mortality

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.838 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S343-S343

Author(s):

Seife Yohannes

Keyword(s):

Septic Shock ◽

Severe Sepsis ◽

Length Of Stay ◽

Performance Improvement ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Intervention Period ◽

Post Intervention ◽

Post Intervention Period ◽

Sepsis And Septic Shock

Abstract Background CMS has implemented the SEP-1 Core Measure, which mandates that hospitals implement sepsis quality improvement initiatives. At our hospital, a 900-bed tertiary hospital, a sepsis performance improvement initiative was implemented in April 2016. In this study, we analyzed patient outcomes before and after these interventions. Methods We studied coding data in patients with a diagnosis of Sepsis reported to CMS using a third-party performance improvement database between October, 2015 and July, 2017. The interventions included a hospital-wide education campaign about sepsis; a 24–7 electronic warning system (EWS) using SIRS criteria; a rapid response nursing team that monitors the EWS; a 24–7 mid-level provider team; a database to monitor compliance and timely treatment; and education in sepsis documentation and coding. We performed a before and after analysis of patient outcomes. Results A total of 4,102 patients were diagnosed with sepsis during the study period. 861 (21%) were diagnosed during the pre-intervention period and 3,241 (80%) were diagnosed in the post-intervention period. The overall incidence of sepsis, severe sepsis, and septic shock were 59%, 13%, and 28% consecutively. Regression analysis showed age, admission through the ED, and severity of illness as independent risk factors for increased mortality. Adjusted for these risk factors, the incidence of severe sepsis and septic was reduced by 5.3% and 6.9% in the post-intervention period, while the incidence of simple sepsis increased by 12%. In the post-intervention period, compliance with all 6 CMS mandated sepsis bundle interventions improved from 11% to 37% (P = 0.01); hospital length of stay was reduced by 1.8 days (P = 0.05); length of stay above predicted was less by 1.5 days (P = 0.05); re-admission rate was reduced by 1.6% (P = 0.05); and death from any sepsis diagnosis was reduced 4.5% (P = 0.01). Based on an average of 2000 sepsis cases at our hospital, this amounted to 90 lives saved per year. Death from severe sepsis and septic shock both were also reduced by 5% (P = 0.01) and 6.5% (P = 0.01). Conclusion A multi-modal sepsis performance improvement initiative reduced the incidence of severe sepsis and septic shock, reduced hospital length of stay, reduced readmission rates, and reduced all-cause mortality. Disclosures All authors: No reported disclosures.

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Sepsis

10.2310/fm.1147 ◽

2020 ◽

Author(s):

Steven P LaRosa ◽

Steven M. Opal

Keyword(s):

Intensive Care Unit ◽

Septic Shock ◽

Severe Sepsis ◽

Intensive Care ◽

Organ Dysfunction ◽

Fluid Resuscitation ◽

Multiorgan Failure ◽

Sepsis Management ◽

The Past ◽

Sepsis And Septic Shock

Sepsis, along with the multiorgan failure that often accompanies this condition, is a leading cause of mortality in the intensive care unit. Although modest improvements in the prognosis have been made over the past two decades and promising new therapies continue to be investigated, innovations in the management of septic shock are still required. This chapter discusses the definitions, epidemiology, and pathogenesis (including microbial factors, host-derived mediators, and organ dysfunction) relating to sepsis. Management of severe sepsis and septic shock is also described. This review contains 5 figures, 11 tables, and 99 references. Keywords:Organ dysfunction, sepsis, septic shock, infection, bacteremia, fluid resuscitation, vasopressor

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Tricuspid Annular Plane of Systolic Excursion (TAPSE) for the Evaluation of Patients with Severe Sepsis and Septic Shock

Western Journal of Emergency Medicine ◽

10.5811/westjem.2019.11.44968 ◽

2020 ◽

Vol 21 (2) ◽

pp. 348-352

Author(s):

Shadi Lahham ◽

Clifton Lee ◽

Qumber Ali ◽

John Moeller ◽

Chanel Fischetti ◽

...

Keyword(s):

Septic Shock ◽

Severe Sepsis ◽

Length Of Stay ◽

Large Scale ◽

Admission Rate ◽

Hospital Length Of Stay ◽

Point Of Care Ultrasound ◽

Septic Cardiomyopathy ◽

Icu Admission ◽

Sepsis And Septic Shock

Introduction: Sepsis is a systemic infection that can rapidly progress into multi organ failure and shock if left untreated. Previous studies have demonstrated the utility of point of care ultrasound (POCUS) in the evaluation of patients with sepsis. However, limited data exists on the evaluation of the tricuspid annular plane of systolic excursion (TAPSE) in patients with sepsis. Methods: We prospectively enrolled patients who presented to the emergency department (ED) with concern for severe sepsis or septic shock in a pilot study. In patients that screened positive, the treating physician then performed POCUS to measure the TAPSE value. We compared the intensive care unit (ICU) admission rate, hospital length of stay, and morbidity with their respective TAPSE values. Results: We enrolled 24 patients in the study. Eight patients had TAPSE values less than 16 millimeters (mm), two patients had TAPSE values between 16mm-20mm, and fourteen patients had TAPSE values greater than 20mm. There was no statistically significant association between TAPSE levels and ICU admission (p=0.16), or death (p=0.14). The difference of length of stay (LOS) was not statistically significant in case of hospital LOS (p= 0.72) or ICU LOS. Conclusion: Our pilot data did not demonstrate a correlation between severe sepsis or septic shock and TAPSE values. This may be due to several factors including patient comorbidities, strict definitions of sepsis and septic shock, as well as the absence of septic cardiomyopathy (SCM) in patients with sepsis and septic shock. Future large-scale studies are needed to determine if TAPSE can be beneficial in the ED evaluation of patients with concern for SCM.

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Hospitals That Report Severe Sepsis and Septic Shock Bundle (SEP-1) Compliance Have More Structured Sepsis Performance Improvement

10.1101/2021.05.11.21257054 ◽

2021 ◽

Author(s):

Ty B. Bolte ◽

Morgan B. Swanson ◽

Anna Kaldjian ◽

Nicholas M. Mohr ◽

Jennifer McDanel ◽

...

Keyword(s):

Septic Shock ◽

Severe Sepsis ◽

Performance Improvement ◽

Administrative Claims ◽

Case Review ◽

Sepsis Mortality ◽

Early Management ◽

Care Plans ◽

Sepsis And Septic Shock ◽

Sepsis Care

Objective: Sepsis is a common cause of death in hospitalized patients. The Centers for Medicare & Medicaid Service (CMS) Severe Sepsis and Septic Shock Bundle (SEP-1) is an evidence-based early management bundle focused on improving sepsis outcomes. It is unknown which quality improvement (QI) practices are associated with SEP-1 compliance and if those practices reduce sepsis mortality. The objectives of this study were to compare sepsis QI practices in SEP-1 reporting and non-reporting hospitals and to measure the association between specific elements of sepsis QI processes and SEP-1 performance and hospital-specific risk-adjusted sepsis mortality. Design, Setting, and Patients: This mixed methods study linked telephone survey data on QI practices from Iowa hospitals to SEP-1 performance data and risk-adjusted mortality from statewide all-payer administrative claims database. The survey assessed sepsis QI practices in eight categories. Characteristics of hospitals and sepsis QI practices were compared by SEP-1 reporting status. Univariable and multivariable logistic and linear regression estimated the association of QI practices with hospital SEP-1 performance and observed-to-expected sepsis mortality ratios. Interventions: None Measurements and Main Results: All 118 Iowa hospitals completed the survey (100% response rate). SEP-1 reporting hospitals were more likely to have sepsis QI practices, including reporting sepsis quality to providers (64% vs. 38%, p = 0.026) and using the case review process to develop sepsis care plans (87% vs. 64%, p = 0.013). Sepsis QI practices were not associated with increased SEP-1 scores. Two were associated with reduced mortality: having a sepsis committee B= -0.11, p = 0.036) and using case review results for sepsis care plans (B= -0.10, p = 0.049). Conclusions: Hospitals reporting SEP-1 compliance to CMS conduct more sepsis QI practices. Most QI practices are not associated with increased SEP-1 performance or decreased sepsis mortality. Future work could explore how to implement these performance improvement practices in hospitals not reporting SEP-1 compliance.

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Vitamin C, Hydrocortisone, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Analysis of Real-World Application

Journal of Clinical Medicine ◽

10.3390/jcm8040478 ◽

2019 ◽

Vol 8 (4) ◽

pp. 478 ◽

Cited By ~ 17

Author(s):

Jane Litwak ◽

Nam Cho ◽

H. Nguyen ◽

Kayvan Moussavi ◽

Thomas Bushell

Keyword(s):

Septic Shock ◽

Severe Sepsis ◽

Length Of Stay ◽

Combination Therapy ◽

Vitamin C ◽

Triple Therapy ◽

Real World ◽

Standard Care ◽

Icu Mortality ◽

Sepsis And Septic Shock

A recent study suggested mortality benefits using vitamin C, hydrocortisone, and thiamine combination therapy (triple therapy) in addition to standard care in patients with severe sepsis and septic shock. In order to further evaluate the effects of triple therapy in real-world clinical practice, we conducted a retrospective observational cohort study at an academic tertiary care hospital. A total of 94 patients (47 in triple therapy group and 47 in standard care group) were included in the analysis. Baseline characteristics in both groups were well-matched. No significant difference in the primary outcome, hospital mortality, was seen between triple therapy and standard care groups (40.4% vs. 40.4%; p = 1.000). In addition, there were no significant differences in secondary outcomes, including intensive care unit (ICU) mortality, requirement for renal replacement therapy for acute kidney injury, ICU length of stay, hospital length of stay, and time to vasopressor independence. When compared to standard care, triple therapy did not improve hospital or ICU mortality in patients with septic shock. A randomized controlled trial evaluating the effects of triple therapy is necessary prior to implementing vitamin C, hydrocortisone, and thiamine combination therapy as a standard of care in patients with septic shock.

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Sepsis

10.2310/im.1147 ◽

2020 ◽

Author(s):

Steven P LaRosa ◽

Steven M. Opal

Keyword(s):

Intensive Care Unit ◽

Septic Shock ◽

Severe Sepsis ◽

Intensive Care ◽

Organ Dysfunction ◽

Fluid Resuscitation ◽

Multiorgan Failure ◽

Sepsis Management ◽

The Past ◽

Sepsis And Septic Shock

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The Use of an Early Alert System to Improve Compliance with Sepsis Bundles and to Assess Impact on Mortality

Critical Care Research and Practice ◽

10.1155/2012/980369 ◽

2012 ◽

Vol 2012 ◽

pp. 1-8 ◽

Cited By ~ 9

Author(s):

Jennifer Anne LaRosa ◽

Noeen Ahmad ◽

Monica Feinberg ◽

Monica Shah ◽

Roseann DiBrienza ◽

...

Keyword(s):

Septic Shock ◽

Severe Sepsis ◽

Screening Tool ◽

Severity Of Illness ◽

Antibiotic Administration ◽

Alert System ◽

Sepsis Management ◽

Sepsis Bundles ◽

Improve Compliance ◽

Early Alert

Introduction. Diagnostic and therapeutic guidelines, organized as sepsis bundles, have been shown to improve mortality, but timely and consistent implementation of these can be challenging. Our study examined the use of a screening tool and an early alert system to improve bundle compliance and mortality.Methods. A screening tool was used to identify patients with severe sepsis or septic shock and an overhead alert system known as Code SMART (Sepsis Management Alert Response Team) was activated at the physician’s discretion. Data was collected for 6 months and compliance with bundle completion and mortality were compared between the Code SMART and non-Code SMART groups.Results.Fifty eight patients were enrolled −34 Code SMART and 24 non-Code SMART. The Code SMART group achieved greater compliance with timely antibiotic administration (P<0.001), lactate draw (P<0.001), and steroid use (P=0.02). Raw survival and survival adjusted for age, leucopenia, and severity of illness scores, were greater in the Code SMART group (P<0.05,P=0.03, andP=0.01).Conclusions. A screening tool and an alert system can improve compliance with sepsis bundle elements and improve survival from severe sepsis and septic shock.

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