Predictors of acute decompensation after admission in ED patients with sepsis

Purposes

The aim of the study was to identify predictors of acute decompensation within 48 hours of admission among infected emergency department (ED) patients admitted to a regular nursing floor.

Procedures

This used a case control study of infected ED patients admitted to a regular nursing floor and who received a discharge diagnosis of sepsis. A multivariate logistic regression model was constructed with the dependent variable as transfer to an intensive care unit (ICU) within 48 hours of admission.

Findings

Seventy-eight patients were enrolled—34 in the ICU group and 44 in the floor group. Only low bicarbonate (<20 mmol/L) (odds ratio [OR], 7.40; 95% confidence interval [CI], 2.35-23.30) and absence of fever (OR, 3.66; 95% CI, 1.11-12.60) were predictive of ICU transfer.

Conclusions

Among infected ED patients admitted to a regular floor, absence of fever and low bicarbonate were independently associated with ICU transfer within 48 hours. Particular attention should be paid to similar patients to ensure appropriate identification of severe infection and appropriate risk stratification.     

Predictors of 30-day mortality in patients admitted to ED for acute heart failure

Objectives

Acute heart failure (AHF) is a leading cause of admission in emergency departments (ED). It is associated with significant in-hospital mortality, suggesting that there is room for improvement of care. Our aims were to investigate clinical patterns, biological characteristics and determinants of 30-day mortality.

Heart rate variability measures as predictors of in-hospital mortality in ED patients with sepsis

Objective

To determine the predictive capability of heart rate variability (HRV) measures of patients with sepsis in the ED for in-hospital death.

Methods

This was a prospective, observational study. A consecutive cohort of patients visiting the ED of a university teaching hospital who met the criteria of sepsis over a 6-month period were enrolled in this study. General demographics, vital signs, laboratory data, and Mortality in Emergency Department Sepsis score were obtained in the ED; the in-patient medical record was reviewed; and a series of continuous 10-minute electrocardiographic signals were recorded for off-line HRV analysis to assess the in-hospital mortality of the patients.

Results

One hundred thirty-two patients aged 27 to 86 years who met the inclusion criteria were enrolled. According to the in-hospital outcome, the patients were categorized into 2 groups: nonsurvivors (n = 10) and survivors (n = 122). The baseline HRV measures, including SDNN, TP, VLFP, LFP, and LFP/HFP ratio, of nonsurvivors were significantly lower, whereas the nHFP was significantly higher, than those of survivors. Multiple logistic regression model identified SDNN and nHFP as the significant independent variables in the prediction of in-hospital mortality for ED patients with sepsis. The receiver operating characteristic area for SDNN and nHFP in predicting the risk of death was 0.700 and 0.739, respectively.

Conclusions

Heart rate variability measures, especially the SDNN and nHFP, may be used as valuable predictors of in-hospital mortality in patients with sepsis attending the ED.     

Plasma adrenomedullin is associated with short-term mortality and vasopressor requirement in patients admitted with sepsis

Introduction

The incidence of death among patients admitted for severe sepsis or septic shock is high. Adrenomedullin (ADM) plays a central role in initiating the hyperdynamic response during the early stages of sepsis. Pilot studies indicate an association of plasma ADM with the severity of the disease. In the present study we utilized a novel sandwich immunoassay of bioactive plasma ADM in patients hospitalized with sepsis in order to assess the clinical utility.

Methods

We enrolled 101 consecutive patients admitted to the emergency department with suspected sepsis in this study. Sepsis was defined by fulfillment of at least two systemic inflammatory response syndrome (SIRS) criteria plus clinical suspicion of infection. Plasma samples for ADM measurement were obtained on admission and for the next four days. The 28-day mortality rate was recorded.

Results

ADM at admission was associated with severity of disease (correlation with Acute Physiology and Chronic Health Evaluation II (APACHE II) score: r = 0.46; P <0.0001). ADM was also associated with 28-day mortality (ADM median (IQR): survivors: 50 (31 to 77) pg/mL; non-survivors: 84 (48 to 232) pg/mL; P <0.001) and was independent from and additive to APACHE II (P = 0.02). Cox regression analysis revealed an additive value of serial measurement of ADM over baseline assessment for prediction of 28-day mortality (P < 0.01). ADM was negatively correlated with mean arterial pressure (r = -0.39; P <0.0001), and it strongly discriminated those patients requiring vasopressor therapy from the others (ADM median (IQR): no vasopressors 48 (32 to 75) pg/mL; with vasopressors 129 (83 to 264) pg/mL, P <0.0001).

Conclusions

In patients admitted with sepsis, severe sepsis or septic shock plasma ADM is strongly associated with severity of disease, vasopressor requirement and 28-day mortality.     

ED identification of patients with severe sepsis/septic shock decreases mortality in a community hospital

Study objectives

Our objective was to quantify the mortality difference between patients with severe sepsis/septic shock (SS/SS) identified in the emergency department (EDI) vs those not identified in the emergency department (NEDI) within our community hospital.

Methods

We conducted a retrospective review of all patients with SS/SS from July 2007 to January 2010 who were admitted to the intensive care unit within our community hospital. Our primary outcome measure was the difference in mortality rates of patients with SS/SS between the EDI and NEDI cohorts. Our secondary outcome measures included the final disposition, the length of stay, and direct cost (DC) for both groups. The data were analyzed using a 2 × 2 contingency table and the Fisher exact test for significance to compare the mortality rates between groups. Lengths of stay and DC between both groups were reported as medians, and significance was calculated using the Mann-Whitney U test.

Results

A total of 267 patients with SS/SS were identified during the 31-month study period. Of these patients, 155 were EDI patients with a mortality rate of 27.7%, and 112 were NEDI patients with a mortality rate of 41.1%. This represents an absolute difference in mortality rates of 13.4% between the 2 groups (P = .0257). The median length of stay between both groups was 7 days for the EDI group and 12.5 days for the NEDI group, translating to median DCs of $9861.01 vs $16 031.07.

Conclusions

Emergency department identification of patients with SS/SS in the community hospital significantly improves mortality.     

Association between sepsis at ICU admission and mortality in patients with ICU-acquired pneumonia: An infectious second-hit model

PurposeWe explore the hypothesis that critically ill patients developing ICU-acquired pneumonia (ICU-AP) have worse outcomes and an altered inflammatory response if their ICU admission was sepsis-related.MethodsProspective cohort study in two centers. Patients with ICU-AP were evaluated according to their previous exposure to sepsis at ICU-admission. Demographic variables, comorbidities, severity scores at admission and at the time of acquisition of ICU-AP, and serum biomarkers of the inflammatory response were evaluated. Primary outcome: 90-day mortality. Secondary outcomes: ICU and hospital length of stay, mortality at days 28 and 180, in-hospital mortality, ventilator-free days (day-28), and inflammatory response. Propensity scoring weighted the risk of previously-acquired sepsis. Multivariate analysis evaluated the risk of mortality by day-90. Sensitivity analyses evaluated the primary outcome in different subgroups.ResultsOf 341 patients enrolled, 147 had sepsis on ICU-admission. Adjusted risk of mortality at 90 days did not differ overall [hazard ratio (HR) = 0.94(CI:0.65–1.37)], nor in subpopulations with a confirmed etiology of pneumonia [HR = 0.93(CI:0.57–1.53)] or sepsis [HR = 0.91(0.54–1.55)], ventilator-associated pneumonia (VAP) [HR = 1.01(CI:0.61–1.68)], nor non-VAP ICU-AP [HR = 0.83(CI:0.40–1.71)]. No differences were found in clinical secondary outcomes, the inflammatory response was similar.ConclusionsPrevious sepsis does not appear to predispose to higher mortality nor worse outcomes in patients who develop ICU-acquired pneumonia.     

ED bedside point-of-care lactate in patients with suspected sepsis is associated with reduced time to iv fluids and mortality

Objective

Early recognition and treatment of sepsis improves outcomes. We determined the effects of bedside point-of-care (POC) lactate measurement on test turnaround time, time to administration of IV fluids and antibiotics, mortality, and ICU admissions in adult ED patients with suspected sepsis. We hypothesized that bedside lactate POC testing would reduce time to IV fluids and antibiotics.

Methods

We compared 80 ED patients with suspected sepsis and a lactate level of 2 mmol/L or greater before and 80 similar patients after introduction of POC lactate measurements. Groups were compared with Χ² and Mann Whitney U tests. A sample size of 80 patients in each group had 85% power to detect a 30-minute difference in time to IV fluids or antibiotics.

Results

Study groups were similar in age, gender, baseline lactate levels, sepsis severity, and Sequential Organ Failure Assessment (SOFA) scores. Introduction of POC lactate was associated with significant reductions in test turnaround time (34 [26-55] vs. 122 [82-149] minutes; P < 0.001), time to IV fluids (55 [34-83] vs. 71 [42-110] minutes; P = 0.03), mortality (6% vs. 19%; P = 0.02), and ICU admissions (33% vs. 51%, P = 0.02), but not time to IV antibiotics (89 [54-156] vs. 88 [60-177] minutes; P = 0.35).

Conclusions

Implementation of bedside POC lactate measurement in adult ED patients with suspected sepsis reduces time to test results and time to administration of IV fluids but not antibiotics. A significant reduction in mortality and ICU admissions was also demonstrated, which is likely due, at least in part, to POC testing.     

Adequate antibiotic therapy prior to ICU admission in patients with severe sepsis and septic shock reduces hospital mortality

IntroductionIn patients with severe sepsis and septic shock as cause of Intensive Care Unit (ICU) admission, we analyze the impact on mortality of adequate antimicrobial therapy initiated before ICU admission.MethodsWe conducted a prospective observational study enrolling patients admitted to the ICU with severe sepsis or septic shock from January 2008 to September 2013. The primary end-point was in-hospital mortality. We considered two groups for comparisons: patients who received adequate antibiotic treatment before or after the admission to the ICU.ResultsA total of 926 septic patients were admitted to ICU, and 638 (68.8%) had available microbiological isolation: 444 (69.6%) received adequate empirical antimicrobial treatment prior to ICU and 194 (30.4%) after admission. Global hospital mortality in patients that received treatment before ICU admission, between 0-6h ICU, 6–12h ICU, 12–24h ICU and after 24 hours since ICU admission were 31.3, 53.2, 57.1, 50 and 50.8% (p<0.001). The multivariate analysis showed that urinary focus (odds ratio (OR) 0.20; 0.09–0.42; p<0.001) and adequate treatment prior to ICU admission (OR 0.37; 0.24–0.56; p<0.001) were protective factors whereas APACHE II score (OR 1.10; 1.07–1.14; p<0.001), septic shock (OR 2.47; 1.57–3.87; p<0.001), respiratory source (OR 1.91; 1.12–3.21; p=0.016), cirrhosis (OR 3.74; 1.60–8.76; p=0.002) and malignancy (OR 1.65; 1.02–2.70; p=0.042) were variables independently associated with in-hospital mortality. Adequate treatment prior to ICU was a protective factor for mortality in patients with severe sepsis (n=236) or in septic shock (n=402).ConclusionsThe administration of adequate antimicrobial therapy before ICU admission is decisive for the survival of patients with severe sepsis and septic shock. Our efforts should be directed to assure the correct administration antibiotics before ICU admission in patients with sepsis.     

Clinical predictors of Pseudomonas aeruginosa or Acinetobacter baumannii bacteremia in patients admitted to the ED

The identification of clinical characteristics that could identify patients at high risk for Pseudomonas aeruginosa or Acinetobacter baumannii bacteremia would aid clinicians in the appropriate management of these life-threatening conditions, especially in patients admitted to the emergency department (ED) with community-onset infections. To determine clinical risk factors for P. aeruginosa or A. baumannii bacteremia in patients with community-onset gram-negative bacteremia (GNB), a post hoc analysis of a nationwide bacteremia surveillance database including patients with microbiologically documented GNB was performed. Ninety-six patients with P. aeruginosa or A. baumannii bacteremia were compared with 1230 patients with Escherichia coli or Klebsiella pneumoniae bacteremia. A solid tumor or hematologic malignancy was more likely to be associated with P. aeruginosa or A. baumannii bacteremia, whereas concurrent neurologic disease was less frequently seen. In regards to the site of infection, pneumonia was more common in P. aeruginosa or A. baumannii bacteremia, whereas a urinary tract infection was less frequently seen. Factors associated with P. aeruginosa or A. baumannii bacteremia in multivariate analysis included pneumonia (odds ratio [OR], 3.60; 95% confidence interval [CI], 1.86-6.99), hematologic malignancy (OR, 2.71; 95% CI, 1.26-5.84), male sex (OR, 2.17; 95% CI, 1.31-3.58), solid tumor (OR, 1.89; 95% CI, 1.15-3.12), and health-care-associated infection (OR, 1.88; 95% CI, 1.48-2.41). Our data suggest that an initial empirical antimicrobial coverage of P. aeruginosa or A. baumannii bacteremia should be seriously considered in patients with pneumonia, a hematologic malignancy, solid tumor, or health-care-associated infection, when GNB is suspected, even in community-onset infections.     

Laboratory risk factors for hospital mortality in acutely admitted patients

BACKGROUND: Many factors affecting hospital mortality in acutely admitted patients are poorly understood. Although scoring systems exist for critically ill patients, usually in intensive care units (ICUs), there are no specific mortality prediction systems for general acute admissions. AIM: To assess the relationship between simple admission laboratory variables on the risk of in-patient mortality. DESIGN: Retrospective analysis of hospital admissions and laboratory databases. METHODS: Where possible, all deceased patients in the 12-month period of study were matched with two surviving controls. The laboratory database was then analysed for admission investigations, including serum sodium, plasma glucose, and white blood cell (WCC) count. Abnormalities of these variables were then compared between cases (those who subsequently died), and controls (those who survived). RESULTS: There were 16 219 admissions, with an overall mortality of 7.6%. We investigated 602 cases and 1073 controls. Hyperglycaemia (glucose >11.0 mmol/l) (OR 2.0, p < 0.0001); severe hyponatraemia (sodium <125 mmol/l) (OR 4.0, p < 0.0001); and leukocytosis (WCC >10 x 10(9)/l) (OR 2.0, p < 0.001) were significantly associated with mortality. The respective associations on logistic regression analysis were: glucose, OR 1.7, p = 0.02; sodium, OR 4.4, p < 0.0001; WCC, OR 1.5, p = 0.006. Low glucose levels, high sodium levels, and low WCC levels were also associated with increased mortality, leading to 'U-shaped' mortality associations. The effect of more than one laboratory abnormality being present was cumulative, in a linear fashion. DISCUSSION: Plasma glucose, serum sodium and WCC are measured in most acutely admitted patients, and abnormalities of these variables have associations with in-hospital mortality. This may provide the basis for the development of a mortality risk scoring system.     

Assessment of urinary dipstick in patients admitted to an ED for blunt abdominal trauma

Introduction

Clinicians still face significant challenge in predicting intra-abdominal injuries in patients admitted to an emergency department for blunt abdominal trauma. This study was thus designed to investigate the value of dipstick urinalysis in patients with blunt abdominal trauma.

Effects of implementing a rapid admission policy in the ED

Objective

The purpose of this study is to determine the impact of a new rapid admission policy (RAP) on emergency department (ED) length of stay (EDLOS) and time spent on ambulance diversion (AD).

Methods

The RAP, instituted in January 2005, allows attending emergency physicians to send stable patients, requiring admission to the general medicine service, directly to available inpatient beds. The RAP thereby eliminates 2 conventional preadmission practices: having admitting physicians evaluate the patient in the ED and requiring all diagnostic testing to be complete before admission. We compared patient characteristics, percentage of patients leaving without being seen, EDLOS for admitted patients, time on AD, and total adjusted facility charge for a 3-month period after the RAP implementation to the same period of the prior year.

Results

There was a 1.1% increase in census with no difference in patient demographics, acuity, or disposition categories for the 2 periods. The EDLOS decreased on average by 10.1 minutes (95% confidence interval [CI], 3.3-17.0 minutes), resulting in an average of 4.2 hours of extra bed availability per day. Weekly minutes of AD decreased 169 minutes (95% CI, 29-310 minutes). There was also a 3.2% increase (95% CI, 3.1%-3.3%) in adjusted facility charge between these periods in 2005 compared with 2004.

Conclusions

The RAP resulted in a small decrease in the EDLOS, which likely decreased AD time. The resulting small increase in ED volume and higher acuity ambulance patients significantly improved ED revenue. Wider implementation of the policy and more uniform use among emergency physicians may further improve these measures.     

Risk factors for 72-hour admission to the ED

This study's purpose was to identify risk factors for return and admission within 72 hours of discharge from the emergency department (ED). During a 2-year period, 104,584 patients were seen and discharged in the ED, and 493 (0.47%) patients returned within 72 hours requiring admission. Risk factors compared were age, sex, race, insurance status, and initial diagnosis. Initial visits were also characterized by weekday, means of arrival, time of arrival and discharge, and time between visits. Older patients, especially over 65 years, and patients with insurance for the elderly (Medicare) were at higher risk. The highest risk initial diagnosis categories were mental disorder (1.2%), genitourinary system (0.93%), and symptom-based diagnoses (0.76%). Also, a high proportion of patients arrived by ambulance. Patients at increased risk of early admission can be identified and should be the first target for prospective prevention strategies that seek to minimize high-risk early returns to the ED.     

Evaluating vancomycin and piperacillin-tazobactam in ED patients with severe sepsis and septic shock

Study objective

To determine the frequency and cause of inadequate initial antibiotic therapy with vancomycin and piperacillin-tazobactam in patients with severe sepsis and septic shock in the emergency department (ED), characterize its impact on patient outcomes, and identify patients who would benefit from an alternative initial empiric regimen.