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BACKGROUND: Over 90 million Americans suffer from advanced illness (AI) and spend their last days of life in critical care units receiving costly, unwanted, aggressive medical care. OBJECTIVE: Evaluate the impact of a specialized care model in medical/surgical units for hospitalized geriatric patients and patients with complex care requirements where designated AI beds align care with patient's wishes/goals, minimize aggressive interventions, and influence efficient resource utilization. DESIGN: US based multi-facility retrospective, longitudinal descriptive study of screened positive AI patients in AI Beds (N = 1,237) from 3 facilities from 2015 to 2017. RESULTS: Patient outcomes included 60% referrals to AI beds from ICU, a decrease of 39-49% in average ICU LOS, a 23% reduction of AI bed patient expirations, 9.0% referrals to hospice, and projected cost savings of $4,361.66/patient, US dollars. CONCLUSION: Allocating AI beds to deliver care to AI patients resulted in a decreased cost of care by reducing overall hospital LOS, mortality, and efficient use of both critical care and hospital resources.
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Cuidados Críticos , Unidades de Cuidados Intensivos , Anciano , Atención a la Salud , Hospitales , Humanos , Estudios Retrospectivos , Estados UnidosRESUMEN
OBJECTIVES: The prevalence of responsiveness to initial fluid challenge among hypotensive sepsis patients is unclear. To avoid fluid overload, and unnecessary treatment, it is important to differentiate these phenotypes. We aimed to 1) determine the proportion of hypotensive sepsis patients sustaining favorable hemodynamic response after initial fluid challenge, 2) determine demographic and clinical risk factors that predicted refractory hypotension, and 3) assess the association between timeliness of fluid resuscitation and refractoriness. DESIGN: Secondary analysis of a prospective, multisite, observational, consecutive-sample cohort. SETTING: Nine tertiary and community hospitals over 1.5 years. PATIENTS: Inclusion criteria 1) suspected or confirmed infection, 2) greater than or equal to two systemic inflammatory response syndrome criteria, 3) systolic blood pressure less than 90 mm Hg, greater than 40% decrease from baseline, or mean arterial pressure less than 65 mm Hg. MEASUREMENTS AND MAIN RESULTS: Sex, age, heart failure, renal failure, immunocompromise, source of infection, initial lactate, coagulopathy, temperature, altered mentation, altered gas exchange, and acute kidney injury were used to generate a risk score. The primary outcome was sustained normotension after fluid challenge without vasopressor titration. Among 3,686 patients, 2,350 (64%) were fluid responsive. Six candidate risk factors significantly predicted refractoriness in multivariable analysis: heart failure (odds ratio, 1.43; CI, 1.20-1.72), hypothermia (odds ratio, 1.37; 1.10-1.69), altered gas exchange (odds ratio, 1.33; 1.12-1.57), initial lactate greater than or equal to 4.0 mmol/L (odds ratio, 1.28; 1.08-1.52), immunocompromise (odds ratio, 1.23; 1.03-1.47), and coagulopathy (odds ratio, 1.23; 1.03-1.48). High-risk patients (≥ three risk factors) had 70% higher (CI, 48-96%) refractory risk (19% higher absolute risk; CI, 14-25%) versus low-risk (zero risk factors) patients. Initiating fluids in greater than 2 hours also predicted refractoriness (odds ratio, 1.96; CI, 1.49-2.58). Mortality was 15% higher (CI, 10-18%) for refractory patients. CONCLUSIONS: Two in three hypotensive sepsis patients were responsive to initial fluid resuscitation. Heart failure, hypothermia, immunocompromise, hyperlactemia, and coagulopathy were associated with the refractory phenotype. Fluid resuscitation initiated after the initial 2 hours more strongly predicted refractoriness than any patient factor tested.
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Soluciones Cristaloides/uso terapéutico , Hipotensión/tratamiento farmacológico , Anciano , Femenino , Humanos , Hipotensión/etiología , Hipotensión/genética , Masculino , Fenotipo , Prevalencia , Estudios Prospectivos , Sepsis/complicaciones , Choque Séptico/complicaciones , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: The objectives of this study were to 1) assess patterns of early crystalloid resuscitation provided to sepsis and septic shock patients at initial presentation and 2) determine the association between time to initial crystalloid resuscitation with hospital mortality, mechanical ventilation, ICU utilization, and length of stay. DESIGN: Consecutive-sample observational cohort. SETTING: Nine tertiary and community hospitals over 1.5 years. PATIENTS: Adult sepsis and septic shock patients captured in a prospective quality improvement database inclusion criteria: suspected or confirmed infection, greater than or equal to two systemic inflammatory response criteria, greater than or equal to one organ-dysfunction criteria. INTERVENTIONS: The primary exposure was crystalloid initiation within 30 minutes or lesser, 31-120 minutes, or more than 120 minutes from sepsis identification. MEASUREMENTS AND MAIN RESULTS: We identified 11,182 patients. Crystalloid initiation was faster for emergency department patients (ß, -141 min; CI, -159 to -125; p < 0.001), baseline hypotension (ß, -39 min; CI, -48 to -32; p < 0.001), fever, urinary or skin/soft-tissue source of infection. Initiation was slower with heart failure (ß, 20 min; CI, 14-25; p < 0.001), and renal failure (ß, 16 min; CI, 10-22; p < 0.001). Five thousand three hundred thirty-six patients (48%) had crystalloid initiated in 30 minutes or lesser versus 2,388 (21%) in 31-120 minutes, and 3,458 (31%) in more than 120 minutes. The patients receiving fluids within 30 minutes had lowest mortality (949 [17.8%]) versus 31-120 minutes (446 [18.7%]) and more than 120 minutes (846 [24.5%]). Compared with more than 120 minutes, the adjusted odds ratio for mortality was 0.76 (CI, 0.64-0.90; p = 0.002) for 30 minutes or lesser and 0.76 (CI, 0.62-0.92; p = 0.004) for 31-120 minutes. When assessed continuously, mortality odds increased by 1.09 with each hour to initiation (CI, 1.03-1.16; p = 0.002). We observed similar patterns for mechanical ventilation, ICU utilization, and length of stay. We did not observe significant interaction for mortality risk between initiation time and baseline heart failure, renal failure, hypotension, acute kidney injury, altered gas exchange, or emergency department (vs inpatient) presentation. CONCLUSIONS: Crystalloid was initiated significantly later with comorbid heart failure and renal failure, with absence of fever or hypotension, and in inpatient-presenting sepsis. Earlier crystalloid initiation was associated with decreased mortality. Comorbidities and severity did not modify this effect.
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Soluciones Isotónicas/uso terapéutico , Resucitación/métodos , Sepsis/mortalidad , Sepsis/terapia , Choque Séptico/mortalidad , Choque Séptico/terapia , Tiempo de Tratamiento , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Soluciones Cristaloides , Servicio de Urgencia en Hospital , Femenino , Fiebre/epidemiología , Insuficiencia Cardíaca/epidemiología , Humanos , Hipotensión/epidemiología , Unidades de Cuidados Intensivos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Admisión del Paciente/estadística & datos numéricos , Insuficiencia Renal/epidemiología , Respiración Artificial/estadística & datos numéricos , Infecciones de los Tejidos Blandos/epidemiología , Estados Unidos/epidemiología , Infecciones Urinarias/epidemiologíaRESUMEN
OBJECTIVE: To compare the association of 3-h sepsis bundle compliance with hospital mortality in non-hypotensive sepsis patients with intermediate versus severe hyperlactemia. METHODS: This was a cohort study of all non-hypotensive, hyperlactemic sepsis patients captured in a prospective quality-improvement database, treated October 2014 to September 2015 at five tertiary-care centers. We defined sepsis as 1) infection, 2) ≥2 SIRS criteria, and 3) ≥1 organ dysfunction criterion. "Time-zero" was the first time a patient met all sepsis criteria. INCLUSION CRITERIA: systolic blood pressure>90 mmHg, mean arterial pressure>65 mmHg, and serum lactate≥2.2 mmol/L. Primary exposures: 1) intermediate(2.2-3.9 mmol/L) versus severe(≥4.0 mmol/L) hyperlactemia and 2) full 3-h bundle compliance. Bundle elements: The primary outcome was 60-day in-hospital mortality. RESULTS: 2417 patients met inclusion criteria. 704(29%) had lactate≥4.0 mmol/L versus 1775 patients with lactate 2.2-3.9 mmol/L. Compliance was 75% for antibiotics and 53% for fluids. Full-compliance was comparable between lactate groups (n=200(29%) and 488(28%), respectively). We observed 424(17.5%) mortalities: intermediate/non-compliant - 182(14.9%), intermediate/compliant - 41(8.4%), severe/non-compliant - 147(29.2%), severe/compliant - 54(27.0%) [difference-of-differences=4.3%, CI=2.6-5.9%]. In multivariable regression, mortality predictors included severe hyperlactemia (OR=1.99, CI=1.51-2.63) and bundle compliance (OR=0.62, CI=0.42-0.90), and their interaction was significant: p(interaction)=0.022. CONCLUSION: We observed a significant interaction between 3-h bundle compliance and initial hyperlactemia. Bundle compliance may be associated with greater mortality benefit for non-hypotensive sepsis patients with less severe hyperlactemia.
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Mortalidad Hospitalaria , Hiperlactatemia/epidemiología , Sepsis/mortalidad , Síndrome de Respuesta Inflamatoria Sistémica/epidemiología , Anciano , Anciano de 80 o más Años , Antibacterianos/uso terapéutico , Bases de Datos Factuales , Femenino , Humanos , Ácido Láctico/sangre , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estudios Prospectivos , Mejoramiento de la Calidad , Sepsis/complicaciones , Sepsis/tratamiento farmacológico , Índice de Severidad de la Enfermedad , Centros de Atención Terciaria , Factores de Tiempo , Estados UnidosRESUMEN
OBJECTIVES: To determine mortality and costs associated with adherence to an aggressive, 3-hour sepsis bundle versus noncompliance with greater than or equal to one bundle element for severe sepsis and septic shock patients. DESIGN: Prospective, multisite, observational study following three sequential, independent cohorts, from a single U.S. health system, through their hospitalization. SETTING: Cohort 1: five tertiary and six community hospitals. Cohort 2: single tertiary, academic medical center. Cohort 3: five tertiary and four community hospitals. PATIENTS: Consecutive sample of all severe sepsis and septic shock patients (defined: infection, ≥ 2 systemic inflammatory response syndrome, and hypoperfusive organ dysfunction) identified by a quality initiative. The exposure was full 3-hour bundle compliance. Bundle elements are as follows: 1) blood cultures before antibiotics; 2) parenteral antibiotics administered less than or equal to 180 minutes from greater than or equal to two systemic inflammatory response syndrome "and" lactate ordered, or less than or equal to 60 minutes from "time-zero," whichever occurs earlier; 3) lactate result available less than or equal to 90 minutes postorder; and 4) 30 mL/kg IV crystalloid bolus initiated less than or equal to 30 minutes from "time-zero." Main outcomes were in-hospital mortality (all cohorts) and total direct costs (cohorts 2 and 3). MEASUREMENTS AND MAIN RESULTS: Cohort 1: 5,819 total patients; 1,050 (18.0%) bundle compliant. Mortality: 604 (22.6%) versus 834 (26.5%); CI, 0.9-7.1%; adjusted odds ratio, 0.72; CI, 0.61-0.86; p value is less than 0.001. Cohort 2: 1,697 total patients; 739 (43.5%) bundle compliant. Mortality: 99 (13.4%) versus 171 (17.8%), CI, 1.0-7.9%; adjusted odds ratio, 0.60; CI, 0.44-0.80; p value is equal to 0.001. Mean costs: $14,845 versus $20,056; CI, -$4,798 to -5,624; adjusted ß, -$2,851; CI, -$4,880 to -822; p value is equal to 0.006. Cohort 3: 7,239 total patients; 2,115 (29.2%) bundle compliant. Mortality: 383 (18.1%) versus 1,078 (21.0%); CI, 0.9-4.9%; adjusted odds ratio, 0.84; CI, 0.73-0.96; p value is equal to 0.013. Mean costs: $17,885 versus $22,108; CI, -$2,783 to -5,663; adjusted ß, -$1,423; CI, -$2,574 to -272; p value is equal to 0.015. CONCLUSIONS: In three independent cohorts, 3-hour bundle compliance was associated with improved survival and cost savings.
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Adhesión a Directriz , Paquetes de Atención al Paciente , Choque Séptico/mortalidad , Choque Séptico/terapia , Anciano , Anciano de 80 o más Años , Algoritmos , Ahorro de Costo , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Paquetes de Atención al Paciente/economía , Estudios Prospectivos , Choque Séptico/economía , Tasa de SupervivenciaRESUMEN
Achieving high vaccination rates of health care personnel (HCP) is critical in preventing influenza transmission from HCP to patients and from patients to HCP; however, acceptance rates remain low. In 2013, New York State adopted the flu mask regulation, requiring unvaccinated HCP to wear a mask when in areas where patients are present. The purpose of this study assessed the impact of the flu mask regulation on the HCP influenza vaccination rate. A 13-question survey was distributed electronically and manually to the HCP to examine their knowledge of influenza transmission and the influenza vaccine and their personal vaccine acceptance history and perception about the use of the mask while working if not vaccinated. There were 1,905 respondents; 87% accepted the influenza vaccine, and 63% were first-time recipients who agreed the regulation influenced their vaccination decision. Of the respondents who declined the vaccine, 72% acknowledge HCP are at risk for transmitting influenza to patients, and 56% reported they did not receive enough information to make an educated decision. The flu mask protocol may have influenced HCP's choice to be vaccinated versus wearing a mask. The study findings supported that HCP may not have adequate knowledge on the morbidity and mortality associated with influenza. Regulatory agencies need to consider an alternative approach to increase HCP vaccination, such as mandating the influenza vaccine for HCP.
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Actitud del Personal de Salud , Personal de Salud/estadística & datos numéricos , Vacunas contra la Influenza/administración & dosificación , Gripe Humana/prevención & control , Vacunación , Femenino , Humanos , Gripe Humana/virología , Masculino , Máscaras , New York , Encuestas y CuestionariosRESUMEN
BACKGROUND: As part of a zero-tolerance approach to preventable deaths, North Shore-LIJ Health System (North Shore-LIJ) leadership prioritized a major patient safety initiative to reduce sepsis mortality in 2009 across 10 acute care hospitals (an 11th joined later). At baseline (2008), approximately 3,500 patients were discharged with a diagnosis of sepsis, which ranked as the top All Patient Refined Diagnosis-Related Group by number of deaths (N = 883). Initially, the focus was sepsis recognition and treatment in the emergency departments (EDs). METHODS: North Shore-LIJ, the 14th largest health care system in the United States, cares for individuals at every stage of life at 19 acute care and specialty hospitals and more than 400 outpatient physician practice sites throughout New York City and the greater New York metropolitan area. The health system launched a strategic partnership with the Institute for Healthcare Improvement (IHI) in August 2011 to accelerate the pace of sepsis improvement. Throughout the course of the initiative, North Shore-LIJ collaborated with many local, state, national, and international organizations to test innovative ideas, share evidence-based best practices, and, more recently, to raise public awareness. RESULTS: North Shore-LIJ reduced overall sepsis mortality by approximately 50% in a six-year period (2008-2013; sustained through 2014) and increased compliance with sepsis resuscitation bundle elements in the EDs and inpatient units in the 11 acute care hospitals. CONCLUSION: Improvements were achieved by engaging leadership; fostering interprofessional collaboration, collaborating with other leading health care organizations; and developing meaningful, real-time metrics for all levels of staff.