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CRITICAL CARE: Incidence of sepsis cases 2009 to 2014

Sepsis is a complication of an infection, for example pneumonia, that can lead to death.  Older people are at higher risk of developing sepsis.  This study, based on data from 409 hospitals, had a dual purpose – to determine the incidence rate of sepsis among hospital inpatients and to compare two different data sources.

In 2014, the incidence of sepsis was found to be 6 percent of adult hospitalizations.  Of patients with sepsis, 15 percent died in the hospital with an additional 6 percent discharged to hospice.

Analysis of these incidence and mortality data over time (2009 to 2014) shows that the incidence rate and overall mortality rate (including inhospital and discharge to hospice) have remained about the same.  This finding, based on a study of hospitals’ electronic medical records, differs from other estimates based on claims data.

Sources:

Mayo Clinic Staff. Sepsis.  Click here: http://www.mayoclinic.org/diseases-conditions/sepsis/symptoms-causes/syc-20351214

Rhee, C., Dantes, R., and Epstein, L. (2017, October 3). Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009-2014. JAMA, 318(13), 1241-1249.  Click here for publisher’s website: https://jamanetwork.com/journals/jama/article-abstract/2654187?widget=personalizedcontent&previousarticle=2654186  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

ICUs: How do high-performing hospitals reduce CLABSI rates?

This is a study out of Johns Hopkins of 17 intensive care units at 7 hospitals – comparing practices related to reducing the central line-associated bloodstream infection (CLABSI) rate.  High performers were defined as those with less than 1 infection per 1000 catheter-days over the period of at least one year.  Low performers were defined as having over 3 infections per 1000 catheter-days.

I particularly like the tables and the appendices to this article.  The tables identify characteristics of high-performers in bullet-point brevity for each of the following levels of hospital employees: senior leadership, ICU managers, infection prevention and quality improvement staff, and frontline staff.  The appendices contain specific questions that make up a CLABSI Conversation – again differentiated between senior management, infection control / quality improvement staff, and ICU staff.

Source: Pham, J.C., and others. (2016, Apr.-June). CLABSI Conversations: Lessons from peer-to-peer assessments to reduce central line-associated bloodstream infections. Quality Management in Health Care, 25(2), 67-78.  Click here for publisher’s website:  http://journals.lww.com/qmhcjournal/pages/articleviewer.aspx?year=2016&issue=04000&article=00001&type=abstract  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

ICU: Wearing gowns and gloves for all ICU patients studied

Caregivers entering patient rooms in intensive care units typically use contact precautions – putting on gowns and gloves – when the patient is known to have antibiotic-resistant bacteria.  This study was a randomized trial of universal gown and glove use for adult patients in intensive care units in 2012.  Data on 1800 patients at different hospitals were studied.  The authors comment that:

  • “The observation that universal glove and gown use may result in fewer adverse events was unanticipated.  Universal glove and gown use could potentially have led to a decrease in HAIs [healthcare-associated infections] by serving as a barrier to acquiring new bacteria both through physical use of gloves and gowns as well as fewer HCW [health care worker] visits and better hand hygiene.”

Source: Croft, L.D., Harris, A.D., Pineles, L., and others. (2015, Aug. 15). The effect of universal glove and gown use on adverse events in intensive care unit patients. Clinical Infectious Diseases, 61(4), 545-553.  Click here for full text: cid.oxfordjournals.org/content/61/4/545.full.pdf  Posted by AHA Resource Center (312) 422-2003, rc@aha.org

 

ICUs: Where do patients come from? Data on source of admissions from large-scale Project IMPACT database

Cerner’s Project IMPACT (Improved Methods of Patient Information Access of Core Clinical Tasks) is – or perhaps was – a database to which many different hospitals submitted information about their intensive care unit (ICU) patients.  Although I have not yet been able to confirm this, it appears that the IMPACT database may no longer be in existence, or perhaps not being added to any more.  Researchers have studied this database and published a number of articles in the medical literature based on it.  Let’s take a look at some interesting data from one such article, based on over 250,000 adult (aged 18 or older) ICU patients who were hospitalized in 138 ICUs during the period 2001-2008.

Notes: All of the following statistics are given in the original source to one decimal place – I’ve rounded them off in this blog post.  The following statistics are based on patients who were admitted for the first time to the ICU during a hospitalization.

Where did they come from?  Source of adult ICU admissions:

  • 42 percent from the emergency department
  • 32 percent from the surgical suite
  • 16 percent from general care floor or step-down unit
  •  8 percent from another hospital
  •  3 percent from another location

What kind of adult patient is admitted to ICU?

  • 66 percent medical
  • 22 percent scheduled surgical
  • 12 percent unscheduled surgical

Is the ICU a closed model or an open model?

  • 75 percent open model with optional or no intensivist consult
  • 20 percent open model with mandatory intensivist consult
  •   4 percent closed model

Payer mix for adult ICU patients

  • 50 percent Medicare
  • 30 percent private insurance
  •  9 percent self pay
  •  9 percent Medicaid
  •  3 percent other

Source: Brown, S.E., Ratcliffe, S.J., and others. (2014, Aug.) An empirical comparison of key statistical attributes among potential ICU quality indicators. Critical Care Medicine, 42(8), 1821-1831. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4212919/pdf/nihms635834.pdf   Posted by AHA Resource Center (312) 422-2050, rc@aha.org  Note: The link takes you to a free full text “author manuscript,” which is what I used to provide the data noted above.  It was later published in the journal Critical Care Medicine, as noted in the citation.

No short-term harm from quicker ICU discharge

The effect on patients when ICUs are busy and nearing capacity was studied in this large-scale analysis of over 200,000 adults discharged from 155 ICUs to hospital  floors between 2001 and 2008.  When ICUs became strained, physicians were more likely to discharge patients to the floors more quickly–with shorter ICU length of stay.  This resulted in a very small likelihood that these patients would be readmitted to ICU.  However, overall, there was little adverse effect observed on patients in the short term.  Longer term outcomes were not assessed in this study.

Source: Wagner, J., Gabler, N.B., and others.  Outcomes among patients discharged from busy intensive care units.  Annals of Internal Medicine;159(7):447-455, Oct. 1, 2013.  Click here for access to article (for purchase): http://annals.org/article.aspx?articleid=1742592  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

ICUs: Are we making the best use of critical care?

Critical care costs the nation about $80 billion per year.  Observers predict a coming shortage of intensive care unit beds and of intensivists.  In this commentary, the authors draw upon the findings of their study of over 100,000 non-surgical patients admitted to 121 Veterans Affairs (VA) hospitals in FY2009.  They found, not surprisingly, that sicker patients tended to be admitted to ICUs.  But this held true for noncardiac patients; for cardiac patients, severity of illness was not strongly related to CCU admission decisions.   The authors conclude that there are factors other than severity of illness that also guide the use of critical care — such as peace of mind, staffing issues, bed availability.  The VA has developed an ICU severity score, which has proved to be a reliable predictor of a patient’s risk of death within 30 days of admission.  Routine incorporation of this tool at patient admission to the hospital is suggested as a way to help plan the overall care process and address the appropriate use of ICU resources.

Source: Chen, L.M., and others.  Use of health IT for higher-value critical care.  The New England Journal of Medicine;368(7):594-597, Feb. 14, 2013.  Click here for full text: http://www.nejm.org/doi/pdf/10.1056/NEJMp1213273  Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

INTENSIVE CARE: About 14% of adult inpatients

How many patients receive intensive care?  In this study of 2006 data for 90 hospitals with critical care admissions in Maryland and the State of Washington, 14 percent of patients over age 18 received intensive care and 86 percent did not.  These findings were based on an analysis of just over 1 million admissions.  The use of intensive care was found to vary widely between hospitals.

Source: Seymour, C.W., and others.  Hospital-level variation in the use of intensive care.  HSR. Health Services Research;47(5):2060-2080, Oct. 2012.  Click here for the publisher’s website: http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2012.01402.x/abstract Posted by AHA Resource Center, (312) 422-2050, rc@aha.org