Andrew Odden

Identifying patients with severe sepsis using administrative claims: Patient-level validation of the angus implementation of the international consensus conference definition of severe sepsis

Background:Severe sepsis is a common and costly problem. Although consistently defined clinically by consensus conference since 1991, there have been several different implementations of the severe sepsis definition using ICD-9-CM codes for research. We conducted a single center, patient-level validation of 1 common implementation of the severe sepsis definition, the so-called “Angus” implementation. Methods:Administrative claims for all hospitalizations for patients initially admitted to general medical services from an academic medical center in 2009–2010 were reviewed. On the basis of ICD-9-CM codes, hospitalizations were sampled for review by 3 internal medicine-trained hospitalists. Chart reviews were conducted with a structured instrument, and the gold standard was the hospitalists’ summary clinical judgment on whether the patient had severe sepsis. Results:Three thousand one hundred forty-six (13.5%) hospitalizations met ICD-9-CM criteria for severe sepsis by the Angus implementation (Angus-positive) and 20,142 (86.5%) were Angus-negative. Chart reviews were performed for 92 randomly selected Angus-positive and 19 randomly-selected Angus-negative hospitalizations. Reviewers had a &kgr; of 0.70. The Angus implementation’s positive predictive value was 70.7% [95% confidence interval (CI): 51.2%, 90.5%]. The negative predictive value was 91.5% (95% CI: 79.0%, 100%). The sensitivity was 50.4% (95% CI: 14.8%, 85.7%). Specificity was 96.3% (95% CI: 92.4%, 100%). Two alternative ICD-9-CM implementations had high positive predictive values but sensitivities of <20%. Conclusions:The Angus implementation of the international consensus conference definition of severe sepsis offers a reasonable but imperfect approach to identifying patients with severe sepsis when compared with a gold standard of structured review of the medical chart by trained hospitalists.

The epidemiology of acute organ system dysfunction from severe sepsis outside of the intensive care unit.

BACKGROUND Severe sepsis is a common, costly, and complex problem, the epidemiology of which has only been well studied in the intensive care unit (ICU). However, nearly half of all patients with severe sepsis are cared for outside the ICU. OBJECTIVE To determine rates of infection and organ system dysfunction in patients with severe sepsis admitted to non-ICU services. DESIGN Retrospective cohort study. SETTING A large, tertiary, academic medical center in the United States. PATIENTS Adult patients initially admitted to non-ICU medical services from 2009 through 2010. MEASUREMENTS All International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes were screened for severe sepsis. Three hospitalists reviewed a sample of medical records evaluating the characteristics of severe sepsis. RESULTS Of 23,288 hospitalizations, 14% screened positive for severe sepsis. A sample of 111 cases was manually reviewed, identifying 64 cases of severe sepsis. The mean age of patients with severe sepsis was 63 years, and 39% were immunosuppressed prior to presentation. The most common site of infection was the urinary tract (41%). The most common organ system dysfunctions were cardiovascular (hypotension) and renal dysfunction occurring in 66% and 64% of patients, respectively. An increase in the number of organ systems affected was associated with an increase in mortality and eventual ICU utilization. Severe sepsis was documented by the treating clinicians in 47% of cases. CONCLUSIONS Severe sepsis was commonly found and poorly documented on the wards at our medical center. The epidemiology and organ dysfunctions among patients with severe sepsis appear to be different from previously described ICU severe sepsis populations.

The Epidemiology of Acute Organ System Dysfunction from Severe Sepsis Outside of the ICU

BACKGROUND Severe sepsis is a common, costly, and complex problem, the epidemiology of which has only been well studied in the intensive care unit (ICU). However, nearly half of all patients with severe sepsis are cared for outside the ICU. OBJECTIVE To determine rates of infection and organ system dysfunction in patients with severe sepsis admitted to non-ICU services. DESIGN Retrospective cohort study. SETTING A large, tertiary, academic medical center in the United States. PATIENTS Adult patients initially admitted to non-ICU medical services from 2009 through 2010. MEASUREMENTS All International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes were screened for severe sepsis. Three hospitalists reviewed a sample of medical records evaluating the characteristics of severe sepsis. RESULTS Of 23,288 hospitalizations, 14% screened positive for severe sepsis. A sample of 111 cases was manually reviewed, identifying 64 cases of severe sepsis. The mean age of patients with severe sepsis was 63 years, and 39% were immunosuppressed prior to presentation. The most common site of infection was the urinary tract (41%). The most common organ system dysfunctions were cardiovascular (hypotension) and renal dysfunction occurring in 66% and 64% of patients, respectively. An increase in the number of organ systems affected was associated with an increase in mortality and eventual ICU utilization. Severe sepsis was documented by the treating clinicians in 47% of cases. CONCLUSIONS Severe sepsis was commonly found and poorly documented on the wards at our medical center. The epidemiology and organ dysfunctions among patients with severe sepsis appear to be different from previously described ICU severe sepsis populations.

Implementation of a multicenter performance improvement program for early detection and treatment of severe sepsis in general medical-surgical wards.

Sepsis is a leading cause of in-hospital death, and evidence suggests a higher mortality in patients presenting with sepsis on the ward compared to those presenting to the emergency department. Ward patients who develop severe sepsis may have poor outcomes for a variety of reasons, including delayed diagnosis, lack of readily available staffing, and delayed treatment. We report on a multihospital quality improvement program for early detection and treatment of sepsis on general medical-surgical wards. We describe a multipronged approach to improve severe sepsis outcomes using the Institute for Healthcare Improvements Plan-Do-Study-Act model. Sixty sites engaged in a collaborative implementation process that aligned people, process, and technology. Based on our experience, we recommend a stepwise approach to implement such a program: (1) both administrative and clinical leadership commit to a common goal; (2) appoint clinical champions and give them authority to engage other clinicians to improve timeliness of interventions; (3) map workflows and processes to rely heavily on the nursing staffs ability to evaluate and report severe sepsis screening results; (4) if available, design and deploy technology with the assistance of clinical informaticians (eg, to enable electronic health records-based continuous screening); (5) to determine success, consider tracking screening compliance and process, and outcome measures such as length of stay and mortality. Journal of Hospital Medicine 2016;S11:32-S39.

Sepsis after Scotland: enough with the averages, show us the effect modifiers

Cuthbertson and colleagues demonstrate that survivors of severe sepsis face, in general continued ongoing high mortality and quite poor quality of life. This cohort caps the initial, problem-definition stage on long-term outcomes after critical illness. Having compellingly demonstrated the opportunities for improvements in outcomes, epidemiologic and behavioral research must now to turn to understanding the mechanisms by which these outcomes can be improved. Such fundamental research will provide the evidence base to drive informed and successful interventional trials.

In Sight and Out of Mind

A 21-year-old man presented to the emergency department with fever and rash. His fever had started about 1 week before presentation and was associated with chills, myalgia, nausea, and vomiting. He also had a headache without photophobia.

Caught red‐handed

Valerie M. Vaughn, MD*, Sean J. Callahan, MD, James Pile, MD, Powel Kazanjian, MD, Andrew Odden, MD Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; The Patient Safety Enhancement Program, University of Michigan and VA Ann Arbor Health System, Ann Arbor, Michigan; Department of Internal Medicine, University of Virginia Health System, Charlottesville, Virginia; Medicine Institute, Cleveland Clinic, Cleveland, Ohio; Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.

Bigger than his bite

A 58-year-old male presented to a local community hospital emergency department with fever and altered mental status. Earlier in the day he had complained of chills, swollen tongue, numbness and tingling in his extremities with associated burning pain, and generalized weakness. En route to the emergency department, he was extremely agitated and moving uncontrollably. On arrival, he was noted to be in respiratory distress and was intubated for hypoxic respiratory failure. He was subsequently transferred to an academic medical center, and in transit was noted to have sustained supraventricular tachycardia with a heart rate of 160 beats per minute.

Emergent Transcutaneous Embolization in an Advanced Carcinosarcoma

Active hemorrhage is a life-threatening complication of advanced tumors. It often signifies the terminal stage of the disease and therefore is usually treated with palliative care. Transcutaneous arterial embolization (TAE) is a safe, noninvasive procedure that halts acute tumor-related bleeding thereby providing effective life-saving treatment for patients with non-operable tumors. Carcinosarcoma is an uncommon tumor that generally affects the head and neck, respiratory tract, colon, uterus, ovaries, and fallopian tubes. The authors present an interesting case of a rare manifestation in an unusual location. A 60-year-old Caucasian male, who presented with abdominal and groin pain, was found to have a large carcinosarcoma in the retroperitoneal space. The tumor was complicated with an active bleed. Since he was not a candidate for surgical intervention, a TAE was performed. Two days later, the patient was discharged to hospice where he was able to live out the rest of his life.

Chronic Obstructive Pulmonary Disease: Inpatient Management

This article outlines the management of patients with acute exacerbations of chronic obstructive pulmonary disease (COPD), which are common in the course of chronic COPD and are associated with substantial morbidity. There are numerous guidelines, but literature suggests that there is substantial variation in care in patients with acute exacerbations of COPD. Key components of acute therapy for most patients include oral steroids, antibiotics, nebulizers, oxygen, and early consideration of noninvasive ventilation. Adjuvant components of care include venous thromboembolism prophylaxis, appropriate immunizations, counseling for smoking cessation, and consideration of pulmonary rehabilitation.