Colleen Karvetski

Urinary obstruction is an important complicating factor in patients with septic shock due to urinary infection

OBJECTIVE Urinary tract infection (UTI) is a common cause of severe sepsis, and anatomic urologic obstruction is a recognized factor for complicated disease. We aimed to identify the incidence of urinary obstruction complicating acute septic shock and determine the characteristics and outcomes of this group. METHODS Patients prospectively enrolled in a sepsis treatment pathway registry between October 2013 and July 2014 were reviewed for the diagnosis of UTI. Standardized medical record review was performed to confirm sepsis due to UTI and determine clinical variables including the presence of anatomic urinary obstruction. Patients with septic shock due to UTI with obstruction were compared with those without obstruction. The primary outcomes were incidence of urinary obstruction and hospital mortality. RESULTS Among 1084 registry enrollees, 209 (19.2%) met inclusion criteria for the study. Acute anatomic obstruction was identified in 22 (10.5%) patients. Hospital mortality in patients with obstruction was 27.3% compared with 11.2% in patients without obstruction (absolute difference of 16.1%; P = .03; 95% confidence interval [CI], 1.2%-30.9%). Hospital length of stay among survivors was 12.8 days compared with 8.3 days (absolute difference of 4.5 days; P = .04; 95% CI, 0.2-8.8 days). History of urinary stone disease was independently associated with obstruction (odds ratio, 5.6; 95% CI, 2.2-14.3). CONCLUSIONS Approximately 1 in 10 patients presenting with septic shock due to a urinary source is complicated by anatomic urinary obstruction. These patients have significantly higher mortality compared with patients without obstruction. Early imaging of patients with septic shock due to suspected urinary source should be considered to identify obstruction requiring emergency intervention.

1493: INITIAL FLUID BY ADJUSTED BODY WEIGHT LINKED TO LOWER MORTALITY IN OBESE PATIENTS WITH SEPTIC SHOCK

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Sepsis Associated Macrophage Activation Syndrome (S-MAS) occurs in children, but little is known about S-MAS in adults. We conducted a systematic review to investigate rates, mortality, pattern of organ compromise and treatment strategies for adult S-MAS. Methods: We reviewed EMBASE, Cochrane and MEDLINE 20012017, using medical subject heading terms and text words with Boolean logic. We included observational and interventional studies in adult (> 18 y) patients with sepsis/infection and MAS, or hemophagocytic lymphohystiocytosis (S-HLH). We excluded studies enrolling patients with rheumatological disorders, family history of HLH or malignancy. Results: We found 3,692 articles and excluded 3,663 for duplications, not reporting outcomes, and including patients with rheumatologic conditions, malignancies or < 18 years. We selected 29 articles, including 1,272 patients -10 case reports, 1 case series, 17 cohort studies, and 1 post-hoc analysis of a randomized trial (ph-RCT) on IL-1R antagonist (IL-1Ra) for treatment of sepsis. Only the ph-RCT reported on the rate of S-MAS (6.1%). Mortality was reported in 12 studies, ranging from 50% in case reports to 60% in the ph-RCT. Six studies reported on organ dysfunction, most often citing hepatobiliary and renal compromise. All 29 studies reported treatment. Eight studies of S-MAS reported treatment with pulse methylprednisolone+etoposide, IL-1Ra, cyclosporine, intravenous immunoglobulin (IVIG)+fresh frozen plasma, IVIG+prednisolone. A case series described 3 patients treated with IL-1Ra and IVIG +/steroids, with 50% survival. The ph-RCT reported mortality reduction from 60 to 29.7% with Anti-IL-1Ra. Nineteen studies on S-HLH reported as most common treatments steroids +/etoposide, etoposide, cyclosporine, IVIG, plasmapheresis, stem cell transplant and Alemtuzumab. Conclusions: There is very little evidence on the frequency, outcome, and potential therapeutic interventions in adult S-MAS. Although the incidence is low, mortality is very high. Treatment strategies varied, however, the best evidence suggested a promising therapeutic role for IL-1Ra.

1477: DELAYS FROM FIRST TO SECOND ANTIBIOTIC ADMINISTRATION IN EMERGENCY DEPARTMENT PATIENTS WITH SEPSIS

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Robust evidence links timely administration of antibiotics to good outcomes in patients with sepsis. Current guidelines recommend an ambitious goal of antibiotic administration within 1 hour from “time zero”. Little is known about the timing of key processes from Emergency Department (ED) arrival to antibiotic administration for patients with sepsis. Methods: We studied patients presenting to the ED with sepsis (defined as suspected infection and organ dysfunction) at two hospitals with mature sepsis treatment pathways including order sets with preselected antibiotic regimens. We conceptualized the total time from ED arrival to antibiotic administration into 3 intervals. Interval 1: time from arrival to the time a physician opens the patient’s medical record (door to doctor time), Interval 2: time from chart open to entering the antibiotic order (doctor to decision time) and Interval 3: time from order entry to administration of the antibiotic (decision to drug time). We retrospectively abstracted these times from medical records. Because we were specifically interested in how antibiotic allergies might affect delays, we recorded whether patients had allergy to any of the preselected antibiotics. Results: Of 155 patients presenting to the ED with sepsis, 18.7% (28) died during hospitalization. Overall, a mean time of 119.08 minutes (SD 88.8) elapsed between ED arrival and antibiotic administration. The mean time between ED arrival and chart opening by a physician was 16.9 minutes (SD 29.8), the mean time required for physicians to enter an antibiotic order was 68.2 minutes (SD 60.5), followed by another mean time of 40.2 minutes (SD 38.2) to begin drug infusion. Patients with allergy to the preselected antibiotics experienced a longer delay from antibiotic order to administration (36.3 vs 50.1 min, p = 0.09) and longer total delay from chart open to administration (101.6 vs 125.2 min, p = 0.16), but similar time from chart open to placement of antibiotic order (65.3 vs 75.7 min, p = 0.43). Conclusions: In order to reduce ED delays in antibiotic administration for patients with sepsis, we examined the critical phases between arrival and treatment. We report average times for 3 intervals, showing that the time from physician chart open to antibiotic order (doctor to decision time) represents the longest interval of delay. Although not statistically significant, allergy to order set antibiotics was associated with longer time from order to administration (decision to drug time).

1476: INTERVALS OF DELAY IN ANTIBIOTIC ADMINISTRATION FOR EMERGENCY DEPARTMENT PATIENTS WITH SEPSIS

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Robust evidence links timely administration of antibiotics to good outcomes in patients with sepsis. Current guidelines recommend an ambitious goal of antibiotic administration within 1 hour from “time zero”. Little is known about the timing of key processes from Emergency Department (ED) arrival to antibiotic administration for patients with sepsis. Methods: We studied patients presenting to the ED with sepsis (defined as suspected infection and organ dysfunction) at two hospitals with mature sepsis treatment pathways including order sets with preselected antibiotic regimens. We conceptualized the total time from ED arrival to antibiotic administration into 3 intervals. Interval 1: time from arrival to the time a physician opens the patient’s medical record (door to doctor time), Interval 2: time from chart open to entering the antibiotic order (doctor to decision time) and Interval 3: time from order entry to administration of the antibiotic (decision to drug time). We retrospectively abstracted these times from medical records. Because we were specifically interested in how antibiotic allergies might affect delays, we recorded whether patients had allergy to any of the preselected antibiotics. Results: Of 155 patients presenting to the ED with sepsis, 18.7% (28) died during hospitalization. Overall, a mean time of 119.08 minutes (SD 88.8) elapsed between ED arrival and antibiotic administration. The mean time between ED arrival and chart opening by a physician was 16.9 minutes (SD 29.8), the mean time required for physicians to enter an antibiotic order was 68.2 minutes (SD 60.5), followed by another mean time of 40.2 minutes (SD 38.2) to begin drug infusion. Patients with allergy to the preselected antibiotics experienced a longer delay from antibiotic order to administration (36.3 vs 50.1 min, p = 0.09) and longer total delay from chart open to administration (101.6 vs 125.2 min, p = 0.16), but similar time from chart open to placement of antibiotic order (65.3 vs 75.7 min, p = 0.43). Conclusions: In order to reduce ED delays in antibiotic administration for patients with sepsis, we examined the critical phases between arrival and treatment. We report average times for 3 intervals, showing that the time from physician chart open to antibiotic order (doctor to decision time) represents the longest interval of delay. Although not statistically significant, allergy to order set antibiotics was associated with longer time from order to administration (decision to drug time).

1274: IMPACT OF MULTIPROFESSIONAL ROUNDS ON OUTCOMES IN A SURGICAL INTENSIVE CARE UNIT

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Multi-professional rounds (MPR) represent a mechanism for the coordination of care in critical ill patients. Herein, we examined the impact of MPR implementation in our surgical ICU (ICU) on ventilator days (Vent-day) and ICU length of stay (LOS). Methods: A multi-professional team developed guidelines, including an organ system-based daily goal checklist, and MPR began in February 2016. Patients admitted from November 2015 to January 2017 with ICU LOS greater than 5 hours were included. Severity of illness was determined using APACHE IVa scores. Outcome data, consisting of Vent-day and ICU LOS, were captured via electronic medical record. Linear regression models were constructed to observe the impact of MPR, by month after implementation, on ICU outcomes. Data are reported as mean and observed/ expected ratios (O/E), calculated by a risk-stratified proprietary methodology. Results: There were a total of 1,892 patients, with a mean APACHE IVa score of 61.3. For patients on mechanical ventilation, MPR led to a reduction in Vent-day, from 3.7 to 2.6 days; and the O/E ratio decreased from 0.93 to 0.78. The mean ICU LOS decreased from 3.5 to 2.9 days, with O/E ratio decreased from 0.64 to 0.50. Conclusions: Implementation of MPR in our surgical ICU, with an organ system-based daily goal checklist, was associated with a reduction in use of ICU resources.

1506: RACIAL DIFFERENCES IN PREDICTORS OF TIMELY ANTIBIOTICS AND MORTALITY IN SUSPECTED SEPTIC SHOCK

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Most research demonstrates that black patients suffer nearly double the incidence of severe sepsis than do white patients, although this is not a universal finding. The disparity in sepsis outcomes persists even after controlling for source of infection and underlying chronic illnesses. The mechanism for this racial disparity is unclear. We previously showed that black patients are less likely to receive timely antibiotics compared to white patients. We examined predictors associated with timely antibiotics and mortality in separate models of black and white patients Methods: We analyzed patients from 9 regional hospitals within Carolinas Healthcare System who presented to the Emergency Department with suspected septic shock based on activation of “code sepsis” treatment pathway. We created separate logistic regression models for black and white patients to identify predictors of antibiotic compliance and mortality. Results: Of the 2,928 patients, 2221 (75.8%) were white and 707 (24.1%) were black. White patients were older than black patients but had a lower burden of comorbid conditions. Health insurance payor mix was significantly different between white and black patients, with higher rates of Medicaid in the black subject group and higher rates of Medicare in white patients. On ED presentation, black patients had higher serum lactate but no statistical difference in shock index compared to white patients. In the adjusted analysis for receipt of antibiotics within 1 hour of triage, higher shock index was associated with greater rate of antibiotic timeliness in black patients whereas higher temperature was the physiologic parameter associated with increased antibiotic timeliness in white patients. In the adjusted model for mortality male sex was significantly associated with mortality for black but not white patients. Conclusions: There may be race-specific factors associated with both antibiotic compliance and mortality in suspected septic shock. Clinicians may be responsive to different signals suggesting infection in black versus white patients.

Inferring Direct Effects of ICU Telemedicine on Cost-Effectiveness

To the Editor: Lilly et al presented financial outcomes associated with the implementation of ICU telemedicine capabilities in a three-phase before and after study design published in the February 2017 issue of CHEST. They demonstrate a compelling increase in direct contribution margin due to increased case volume, higher relative case revenue, and decreased length of stay. At Carolinas HealthCare System, we also have a robust tele-ICU program that is associated with overall positive outcomes in multiple clinical and cost domains. Knowing the complexities of acquiring precise financial performance data in this realm, we applaud the authors’ ability to obtain and analyze such granular detail, which serves to advance our understanding of the value of teleICU.