Edgar Black

Relationship of pulmonary artery catheter use to mortality and resource utilization in patients with severe sepsis.

ObjectiveTo examine the relationship of pulmonary artery catheter (PAC) use to patient outcomes, including mortality rate and resource utilization, in patients with severe sepsis in eight academic medical centers. DesignCase-control, nested within a prospective cohort study. SettingEight academic tertiary care centers. PatientsStratified random sample of 1,010 adult admissions with severe sepsis. InterventionsNone. Measurements and Main ResultsThe main outcome measures were in-hospital mortality, total hospital charge, and length of stay (LOS) for patients with and without PAC use. The case-matched subset of patients included 141 pairs managed with and without the use of a PAC. The mortality rate was slightly but not statistically significantly lower among the PAC use group compared with those not using a PAC (41.1% vs. 46.8%, p = .34). Even this trend disappeared after we adjusted for the Charlson comorbidity score and sepsis-specific Acute Physiology and Chronic Health Evaluation (APACHE) III (adjusted odds ratio, 1.02; 95% confidence interval, 0.61–1.72). In linear regression models adjusted for the Charlson comorbidity score, sepsis-specific APACHE III, surgical status, receipt of a steroid before sepsis onset, presence of a Hickman catheter, and preonset LOS, no significant differences were found for total hospital charges (US

Limulus Amebocyte Lysate Assay for Detection of Endotoxin in Patients with Sepsis Syndrome

139,207 vs. 148,190, adjusted mean comparing PAC and non-PAC group, p = .57), postonset LOS (23.4 vs. 26.9 days, adjusted mean, p = .32), or total LOS in intensive care unit (18.2 vs. 18.8 days, adjusted mean, p = .82). ConclusionsAmong patients with severe sepsis, PAC placement was not associated with a change in mortality rate or resource utilization, although small nonsignificant trends toward lower resource utilization were present in the PAC group.

Resource utilization among patients with sepsis syndrome

Clinical predictions alone are insufficiently accurate to identify patients with specific types of bloodstream infection; laboratory assays might improve such predictions. Therefore, we performed a prospective cohort study of 356 episodes of sepsis syndrome and did Limulus amebocyte lysate (LAL) assays for endotoxin. The main outcome measures were bacteremia and infection due to gram-negative organisms; other types of infection were secondary outcomes. Assays were defined as positive if the result was > or = 0.4 enzyme-linked immunosorbent assay units per milliliter. There were positive assays in 119 (33%) of 356 episodes. Assay positivity correlated with the presence of fungal bloodstream infection (P < .003) but correlated negatively with the presence of gram-negative organisms in the bloodstream (P = .04). A trend toward higher rates of mortality in the LAL assay-positive episodes was no longer present after adjusting for severity. Thus, results of LAL assay did not correlate with the presence of bacteremia due to gram-negative organisms or with mortality after adjusting for severity but did correlate with the presence of fungal bloodstream infection.

Quality of care during a community-wide experiment in prospective payment to hospitals.

OBJECTIVE To assess the resource utilization associated with sepsis syndrome in academic medical centers. DESIGN Prospective cohort study. SETTING Eight academic, tertiary-care centers. PATIENTS Stratified random sample of 1,028 adult admissions with sepsis syndrome and all 248,761 other adult admissions between January 1993 and April 1994. The main outcome measures were length of stay (LOS) in total and after onset of sepsis syndrome (post-onset LOS) and total hospital charges. RESULTS The mean LOS for patients with sepsis was 27.7 +/- 0.9 days (median, 20 days), with sepsis onset occurring after a mean of 8.1 +/- 0.4 days (median, 3 days). For all patients without sepsis, the LOS was 7.2 +/- 0.03 days (median, 4 days). In multiple linear regression models, the mean for patients with sepsis syndrome was 18.2 days, which was 11.0 days longer than the mean for all other patients (P < .0001), whereas the mean difference in total charges was

Pseudoephedrine did not increase blood pressure in hypertension

43,000 (both P < .0001). These differences were greater for patients with nosocomial as compared with community-acquired sepsis, although the groups were similar after adjusting for pre-onset LOS. Eight independent correlates of increased post-onset LOS and 12 correlates of total charges were identified. CONCLUSIONS These data quantify the resource utilization associated with sepsis syndrome, and demonstrate that resource utilization is high in this group. Additional investigation is required to determine how much of the excess post-onset LOS and charges are attributable to sepsis syndrome rather than the underlying medical conditions.

Epidemiology of Sepsis Syndrome in 8 Academic Medical Centers

To determine whether a community-wide experiment in hospital prospective payment adversely affected quality of care, availability and outcomes of care were studied in Rochester, NY from 1980 to 1984. During this 5-year period, prospective payment contained hospital expenditures in a community that was already below the national average in health-care costs. Access to necessary care was maintained, and there were increased admissions for management of maternal illness and acute myocardial infarction. Rates of inpatient elective surgery declined. Outcomes of care remained stable, including neonatal deaths, ischemic heart disease deaths, deaths from five selected surgical conditions, and rates of adverse outcomes from sentinel medical and surgical conditions. These results indicated that prospective payment programs in which incentives to decrease marginal or unneeded care are linked with a community-wide effort to plan for the delivery of services can be financially and clinically successful.

Predictive value of dobutamine echocardiography just before noncardiac vascular surgery

Source Citation Coates ML, Rembold CM, Farr BM. Does pseudoephedrine increase blood pressure in patients with controlled hypertension? J Fam Pract. 1995 Jan; 40:22-6.