Jim E. Banta

Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality

Objective:The purpose of this study was to examine the outcome implications of implementing a severe sepsis bundle in an emergency department as a quality indicator set with feedback to modify physician behavior related to the early management of severe sepsis and septic shock. Design:Two-year prospective observational cohort. Setting:Academic tertiary care facility. Patients:Patients were 330 patients presenting to the emergency department who met criteria for severe sepsis or septic shock. Interventions:Five quality indicators comprised the bundle for severe sepsis management in the emergency department: a) initiate central venous pressure (CVP)/central venous oxygen saturation (Scvo2) monitoring within 2 hrs; b) give broad-spectrum antibiotics within 4 hrs; c) complete early goal-directed therapy at 6 hrs; d) give corticosteroid if the patient is on vasopressor or if adrenal insufficiency is suspected; and e) monitor for lactate clearance. Measurements and Main Results:Patients had a mean age of 63.8 ± 18.5 yrs, Acute Physiology and Chronic Health Evaluation II score 29.6 ± 10.6, emergency department length of stay 8.5 ± 4.4 hrs, hospital length of stay 11.3 ± 12.9 days, and in-hospital mortality 35.2%. Bundle compliance increased from zero to 51.2% at the end of the study period. During the emergency department stay, patients with the bundle completed received more CVP/Scvo2 monitoring (100.0 vs. 64.8%, p < .01), more antibiotics (100.0 vs. 89.7%, p = .04), and more corticosteroid (29.9 vs. 16.2%, p = .01) compared with patients with the bundle not completed. In a multivariate regression analysis including the five quality indicators, completion of early goal-directed therapy was significantly associated with decreased mortality (odds ratio, 0.36; 95% confidence interval, 0.17–0.79; p = .01). In-hospital mortality was less in patients with the bundle completed compared with patients with the bundle not completed (20.8 vs. 39.5%, p < .01). Conclusions:Implementation of a severe sepsis bundle using a quality improvement feedback to modify physician behavior in the emergency department setting was feasible and was associated with decreased in-hospital mortality.

Mortality predictions using current physiologic scoring systems in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle.

Physiologic scoring systems are often used to prognosticate mortality in critically ill patients. This study examined the performance of Acute Physiology and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score (SAPS) II, Mortality in Emergency Department Sepsis (MEDS), and Mortality Probability Models (MPM) II0 in predicting in-hospital mortality of patients in the emergency department meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. The discrimination and calibration characteristics of APACHE II, SAPS II, MEDS, and MPM II0 were evaluated. Data are presented as median and quartiles (25th, 75th). Two-hundred forty-six patients aged 68 (52, 81) years were analyzed from a prospectively maintained sepsis registry, with 76.0% of patients in septic shock, 45.5% blood culture positive, and 35.0% in-hospital mortality. Acute Physiology and Chronic Health Evaluation II, SAPS II, and MEDS scores were 29 (21, 37), 54 (40, 70), and 13 (11, 16), with predicted mortalities of 64% (40%, 85%), 58% (25%, 84%), and 16% (9%, 39%), respectively. Mortality Probability Models II0 showed a predicted mortality of 60% (27%, 80%). The area under the receiver operating characteristic curves was 0.73 for APACHE II, 0.71 for SAPS II, 0.60 for MEDS, and 0.72 for MPM II0. The standardized mortality ratios were 0.59, 0.63, 1.68, and 0.64, respectively. Thus, APACHE II, SAPS II, MEDS, and MPM II0 have variable abilities to discriminate early and estimate in-hospital mortality of patients presenting to the emergency department requiring the severe sepsis resuscitation bundle. Adoption of these prognostication tools in this setting may influence therapy and resource use for these patients.

Patient and hospital characteristics associated with inpatient severe sepsis mortality in California, 2005-2010.

Objectives:The primary objective of this study was to identify which patient demographic, patient health, and hospital characteristics were associated with in-hospital mortality. A secondary objective was to determine the relative influence of these characteristics on mortality. Design and Setting:Public-use data for 2005–2010 were used in this retrospective, cross-sectional analysis of discharges from nonfederal, general acute hospitals in California. A staged logistic regression approach was used to examine the relative influence of variables associated with in-hospital mortality. Patients:A total of 1,213,219 patient discharges for adults (aged ≥18 yrs) having International Classification of Diseases-9 diagnosis and procedure codes indicating severe sepsis. Intervention:None. Measurements and Main Results:Patient demographics (age, gender, race, ethnicity, and payer category), patient health status (acute transfer, Charlson-Deyo comorbidity index, and organ failures), and hospital characteristics (ownership type, teaching status, bed size, annual patient days, acute discharges, emergency department visits, inpatient surgeries, severe sepsis as a percentage of all discharges, and year) were obtained from the California Office of Statewide Health Planning and Development. Overall, in-hospital mortality was 17.8%. There was a steady annual increase in the number of sepsis discharges, but a decrease in mortality throughout the study period. Mortality increased with age and was associated with white race, and Medicaid (Medi-Cal) and private insurance. Patient health status additionally explained inpatient mortality. Hospital volume measures were statistically significant in regression analysis, whereas static structural measures were not. There were modest associations between measures of annual treatment volume and likelihood of inpatient mortality, notably decreasing likelihood with more acute discharges and with greater severe sepsis volume. Conclusions:Although patient demographics and health status are the most important predictors of in-hospital mortality of patients with severe sepsis, hospital characteristics do play a substantial role. Findings regarding hospital volume can be used to improve processes and improve patient outcomes.

Comparison of Predisposition, Insult/Infection, Response, and Organ dysfunction, Acute Physiology And Chronic Health Evaluation II, and Mortality in Emergency Department Sepsis in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle ☆

PURPOSE The aim of the study was to examine the performance of the Predisposition, Insult/Infection, Response, and Organ dysfunction (PIRO) model compared with the Acute Physiology and Chronic Health Evaluation (APACHE) II and Mortality in Emergency Department Sepsis (MEDS) scoring systems in predicting in-hospital mortality for patients presenting to the emergency department (ED) with severe sepsis or septic shock. MATERIALS AND METHODS This study was an analysis of a prospectively maintained registry including adult patients with severe sepsis or septic shock meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle over a 6-year period. The registry contains data on patient demographics, sepsis category, vital signs, laboratory values, ED length of stay, hospital length of stay, physiologic scores, and outcome status. The discrimination and calibration characteristics of PIRO, APACHE II, and MEDS were analyzed. RESULTS Five-hundred forty-one patients with age 63.5 ± 18.5 years were enrolled, 61.9% in septic shock, 46.9% blood-culture positive, and 31.8% in-hospital mortality. Median (25th and 75th percentile) PIRO, APACHE II, and MEDS scores were 6 (5 and 8), 28 (22 and 34), and 12 (9 and 15), with predicted mortalities of 48.5% (40.1 and 63.9), 66.0% (42.0 and 83.0), and 16.0% (9.0 and 39.0), respectively. The area under the receiver operating characteristic curves for PIRO was 0.71 (95% confidence interval, 0.66-0.75); APACHE II, 0.71 (0.66-0.76); and MEDS, 0.63 (0.60-0.70). The standardized mortality ratio was 0.70 (0.08-1.41), 0.70 (-0.46 to 1.80), and 4.00 (-8.53 to 16.62), respectively. Actual mortality significantly increased with increasing PIRO score in patients with APACHE II 25 or more (P < .01). CONCLUSIONS The PIRO, APACHE II, and MEDS have variable abilities to early discriminate and estimate in-hospital mortality of patients presenting to the ED meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. The PIRO may provide additional risk stratification in patients with APACHE II 25 or more. More studies are required to evaluate the clinical applicability of PIRO in high-risk patients with severe sepsis and septic shock.

Binge drinking by gender and race/ethnicity among California adults, 2007/2009.

Abstract Background: This study provides binge drinking population estimates for California adults by gender and detailed race/ethnicity categories. This information may be helpful for planning targeted initiatives to decrease binge drinking. Method: Data were from the 2007 and 2009 California Health Interview Surveys. The 98 662 respondents represent an annual estimated population of 27.2 million adults. Survey adjusted binary logistic regression was used to calculate gender-specific binge drinking population rates and multinomial logit regression to estimate binge drinking frequency. Results: Adjusting for socio-demographics, any binge drinking during the past year was reported by 31.0% (95% Confidence Interval = 30.5–31.4%) of men and 18.0% (17.7–18.3%) of women. Rates among White men and women were 30.5% and 19.6%, respectively. Binge drinking rates ranged from 11.9% among Chinese to 42.9% among Mexican men and from 4.8% among Vietnamese to 25.7% among “Other Latino” women. Five race/ethnicity categories of men and seven categories of women were significantly less likely to binge drink compared to Whites. Although Whites had the highest overall binge drinking rates, an estimated 12.5% of White men binge drank less than monthly, significantly exceeded by Mexican and Central American men, 19.9 and 19.6%, respectively. An estimated 9.6% of White women binge drank less than monthly, exceeded only by “Other Latino” women, 13.6%. Conclusion: These findings underscore the importance of detailed gender and race/ethnicity breakdowns when examining any binge drinking. Furthermore, there is variability across Asian and Latino subgroups in the frequency of binge drinking episodes, which is not evident in broad-group population studies.

Retrospective Analysis of Diabetes Care in California Medicaid Patients with Mental Illness

BackgroundSerious mental illness often is associated with an increased risk of diabetes and sub-optimal diabetes care.ObjectiveTo examine diabetes prevalence and care among Medicaid patients from one county mental health system.DesignRetrospective cohort study combining county records and 12 months of state Medicaid claims.SubjectsPatients ages 18 to 59 receiving mental health services between November 1 and 14, 2004.MeasurementsDependent variables were glycolated hemoglobin A1C (HbA1c) testing, lipid testing, and eye examinations. Psychiatric status was assessed by second generation antipsychotic prescription (SGA) and low Global Assessment of Functioning (GAF) score.ResultsAmong psychiatric patients, 482 (11.8%) had diabetes. Among those with diabetes, 47.3% received annual HbA1c testing, 56.0% lipid testing, and 31.7% eye examinations. Low GAF scores were associated with lower likelihood of lipid testing (OR 0.43). SGA prescription reduced the likelihood of HbA1c testing (OR 0.58) but increased the likelihood of eye examinations (OR 2.02). Primary care visits were positively associated with HbA1c and lipid testing (ORs 5.01 and 2.21, respectively). Patients seen by a fee-for-service psychiatrist were more likely to have lipid testing (OR 2.35) and eye examinations (OR 2.03).ConclusionAmong Medicaid psychiatric patients, worse diabetes care was associated with SGA prescription, more serious psychiatric symptoms, and receiving psychiatric care only in public mental health clinics. Diabetes care improved when patients were seen by fee-for-service psychiatrists or primary care physicians. Further study is needed to identify methods for improving diabetes care of public mental health patients.

Mental Health, Binge Drinking, and Antihypertension Medication Adherence.

OBJECTIVES To evaluate the relationship between self-reported mental health and binge drinking, as well as health status, sociodemographic, social support, economic resource, and health care access indicators to antihypertension medication adherence. METHOD Analysis of 2003 California Health Interview Survey data. RESULTS Having poor mental health days predicted medication nonadherence, whereas binge drinking did not. Nonadherence predictors included younger age, Latino, non-US citizen, uninsured, less education, and no regular medical care. Adherence predictors were older age, African American, having prescription insurance, a college degree, poor health, comorbid diabetes or heart disease, and overweight or obese. CONCLUSION Better mental health may improve medication adherence among hypertensive individuals.

Binge Drinking Among California Adults: Results from the 2005 California Health Interview Survey

Objective: To calculate binge drinking rates among California adults and describe the characteristics of female and male binge drinkers. Method: Analyses of 2005 California Health Interview Survey (CHIS) data. Results: At least one binge drinking episode over a 30-day period was reported by 1.4 million California women (10.7% of all adult women) and 3.2 million California men (24.7%). For both women and men, factors associated with binge drinking included being 18–44 years of age, smoking, and having mid-range psychological distress scores. There were gender differences in binge drinking risk by race/ethnicity and health status. Method: Given the multi-stage sampling design and non-responses in the 2005 California Health Interview Survey-Specific techniques were employed to ensure that the 43,020 compteted result yeilded reasonable state wide estimates. Conclusion: Binge drinking is a serious public health concern that affects millions of adult Californians.

Social Determinants of Physical Activity Among Adult Asian-Americans: Results from a Population-Based Survey in California

The objective of this study was to evaluate the key social determinants of physical activity among six Asian-American subgroups using public access 2007 California Health Interview Survey data. Physical activity was defined as meeting the American College of Sports Medicine recommendation of 450 metabolic equivalent-minutes per week. Factors positively associated with meeting physical activity recommendations included being bilingual among Chinese and Vietnamese, and increasing age for Chinese only. On the other hand, being middle aged, currently married, and low neighborhood safety were significantly associated with lower odds of meeting physical activity recommendations, as were being female for Japanese and Koreans, and living above the poverty level for Vietnamese. Such results highlight the heterogeneity among Asian-Americans and need for health messages targeted at specific subgroups. Additionally, the role of built environment, particularly in areas with high Filipino residents, should be a public health priority for increasing physical activity outcomes.

Psychiatric Comorbidity and Mortality among Veterans Hospitalized for Congestive Heart Failure

A Behavioral Model of Health Services Utilization approach was used to examine the impact of comorbid mental illness on mortality of veterans admitted to Veterans Affairs medical centers in fiscal year 2001 with a primary diagnosis of congestive heart failure (n = 15,497). Thirty percent had a psychiatric diagnosis, 4.7% died during the index hospitalization, and 11.5% died during the year following discharge. Among those with mental illness, 23.6% had multiple psychiatric disorders. Multivariable logistic regression models found dementia to be positively associated with inpatient mortality. Depression alone (excluding other psychiatric disorders) was positively associated with one-year mortality. Primary care visits were associated with a reduced likelihood of both inpatient and one-year mortality. Excepting dementia, VA patients with a mental illness had comparable or higher levels of primary care visits than those having no mental illness. Patients with multiple psychiatric disorders had more outpatient care than those with one psychiatric disorder.