M.F. Ward

Association of Fluid Resuscitation Initiation Within 30 Minutes of Severe Sepsis and Septic Shock Recognition With Reduced Mortality and Length of Stay.

STUDY OBJECTIVEnWe evaluate the association of intravenous fluid resuscitation initiation within 30 minutes of severe sepsis or septic shock identification in the emergency department (ED) with inhospital mortality and hospital length of stay. We also compare intravenous fluid resuscitation initiated at various times from severe sepsis or septic shock identifications association with the same outcomes.nnnMETHODSnThis was a review of a prospective, observational cohort of all ED severe sepsis or septic shock patients during 13 months, captured in a performance improvement database at a single, urban, tertiary care facility (90,000 ED visits/year). The primary exposure was initiation of a crystalloid bolus at 30 mL/kg within 30 minutes of severe sepsis or septic shock identification. Secondary analysis compared intravenous fluid initiated within 30, 31 to 60, or 61 to 180 minutes, or when intravenous fluid resuscitation was initiated at greater than 180 minutes or not provided.nnnRESULTSnOf 1,866 subjects, 53.6% were men, 72.5% were white, mean age was 72 years (SD 16.6 years), and mean initial lactate level was 2.8 mmol/L. Eighty-six percent of subjects were administered intravenous antibiotics within 180 minutes; 1,193 (64%) had intravenous fluid initiated within 30 minutes. Mortality was lower in the within 30 minutes group (159 [13.3%] versus 123 [18.3%]; 95% confidence interval [CI] 1.4% to 8.5%), as was median hospital length of stay (6 days [95% CI 6 to 7] versus 7 days [95% CI 7 to 8]). In multivariate regression that included adjustment for age, lactate, hypotension, acute organ dysfunction, and Emergency Severity Index score, intravenous fluid within 30 minutes was associated with lower mortality (odds ratio 0.63; 95% CI 0.46 to 0.86) and 12% shorter length of stay (hazard ratio=1.14; 95% CI 1.02 to 1.27). In secondary analysis, mortality increased with later intravenous fluid resuscitation initiation: 13.3% (≤30 minutes) versus 16.0% (31 to 60 minutes) versus 16.9% (61 to 180 minutes) versus 19.7% (>180 minutes). Median hospital length of stay also increased with later intravenous fluid initiation: 6 days (95% CI 6 to 7 days) versus 7 days (95% CI 6 to 7 days) versus 7 days (95% CI 6 to 8 days) versus 8 days (95% CI 7 to 9 days).nnnCONCLUSIONnThe time of intravenous fluid resuscitation initiation was associated with improved mortality and could be used as an easier obtained alternative to intravenous fluid completion time as a performance indicator in severe sepsis and septic shock management.

Delphi Consensus on the Feasibility of Translating the ACEP Clinical Policies Into Computerized Clinical Decision Support

Clinical practice guidelines are developed to reduce variations in clinical practice, with the goal of improving health care quality and cost. However, evidence-based practice guidelines face barriers to dissemination, implementation, usability, integration into practice, and use. The American College of Emergency Physicians (ACEP) clinical policies have been shown to be safe and effective and are even cited by other specialties. In spite of the benefits of the ACEP clinical policies, implementation of these clinical practice guidelines into physician practice continues to be a challenge. Translation of the ACEP clinical policies into real-time computerized clinical decision support systems could help address these barriers and improve clinician decision making at the point of care. The investigators convened an emergency medicine informatics expert panel and used a Delphi consensus process to assess the feasibility of translating the current ACEP clinical policies into clinical decision support content. This resulting consensus document will serve to identify limitations to implementation of the existing ACEP Clinical Policies so that future clinical practice guideline development will consider implementation into clinical decision support at all stages of guideline development.

Real-Time Inter-Rater Reliability of the Council of Emergency Medicine Residency Directors Standardized Direct Observation Assessment Tool

OBJECTIVESnDeveloped by the Council of Emergency Medicine Residency Directors (CORD), the standardized direct observation assessment tool (SDOT) is an evaluation instrument used to assess residents clinical skills in the emergency department (ED). In a previous study examining the inter-rater agreement of the tool, faculty scored simulated resident-patient encounters. The objective of the present study was to evaluate the inter-rater agreement of the SDOT in real-time evaluations of residents in the ED.nnnMETHODSnThis was a multi-center, prospective, observational study in which faculty raters were paired to simultaneously observe and independently evaluate a residents clinical performance using the SDOT. Data collected from eight emergency medicine (EM) residency programs produced 99 unique resident-patient encounters and reported on 26 individual behaviors related to specific core competencies, global evaluation scores for each core competency, and an overall clinical competency score. Inter-rater agreement was assessed using percentage agreement analyses with three constructs: exact agreement, liberal agreement, and binary (pass/fail) agreement.nnnRESULTSnInter-rater agreement between faculty raters varied according to category of measure used. Exact agreement ranged from poor to good, depending on the measure: the overall competency score (good), the competency score for each of the six core competencies (poor to good), and the individual item scores (fair to very good). Liberal agreement and binary agreement were excellent for the overall competency score and the competency score for each of the six core competencies and very good to excellent for the individual item scores.nnnCONCLUSIONSnThe SDOT demonstrated excellent inter-rater agreement when analyzed with liberal agreement and when dichotomized as a pass/fail measure and fair to good agreement for most measures with exact agreement. The SDOT can be useful and reliable when evaluating residents clinical skills in the ED, particularly as it relates to marginal performance.

Survey of Emergency Medical Services Professionals’ Experience with Advance Directives and Medical Orders for Life-Sustaining Treatment

1. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes (UKPDS 38). BMJ 1998;317:703–713. 2. Whitmer RA, Karter AJ, Yaffe K et al. Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus. JAMA 2009;301:1565–1572. 3. Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Engl J Med 2003;348:42–49. 4. Huang ES, Karter AJ, Danielson KK et al. The association between the number of prescription medications and incident falls in a multi-ethnic population of adult type-2 diabetes patients: The diabetes and aging study. J Gen Intern Med 2010;25:141–146. Epub 2009 Dec 5. 5. Calles-Escandón J, Lovato LC, Simons-Morton DG et al. Effect of intensive compared with standard glycemia treatment strategies on mortality by baseline subgroup characteristics: The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Diabetes Care 2010;33:721–727. 6. American Diabetes Association: Standards of medical care in diabetes— 2011. Diabetes Care 2011;34 (Suppl 1):S11–S61. 7. Brown AF, Mangione CM, Saliba D et al. Guidelines for improving the care of the older individual with diabetes mellitus. J Am Geriatr Soc 2003;51 (Suppl):S265–S280. 8. Pogach L, Conlin PR, Hobbs C et al.; for the VA-DoD Diabetes Guideline Working Group. What clinicians need to know about absolute risk of benefits and harms of A1c laboratory accuracy. Federal Practitioner 2011;39: 39–44.