Sarah Sokol

Quick Sepsis-related Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and Early Warning Scores for Detecting Clinical Deterioration in Infected Patients outside the Intensive Care Unit

Rationale: The 2016 definitions of sepsis included the quick Sepsis‐related Organ Failure Assessment (qSOFA) score to identify high‐risk patients outside the intensive care unit (ICU). Objectives: We sought to compare qSOFA with other commonly used early warning scores. Methods: All admitted patients who first met the criteria for suspicion of infection in the emergency department (ED) or hospital wards from November 2008 until January 2016 were included. The qSOFA, Systemic Inflammatory Response Syndrome (SIRS), Modified Early Warning Score (MEWS), and the National Early Warning Score (NEWS) were compared for predicting death and ICU transfer. Measurements and Main Results: Of the 30,677 included patients, 1,649 (5.4%) died and 7,385 (24%) experienced the composite outcome (death or ICU transfer). Sixty percent (n = 18,523) first met the suspicion criteria in the ED. Discrimination for in‐hospital mortality was highest for NEWS (area under the curve [AUC], 0.77; 95% confidence interval [CI], 0.76‐0.79), followed by MEWS (AUC, 0.73; 95% CI, 0.71‐0.74), qSOFA (AUC, 0.69; 95% CI, 0.67‐0.70), and SIRS (AUC, 0.65; 95% CI, 0.63‐0.66) (P < 0.01 for all pairwise comparisons). Using the highest non‐ICU score of patients, ≥2 SIRS had a sensitivity of 91% and specificity of 13% for the composite outcome compared with 54% and 67% for qSOFA ≥2, 59% and 70% for MEWS ≥5, and 67% and 66% for NEWS ≥8, respectively. Most patients met ≥2 SIRS criteria 17 hours before the combined outcome compared with 5 hours for ≥2 and 17 hours for ≥1 qSOFA criteria. Conclusions: Commonly used early warning scores are more accurate than the qSOFA score for predicting death and ICU transfer in non‐ICU patients. These results suggest that the qSOFA score should not replace general early warning scores when risk‐stratifying patients with suspected infection.

New-Onset Atrial Fibrillation Is an Independent Predictor of Mortality in Medical Intensive Care Unit Patients:

Background: Atrial fibrillation (AF) has been extensively studied in postoperative critically ill surgical patients, but little literature exists to describe the outcomes of patients in the medical intensive care unit (ICU). Objectives: To determine the incidence of new-onset AF in patients admitted to a medical ICU and if new-onset AF was associated with adverse clinical outcomes. Methods: This was a single-center, retrospective study of all adult patients admitted to the medical ICU at an academic medical center for >24 hours between December 2008 and April 2010. Collected data included past medical history, incidence of new-onset AF, Acute Physiology and Chronic Health Evaluation II scores, organ failure, length of stay in the ICU and hospital, and in-hospital and 60-day survival. Results: A total of 741 patients were included. New-onset AF occurred in 53 patients (7.2%). In-hospital mortality was significantly greater for patients with new-onset AF (45% vs 16%; adjusted odds ratio [OR] = 2.21, 95% CI 1.07-4.54, P = 0.032), as was 60-day mortality (51% vs 23%; adjusted OR = 1.99, 95% CI = 1.01-3.91, P = 0.047). Patients with new-onset AF experienced greater ICU (6 ± 10.2 days vs 3 ± 3.6 days, P < 0.01) and hospital (15 ± 19 days vs 7 ± 9 days, P < 0.01) lengths of stay. Conclusions: Medical ICU patients who developed new-onset AF experienced a 2-fold increase in the odds of in-hospital mortality and death at 60 days. Further research investigating contributing factors to new-onset AF and potential treatments is warranted.

A Multicenter Evaluation of Off-Label Medication Use and Associated Adverse Drug Reactions in Adult Medical ICUs.

Objective:Prior research indicates that off-label use is common in the ICU; however, the safety of off-label use has not been assessed. The study objective was to determine the prevalence of adverse drug reactions associated with off-label use and evaluate off-label use as a risk factor for the development of adverse drug reactions in an adult ICU population. Design:Multicenter, observational study Setting:Medical ICUs at three academic medical centers. Patients:Adult patients (age ≥ 18 yr old) receiving medication therapy. Interventions:All administered medications were evaluated for Food and Drug Administration–approved or off-label use. Patients were assessed daily for the development of an adverse drug reaction through active surveillance. Three adverse drug reaction assessment instruments were used to determine the probability of an adverse drug reaction resulting from drug therapy. Severity and harm of the adverse drug reaction were also assessed. Cox proportional hazard regression was used to identify a set of covariates that influenced the rate of adverse drug reactions. Measurements and Main Results:Overall, 1,654 patient-days (327 patients) and 16,391 medications were evaluated, with 43% of medications being used off-label. One hundred and sixteen adverse drug reactions were categorized dichotomously (Food and Drug Administration or off-label), with 56% and 44% being associated with Food and Drug Administration–approved and off-label use, respectively. The number of adverse drug reactions for medications administered and the number of harmful and severe adverse drug reactions did not differ for medications used for Food and Drug Administration–approved or off-label use (0.74% vs 0.67%; p = 0.336; 33 vs 31 events, p = 0.567; 24 vs 24 events, p = 0.276). Age, sex, number of high-risk medications, number of off-label medications, and severity of illness score were included in the Cox proportional hazard regression. It was found that the rate of adverse drug reactions increases by 8% for every one additional off-label medication (hazard ratio = 1.08; 95% CI, 1.018–1.154). Conclusion:Although adverse drug reactions do not occur more frequently with off-label use, adverse drug reaction risk increases with each additional off-label medication used.

Investigating the Impact of Different Suspicion of Infection Criteria on the Accuracy of Quick Sepsis-related Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and Early Warning Scores*

Objective: Studies in sepsis are limited by heterogeneity regarding what constitutes suspicion of infection. We sought to compare potential suspicion criteria using antibiotic and culture order combinations in terms of patient characteristics and outcomes. We further sought to determine the impact of differing criteria on the accuracy of sepsis screening tools and early warning scores. Design: Observational cohort study. Setting: Academic center from November 2008 to January 2016. Patients: Hospitalized patients outside the ICU. Interventions: None. Measurements and Main Results: Six criteria were investigated: 1) any culture, 2) blood culture, 3) any culture plus IV antibiotics, 4) blood culture plus IV antibiotics, 5) any culture plus IV antibiotics for at least 4 of 7 days, and 6) blood culture plus IV antibiotics for at least 4 of 7 days. Accuracy of the quick Sepsis-related Organ Failure Assessment score, Sepsis-related Organ Failure Assessment score, systemic inflammatory response syndrome criteria, the National and Modified Early Warning Score, and the electronic Cardiac Arrest Risk Triage score were calculated for predicting ICU transfer or death within 48 hours of meeting suspicion criteria. A total of 53,849 patients met at least one infection criteria. Mortality increased from 3% for group 1 to 9% for group 6 and percentage meeting Angus sepsis criteria increased from 20% to 40%. Across all criteria, score discrimination was lowest for systemic inflammatory response syndrome (median area under the receiver operating characteristic curve, 0.60) and Sepsis-related Organ Failure Assessment score (median area under the receiver operating characteristic curve, 0.62), intermediate for quick Sepsis-related Organ Failure Assessment (median area under the receiver operating characteristic curve, 0.65) and Modified Early Warning Score (median area under the receiver operating characteristic curve 0.67), and highest for National Early Warning Score (median area under the receiver operating characteristic curve 0.71) and electronic Cardiac Arrest Risk Triage (median area under the receiver operating characteristic curve 0.73). Conclusions: The choice of criteria to define a potentially infected population significantly impacts prevalence of mortality but has little impact on accuracy. Systemic inflammatory response syndrome was the least predictive and electronic Cardiac Arrest Risk Triage the most predictive regardless of how infection was defined.

Evaluation of a Trainee-Led Project to Reduce Inappropriate Proton Pump Inhibitor Infusion in Patients With Upper Gastrointestinal Bleeding: Skip the Drips

LESS IS MORE Evaluation of a Trainee-Led Project to Reduce Inappropriate Proton Pump Inhibitor Infusion in Patients With Upper Gastrointestinal Bleeding: Skip the Drips Continuous infusion of proton pump inhibitors (PPIs) is recommended in patients with upper gastrointestinal bleeding (UGIB) for specific situations, such as before endoscopic identification of ulcers with high-risk features1-4 (Box). Unfortunately, PPI infusions may be continued for 72 hours without indication.2,5 Reducing the overuse of these infusions is important because, in addition to increasing the length of stay and cost, PPI overuse is associated with various complications.6 In July 2015, a fellowand resident-led intervention was initiated with the goals of decreasing the inappropriate use of PPI infusions in patients with UGIB and promoting evidencebased care at lower costs for these patients.

Association between opioid and benzodiazepine use and clinical deterioration in ward patients

BACKGROUND: Opioids and benzodiazepines are frequently used in hospitals, but little is known about outcomes among ward patients receiving these medications. OBJECTIVE: To determine the association between opioid and benzodiazepine administration and clinical deterioration. DESIGN: Observational cohort study. SETTING: 500‐bed academic urban tertiary‐care hospital. PATIENTS: All adults hospitalized on the wards from November 2008 to January 2016 were included. Patients who were “comfort care” status, had tracheostomies, sickle‐cell disease, and patients at risk for alcohol withdrawal or seizures were excluded. MEASUREMENTS: The primary outcome was the composite of intensive care unit transfer or ward cardiac arrest. Discrete‐time survival analysis was used to calculate the odds of this outcome during exposed time periods compared to unexposed time periods with respect to the medications of interest, with adjustment for patient demographics, comorbidities, severity of illness, and pain score. RESULTS: In total, 120,518 admissions from 67,097 patients were included, with 67% of admissions involving opioids, and 21% involving benzodiazepines. After adjustment, each equivalent of 15 mg oral morphine was associated with a 1.9% increase in the odds of the primary outcome within 6 hours (odds ratio [OR], 1.019; 95% confidence interval [CI], 1.013‐1.026; P < 0.001), and each 1 mg oral lorazepam equivalent was associated with a 29% increase in the odds of the composite outcome within 6 hours (OR, 1.29; CI, 1.16‐1.45; P < 0.001). CONCLUSION: Among ward patients, opioids were associated with increased risk for clinical deterioration in the 6 hours after administration. Benzodiazepines were associated with even higher risk. These results have implications for ward‐monitoring strategies.

Implications of Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock Early Management Bundle and Initial Lactate Measurement on the Management of Sepsis

Background Sepsis remains a significant cause of morbidity and mortality in the United States, leading to the implementation of the Severe Sepsis and Septic Shock Early Management Bundle (SEP‐1). SEP‐1 identifies patients with “severe sepsis” via clinical and laboratory criteria and mandates interventions, including lactate draws and antibiotics, within a specific time window. We sought to characterize the patients affected and to study the implications of SEP‐1 on patient care and outcomes. Methods All adults admitted to the University of Chicago from November 2008 to January 2016 were eligible. Modified SEP‐1 criteria were used to identify appropriate patients. Time to lactate draw and antibiotic and IV fluid administration were calculated. In‐hospital mortality was examined. Results Lactates were measured within the mandated window 32% of the time on the ward (n = 505) compared with 55% (n = 818) in the ICU and 79% (n = 2,144) in the ED. Patients with delayed lactate measurements demonstrated the highest in‐hospital mortality at 29%, with increased time to antibiotic administration (median time, 3.9 vs 2.0 h). Patients with initial lactates > 2.0 mmol/L demonstrated an increase in the odds of death with hourly delay in lactate measurement (OR, 1.02; 95% CI, 1.0003‐1.05; P = .04). Conclusions Delays in lactate measurement are associated with delayed antibiotics and increased mortality in patients with initial intermediate or elevated lactate levels. Systematic early lactate measurement for all patients with sepsis will lead to a significant increase in lactate draws that may prompt more rapid physician intervention for patients with abnormal initial values.

890: Implications of the first 48 hours of sedation on duration of mechanical ventilation

Introduction: Patients receiving mechanical ventilation (MV) may require the administration of sedatives and opioids to promote patient comfort and ventilator synchrony. The monitoring of pain, agitation, and delirium can be subjective and patients may experience undesirable outcomes due to variations in sedation assessment and drug administration. The study purpose is to determine if the incidence of deep sedation within the initial 48 hours of MV is associated with increased MV days for patients admitted to a medical intensive care unit. methods: This is a single center, retrospective, epidemiological study to assess sedation practices in the first 48 hours of MV and the impact on duration of ventilator days for all mechanically ventilated adult patients admitted to the medical ICU service at the University of Chicago Medical Center from September 2011 to August 2012. Patients were categorized according to documented RASS scores. Patients that received a single RASS of -3, -4 or-5 within the first 48 hours were classified as deep sedation (DS). Patients with RASS ≥ -2 were categorized in the light sedation (LS) group. results: We studied 100 consecutive patients requiring MV, excluding those intubated and transferred from an outside hospital, post-cardiac arrest requiring MV, active treatment for alcohol withdrawal, or requiring pharmacological paralysis. Overall, 71% of patients were categorized as DS. Sixty-five patients were categorized as DS in the first 24-hour interval and 45 DS patients in the subsequent 24-hour interval. The incidence of DS had no effect on MV days (6.3 days vs. 7.2 days, p=0.45). The incidence of DS also was not associated with longer lengths of ICU stay (11.9 days vs. 9.5 days, p=0.20). DS was associated with the administration of greater amounts of fentanyl (4194 mcg vs. 2408 mcg, p< 0.001) when compared to the LS group during the initial 48-hour timeframe. conclusions: The data demonstrates that the incidence of DS did not affect MV days within our MICU. However, DS was associated with increased drug administration, specifically fentanyl, within the first 48 hours of MV. This information could be incorporated to potentially modify patient-specific sedation regimens and practice behaviors that reduce the incidence of DS.