Stephen W. Corbett

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.

Violence against emergency medical services personnel

Background. Emergency medical services (EMS) providers may be exposed to violent behavior while performing their routine duties. Objectives. To determine the prevalence of violence against EMS providers in the prehospital setting and to determine factors associated with such violence. Methods. Consecutive medical calls for EMS agencies in a southern California metropolitan area were prospectively analyzed for one month. Following each call, prehospital personnel recorded information about any episodes of violence (verbal or physical) during the run as well as variables felt to be associated with these behaviors. Results. There were 4,102 cases available for analysis. Overall, some sort of violence occurred in 8.5% (349/4,102) of patient encounters. Of this reported violence, 52.7% (184/349) was directed against prehospital care providers, while 47.3% (165/349) was directed against others. The prevalence of violence directed against prehospital care personnel was therefore 4.5% (184/4,102). Patients accounted for most (89.7%; 165/184) of this violent behavior. The type of violence varied, with 20.7% (38/184) being verbal only, 48.9% (90/184) being physical, and 30.4% (56/184) constituting both verbal and physical attacks. Male sex, patient age, and hour of the day were significantly associated with episodes of violence. Logistic regression analysis provided odds ratios (ORs) with confidence intervals (CIs) for factors that were predictive of violent behavior. These included police presence (OR 2.8; 95% CI 1.8–4.4), apparent presence of gang members (OR 2.9; 95% CI 1.6–5.3), perceived psychiatric disorder (OR 5.9; 95% CI 3.5–9.9), and perceived presence of alcohol or drug use (OR 7.0; 95% CI 4.4–11.2). Conclusion. Emergency medical services providers in some areas are at substantial risk for encountering violence in the prehospital setting. Certain situational factors may be used to predict the risk of encountering violence. Training, protocols, and protective gear for dealing with violent situations should be encouraged for all prehospital personnel.

Iatrogenic cardiopulmonary arrest during pediatric sedation with meperidine, promethazine, and chlorpromazine.

The pediatric sedative combination of meperidine, promethazine, and chlorpromazine (MPC) has been widely used for more than 40 years. Despite its relatively poor efficacy and questionable safety profile, many emergency departments (EDs) continue to stock specially formulated mixtures of these three agents. We report a case of iatrogenic cardiac arrest in a 2-month-old infant in whom a consulting resident administered too much MPC (10 times the expected dose) by the wrong route (intravenous instead of intramuscular). The child was successfully resuscitated with no apparent neurologic deficit. Subsequently, we have removed MPC entirely from our ED and instituted a policy restricting ED procedural sedation privileges to emergency physicians. We urge other EDs to do likewise.

ED evaluation of the pediatric trauma patient by ultrasonography.

The purpose of this study was to determine the accuracy of ultrasound examination of pediatric trauma patients by emergency physicians. Pediatric (age less than 18 years) trauma patients presenting to the emergency department of a level I trauma center were prospectively examined with bedside ultrasound during the secondary survey of their trauma resuscitation. Examinations were performed by emergency medicine residents and attending physicians who had completed an 8-hour course on trauma ultrasonography. Trauma physicians providing care to the patient were blinded to the results of the examination. In 47 children (median age 9 years) computed tomography of the abdomen/pelvis or laparotomy were also performed and served as gold standards to verify the presence or absence of free fluid in the abdomen. Sensitivity, specificity, and accuracy of the ultrasound examination for the detection of free fluid in the abdominal cavity was 75% (95% confidence interval [CI] 36% to 95%), 97% (95% CI 81% to 100%), and 92% (95% Cl 77% to 98%). Positive and negative predictive values were 90% (95% CI 46% to 100%) and 92% (95% CI 74% to 99%), respectively. Ultrasound examinations took an average of 7 minutes and 36 seconds, although this did not take into consideration delays created by interruptions for other diagnostic tests or procedures. An emergency physician and radiologist agreed on blinded interpretations of 83% of the examinations (kappa = 0.56). Bedside ultrasonography is a reliable and rapid method for screening traumatized children for the presence or absence of free fluid in the peritoneum even in the hands of novice sonographers.

Benefits of an informational videotape for emergency department patients

To determine if an informational videotape affected patients attitudes towards their emergency department visit, we conducted a prospective study using a convenience sample of patients waiting to be seen at a southern California emergency department. Patients waiting to be treated were randomized to view an informational videotape or to receive standard management (no videotape). The informational videotape lasted 6 minutes and served to orient the patients to the emergency department. It showed the sequence of steps from entry into the department to discharge, the nature of triage and causes for delays, the different services offered by the emergency department, and the roles of each of the department staff members. One week after discharge, patients were contacted at home by telephone and were asked to rate various aspects of their emergency department experience. A comparison of the telephone survey rankings between those who viewed the videotape (98 patients) and those who did not (100 patients) revealed statistically significant improvements in the former group on questions about level of anxiety and appropriateness of delays. An informational videotape for patients in waiting areas may be a useful tool to educate about emergency medical services, to reduce anxiety, and to improve satisfaction with the emergency department stay.

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.

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.

Detection of traumatic complications of cardiopulmonary resuscitation by ultrasound

STUDY OBJECTIVE We conducted a pilot study to assess the feasibility of ultrasonography in the detection of traumatic complications of CPR. METHODS A prospective case series was undertaken with a convenience sample of 21 emergency department patients who sustained nontraumatic cardiopulmonary arrest. A 5- to 7-minute ultrasound examination was performed during resuscitation. The presence or absence of free fluid was noted in the left and right upper quadrants, coronal views of the kidneys, the pelvis, and the pericardium; autopsies to determine the source of fluid were not performed. Cardiac activity and the concurrent electrical rhythm were also noted. All ultrasonographers had previously been trained in the use of this technique for the evaluation of trauma patients. Examinations were stored on videotape for further review. RESULTS Seven of 20 patients (29%) had findings on ultrasound that could have resulted from CPR-related trauma. In one additional case, findings of free fluid were probably the result of preexisting illness (ascites). Pericardial effusion was found in three patients, perihepatic fluid in four, pleural fluid in one, perirenal fluid in four, perisplenic fluid in two, and pelvic fluid in three; several patients had multiple findings. Cardiac motion with pulseless electrical activity was noted in seven patients. Five patients had return of spontaneous circulation and survived to hospitalization, and one survived to discharge. CONCLUSION Traumatic complications of CPR are well known but typically difficult to assess. Ultrasonography may identify injuries, help guide procedures, and serve as a means to assess pharmacologic effects on cardiac performance during CPR. It is a readily available, noninvasive means to assess these critically ill patients.

Inter-rater Reliability for Noninvasive Measurement of Cardiac Function in Children

Introduction: A transcutaneous ultrasound monitor has recently been developed which noninvasively and quickly measures cardiac output. Validity and reliability testing has been reported in adults. No reliability testing has been undertaken in the pediatric population. Objective: Our objective was to evaluate the inter-rater reliability of a transcutaneous Doppler ultrasound technique to measure cardiac index (CI) and stroke volume index (SVI) in pediatric emergency department patients. Methods: An 8-month prospective observational study was conducted on a convenience sample of emergency department patients younger than 18 years old. Five raters were trained to use an ultrasound cardiac output monitoring device. Two raters, blinded to each others results, obtained independent measurements from the same patient within 15 minutes of each other. Inter-rater agreement was measured with the Pearson product correlation coefficient. Bland-Altman analysis demonstrated the extent of deviation from a line of agreement between raters. Results: Ninety-seven patients were enrolled. Major diagnostic categories included infection, trauma, and gastrointestinal disorders. There was significant inter-rater correlation for CI (r = 0.76; 95% confidence interval, 0.66-0.83; P < 0.0001) and SVI (r = 0.79; 95% confidence interval, 0.70-0.86; P < 0.0001). Bland-Altman analysis of CI measurements between 2 raters showed bias of 0.06, SD of bias 1.00, and 95% limits of agreement −1.91 to 2.02 L/min/m2. Stroke volume index showed bias of −0.5, SD of bias 11.01, and 95% limits of agreement −22.08 to 21.08 mL/m2. Conclusions: Transcutaneous Doppler ultrasound technique demonstrates acceptable inter-rater agreement for measuring CI and SVI in children.

STANDARDIZATION OF SEVERE SEPSIS MANAGEMENT: A SURVEY OF METHODOLOGIES IN ACADEMIC AND COMMUNITY SETTINGS

BACKGROUND Evidence-based therapies for severe sepsis include early antibiotics, early goal-directed therapy, corticosteroids, recombinant human activated protein C, glucose control, and lung protective strategies. OBJECTIVE The objective of this study was to analyze methods, challenges, and outcomes observed by hospitals that implemented a hospital-wide sepsis management protocol incorporating evidence-based therapies. METHODS In a cross-sectional multi-center telephone survey over a 4-month period, clinicians (participants) responsible for developing a hospital sepsis protocol were questioned regarding its development and outcomes. RESULTS Participants completing surveys represented 40 hospitals (20 academic and 20 community). Twenty-seven percent of protocol champions were Emergency physicians or nurses. Sixty-three percent reported protocol development time of 6-12 months. Eighty-eight percent of participants reported protocol initiation in the Emergency Department. Three participants reported hiring a nurse educator to implement the protocol. Ninety-five percent of participants measure lactate as part of patient screening. Protocol therapies reported included early antibiotics (98%), early goal directed-therapy (EGDT) (98%), corticosteroids (80%), and activated protein C (73%). Contributions to success included having a protocol champion (85%) and sepsis education program (65%). Twenty-one participants had recorded patient-level data, totaling 2319 protocol patients, compared to 1719 non-protocol patients, with in-hospital mortality of 23% and 44%, respectively. CONCLUSIONS Implementation of a sepsis management protocol incorporating evidence-based therapies can be accomplished in both academic and community hospitals, with minimal additional staffing. The presence of a protocol champion and education program is crucial to success, and may result in improved patient outcome.