Improving care of the sepsis patient.

BACKGROUND: In 2004, Christiana Care Health System (Christiana Care), a 1,100-bed tertiary care facility, used the Surviving Sepsis Campaign guidelines as the foundation for an independent initiative to reduce the mortality rate by at least 25%. METHODS: In 2004, an interdisciplinary sepsis team developed a process for rapidly recognizing at-risk patients; evaluating a patient's clinical status; and providing appropriate, timely therapy in three major areas of sepsis care; recognition of the sepsis patient, resuscitation priorities, and intensive care management. The Sepsis Alert program, which did not require additional staffing, was developed and implemented in 10 months. The Sepsis Alert packet included a care management guideline, a treatment algorithm, an emergency department treatment order set, and multiple adjuncts to streamline patient identification and management. RESULTS: Introduction of sepsis resuscitation and critical care management standards led to a 49.4% decrease in mortality rates (p < .0001), a 34.0% decrease in average length of hospital stay (p < .0002), and a 188.2% increase in the proportion of patients discharged to home (p < .0001) when the historic control group is compared with the postimplementation group from January 2005 through December 2007. DISCUSSION: An integrated leadership team, using existing resources, transformed frontline clinical practice by providers from multiple disciplines to reduce mortality in the population of patients with sepsis.

Antibiotic timing and diagnostic uncertainty in Medicare patients with pneumonia: is it reasonable to expect all patients to receive antibiotics within 4 hours?

BACKGROUND: Many organizations, including the Centers for Medicare & Medicaid Services, measure the percentage of patients hospitalized with pneumonia who receive antibiotics within 4 h of presentation. Because the diagnosis of pneumonia can be delayed in patients with an atypical presentation, there are concerns that attempts to achieve a performance target of 100% may encourage inappropriate antibiotic usage and the diversion of limited resources from seriously ill patients. This study was performed to determine how frequently Medicare patients with a hospital discharge diagnosis of pneumonia present in a manner that could potentially lead to diagnostic uncertainty and a resulting appropriate delay in antibiotic administration. METHODS: Randomly selected charts of hospitalized Medicare patients who have received diagnoses of pneumonia were reviewed independently by three reviewers to determine whether there was a potential reason for a delay of antibiotic administration other than quality of care. Antibiotic administration timing, patient demographic, and clinical characteristics were also abstracted. RESULTS: Nineteen of 86 patients (22%; 95% confidence interval, 13.7 to 32.2) presented in a manner that had the potential to result in delayed antibiotic treatment due to diagnostic uncertainty. Diagnostic uncertainty was significantly associated with the lack of rales, normal pulse oximetry findings, and lack of an infiltrate seen on the chest radiograph. There was a nonsignificant trend toward a longer time until antibiotic treatment in patients with diagnostic uncertainty. CONCLUSIONS: Many Medicare patients in whom pneumonia has been diagnosed present in an atypical manner. Delivering antibiotic treatment within 4 h for all patients would necessitate the treatment of many patients before a firm diagnosis can be made.

An algorithmic approach to prehospital airway management.

Airway management, including endotracheal intubation, is considered one of the most important aspects of prehospital medical care. This concept paper proposes a systematic algorithm for performing prehospital airway management. The algorithm may be valuable as a tool for ensuring patient safety and reducing errors as well as for training rescuers in airway management.

Effectiveness of a medical priority dispatch protocol for abdominal pain.

OBJECTIVE: Medical Priority Dispatch System (MPDS) protocols are used to determine the appropriate level of emergency medical services (EMS) response that is sent to care for patients in the prehospital setting. The objective of this study was to determine the proportion of patients with abdominal pain who would benefit from advanced life support (ALS) when called for by these protocols. METHODS: All 9-1-1 calls were processed using MPDS protocols to determine whether the patient required ALS or basic life support (BLS) services. Consecutive patients having an ALS response for a chief complaint of abdominal pain were included. Dispatch decisions that did not follow the MPDS protocols, and cases taken to facilities other than the primary study hospitals, were excluded. EMS run sheets and hospital records were reviewed to determine: 1) whether prehospital ALS interventions were required, 2) emergency department (ED) disposition, 3) hospital course, and 4) final diagnosis. Calls were classified according to the need for ALS and the seriousness of the subsequent diagnosis. Data analysis was performed by determining 95%, confidence intervals (CIs). RESULTS: Of the 343 patients classified as 1C1 or 1C2 who were transported by ALS during the time period, 227 (67%) were transported to the study hospitals. Nine (4%) were excluded because of inappropriate dispatch, leaving 218 for analysis. Hospital records were available for 186 (86%) cases, of which 12 (6%; CI 3%, 9%) were potentially life-threatening, requiring ALS intervention. Seventeen (9%; CI 5%, 1%) were non-life-threatening, but potentially benefited from ALS intervention. The remaining 157 (84%; CI 79%, 89%) were classified as not requiring ALS. CONCLUSIONS: Use of age- and gender-specific MPDS protocols for patients with a chief complaint of abdominal pain results in significant overtriage and overuse of ALS. Steps should be taken to develop key questions that provide more accurate classification of these patients that goes beyond age and gender classification alone.