Physician Variation in Time to Antimicrobial Treatment for Septic Patients Presenting to the Emergency Department.

OBJECTIVES: Delayed initiation of appropriate antimicrobials is linked to higher sepsis mortality. We investigated interphysician variation in septic patients' door-to-antimicrobial time. DESIGN: Retrospective cohort study. SETTING: Emergency department of an academic medical center. SUBJECTS: Adult patients treated with antimicrobials in the emergency department between 2009 and 2015 for fluid-refractory severe sepsis or septic shock. Patients who were transferred, received antimicrobials prior to emergency department arrival, or were treated by an attending physician who cared for less than five study patients were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We employed multivariable linear regression to evaluate the association between treating attending physician and door-to-antimicrobial time after adjustment for illness severity (Acute Physiology and Chronic Health Evaluation II score), patient age, prehospital or arrival hypotension, admission from a long-term care facility, mode of arrival, weekend or nighttime admission, source of infection, and trainee involvement in care. Among 421 eligible patients, 74% received antimicrobials within 3 hours of emergency department arrival. After covariate adjustment, attending physicians' (n = 40) median door-to-antimicrobial times varied significantly, ranging from 71 to 359 minutes (p = 0.002). The percentage of each physician's patients whose antimicrobials began within 3 hours of emergency department arrival ranged from 0% to 100%. Overall, 12% of variability in antimicrobial timing was explained by the attending physician compared with 4% attributable to illness severity as measured by the Acute Physiology and Chronic Health Evaluation II score (p < 0.001). Some but not all physicians started antimicrobials later for patients who were normotensive on presentation (p = 0.017) or who had a source of infection other than pneumonia (p = 0.006). The adjusted odds of in-hospital mortality increased by 20% for each 1 hour increase in door-to-antimicrobial time (p = 0.046). CONCLUSIONS: Among patients with severe sepsis or septic shock receiving antimicrobials in the emergency department, door-to-antimicrobial times varied five-fold among treating physicians. Given the association between antimicrobial delay and mortality, interventions to reduce physician variation in antimicrobial initiation are likely indicated.

Cystic Fibrosis is Associated with Adverse Neonatal Outcomes in Washington State, 1996-2013.

OBJECTIVE: To determine whether cystic fibrosis (CF) is associated with adverse neonatal outcomes in a recent birth cohort in the US. STUDY DESIGN: A retrospective matched cohort study of infants born in Washington State from 1996 to 2013 was identified through birth certificate data and linked to statewide hospital discharge data. Infants with CF were identified by hospitalization (through age 5 years) in which a CF-specific International Classification of Diseases, Ninth Revision code was recorded. "Unexposed" infants lacked CF-related International Classification of Diseases, Ninth Revision codes and were randomly selected among births, frequency-matched to "exposed" infants on birth year. Associations of CF with adverse neonatal outcomes (low birth weight [LBW], small for gestational age [SGA], preterm birth, and infant mortality) were estimated through Poisson regression. We performed extreme value imputation to address possible ascertainment bias. RESULTS: We identified 170 infants with CF and 3400 unexposed infants. CF was associated with increased relative risk (95% CI) of 3.5 (2.5-4.9), 1.6 (1.1-2.4), 3.0 (2.2-4.0), and 6.8 (1.7-26.5) for LBW, SGA, preterm birth, and infant death, respectively. The estimated relative risks were similar among infants born from 2006 to 2013, except SGA was no longer associated with CF diagnosis. Results were robust to extreme value imputation and exclusion of infants with meconium ileus. CONCLUSIONS: Observed associations of CF with LBW, preterm birth, and infant death are unlikely to be due to ascertainment bias. Further work is needed to determine how to prevent these adverse neonatal outcomes.

Low tidal volume ventilation use remains low in patients with acute respiratory distress syndrome at a single center.

PURPOSE: Low tidal volume ventilation (LTVV) reduces mortality in acute respiratory distress syndrome (ARDS) patients. Understanding local barriers to LTVV use at a former ARDS Network hospital may provide new insight to improve LTVV implementation. METHODS: A cohort of 214 randomly selected adults met the Berlin definition of ARDS at Harborview Medical Center between 2008 and 2012. The primary outcome was the receipt of LTVV (tidal volume of ≤6.5mL/kg predicted body weight) within 48h of ARDS onset. We constructed a multivariable logistic regression model to identify factors associated with the outcome. RESULTS: Only 27% of patients received tidal volumes of ≤6.5mL/kg PBW within 48h of ARDS onset. Increasing plateau pressure (OR 1.11; 95% CI 1.03 to 1.19; p-value<0.01) was positively associated with LTVV use while increasing PaO2:FIO2 ratio was negatively associated (OR 0.75; 95% CI 0.57 to 0.98; p-value 0.03). Physicians documented an ARDS diagnosis in only 21% of the cohort. Neither patient height nor gender was associated with LTVV use. CONCLUSIONS: Most ARDS patients did not receive LTVV despite implementation of a protocol. ARDS was also recognized in a minority of patients, suggesting an opportunity for improvement of care.

Prehospital Care and Emergency Department Door-to-Antibiotic Time in Sepsis.

RATIONALE: Early antibiotics improve outcomes for patients with sepsis. Factors influencing antibiotic timing in emergency department (ED) sepsis remain unclear. OBJECTIVES: Determine the relationship between prehospital level of care of patients with sepsis and ED door-to-antibiotic time. METHODS: This retrospective cohort study comprised patients admitted from the community to an academic ED June 2009 to February 2015 with fluid-refractory sepsis or septic shock. Transfer patients and those whose antibiotics began before ED arrival or after ED discharge were excluded. We used multivariable regression to evaluate the association between the time from ED arrival to antibiotic initiation and prehospital level of care, defined as the highest level of emergency medical services received: none, basic life support (BLS) ambulance, or advanced life support (ALS) ambulance. We measured variation in this association when hypotension was or was not present by ED arrival. RESULTS: Among 361 community-dwelling patients with sepsis, the level of prehospital care correlated with illness severity. ALS-treated patients received antibiotics faster than patients who did not receive prehospital care (median, 103 [interquartile range, 75 to 135] vs. 144 [98 to 251] minutes, respectively) or BLS-only patients (168 [100-250] minutes; P < 0.001 for each pairwise comparison with ALS). This pattern persisted after multivariable adjustment, where ALS care (-43 min; 95% confidence interval [CI], -84 to -2; P = 0.033) but not BLS-only care (-4 min; 95% CI, -41 to +34; P = 0.97) was associated with less antibiotic delay compared with no prehospital care. ALS-treated patients more frequently received antibiotics within 3 hours of ED arrival (91%) compared with walk-in patients (62%; adjusted odds ratio, 3.11; 95% CI, 1.20 to 8.03; P = 0.015) or BLS-treated patients (56%; adjusted odds ratio, 4.51; 95% CI, 1.89 to 11.35; P < 0.001). ALS-treated patients started antibiotics faster than walk-in patients in the absence of hypotension by ED arrival (-41 min; 95% CI, -110 to -13; P = 0.009) but not when hypotension was present (+25 min; 95% CI, -43 to +92; P = 0.66). CONCLUSIONS: Prehospital ALS but not BLS-only care was associated with faster antibiotic initiation for patients with sepsis without hypotension. Process redesign for non-ALS patients may improve antibiotic timeliness for ED sepsis.

Volume Overload: Prevalence, Risk Factors, and Functional Outcome in Survivors of Septic Shock.

RATIONALE: Survivors of septic shock have impaired functional status. Volume overload is associated with poor outcomes in patients with septic shock, but the impact of volume overload on functional outcome and discharge destination of survivors is unknown. OBJECTIVES: This study describes patterns of fluid management both during and after septic shock. We examined factors associated with volume overload upon intensive care unit (ICU) discharge. We then examined associations between volume overload upon ICU discharge, mobility limitation, and discharge to a healthcare facility in septic shock survivors, with the hypothesis that volume overload is associated with increased odds of these outcomes. METHODS: We retrospectively reviewed the medical records of 247 patients admitted with septic shock to an academic county hospital between June 2009 and April 2012 who survived to ICU discharge. We defined volume overload as a fluid balance expected to increase the subject's admission weight by 10%. Statistical methods included unadjusted analyses and multivariable logistic regression. MEASUREMENTS AND MAIN RESULTS: Eighty-six percent of patients had a positive fluid balance, and 35% had volume overload upon ICU discharge. Factors associated with volume overload in unadjusted analyses included more severe illness, cirrhosis, blood transfusion during shock, and higher volumes of fluid administration both during and after shock. Blood transfusion during shock was independently associated with increased odds of volume overload (odds ratio [OR], 2.65; 95% confidence interval [CI], 1.33-5.27; P = 0.01) after adjusting for preexisting conditions and severity of illness. Only 42% of patients received at least one dose of a diuretic during their hospitalization. Volume overload upon ICU discharge was independently associated with inability to ambulate upon hospital discharge (OR, 2.29; 95% CI, 1.24-4.25; P = 0.01) and, in patients admitted from home, upon discharge to a healthcare facility (OR, 2.34; 95% CI, 1.1-4.98; P = 0.03). CONCLUSIONS: Volume overload is independently associated with impaired mobility and discharge to a healthcare facility in survivors of septic shock. Prevention and treatment of volume overload in patients with septic shock warrants further investigation.