Inter-rater Agreement for Abstraction of the Early Management Bundle, Severe Sepsis/Septic Shock (SEP-1) Quality Measure in a Multi-Hospital Health System.

BACKGROUND: The Early Management Bundle, Severe Sepsis/Septic Shock (SEP-1) quality measure is complex to abstract, which may lead to discrepancies between abstractors. This study was designed to evaluate inter-rater agreement between abstractors at individual hospitals in a health system and a lead abstractor on abstraction elements and measure compliance for SEP-1. METHODS: Patient cases qualifying for abstraction for SEP-1 over a four-month period in 2016 were initially abstracted at a local hospital and then centrally by a lead abstractor. Abstraction results were retrospectively compared to determine inter-rater agreement. RESULTS: A total of 580 SEP-1 cases were abstracted locally and centrally. Each site contributed a median (interquartile range) of 63 (49, 86) cases. There was complete concordance of measure-related elements in 391 cases (67%) (inter-rater agreement: κ = 0.40, p < 0.01). The most common discrepancy (60 cases) was severe sepsis presentation time. There was a weak correlation between SEP-1 compliance adjudicated locally and centrally (r2 = 0.41, p < 0.01). The average change in monthly SEP-1 measure compliance at each site after central adjudication was a 1% increase but ranged from a 49% decrease to a 40% increase. CONCLUSIONS: Concordance on SEP-1 abstraction elements between local and expert adjudicators was fair, and SEP-1 performance varied considerably from initial site-reported performance. The detailed nature of SEP-1 can lead to unreliable abstraction, which may lead to inaccurate reporting of compliance with the measure and affect comparability of performance between hospitals. Abstraction by a dedicated team for SEP-1 can reduce variability and improve efficiency.

Does inpatient hyperglycemia predict a worse outcome in COVID-19 intensive care unit patients?

BACKGROUND: We undertook this study to evaluate the association between hyperglycemia and outcomes in patients with coronavirus disease 2019 (COVID-19) admitted to the intensive care unit (ICU). METHODS: We conducted a multicenter retrospective study involving all adults with COVID-19 admitted to the ICU between March and May 2020. Patients were divided into normoglycemic (average blood glucose <140 mg/dL) and hyperglycemic (average blood glucose ≥140 mg/dL) groups. Outcomes such as mortality, need and duration of mechanical ventilation, and length of hospital and ICU stays were measured. RESULTS: Among 495 patients, 58.4% were male with a median age of 68 years (interquartile range [IQR]: 58.00-77.00), and baseline average blood glucose was 186.6 (SD ± 130.8). Preexisting diabetes was present in 35.8% of the studied cohort. Combined ICU and hospital mortality rates were 23.8%; mortality and mechanical ventilation rates were significantly higher in the hyperglycemic group with 31.4% vs 16.6% (P = .001) and 50.0% vs 37.2% (P = .004), respectively. Age above 60 years (hazard ratio [HR] 3.21; 95% CI 1.78, 5.78) and hyperglycemia (HR 1.79; 95% CI 1.14, 2.82) were the only significant predictors of in-hospital mortality. Increased risk for hyperglycemia was found in patients with steroid use (odds ratio [OR] 1.521; 95% CI 1.054, 2.194), triglycerides ≥150 mg/dL (OR 1.62; 95% CI 1.109, 2.379), and African American race (OR 0.79; 95% CI 0.65, 0.95). CONCLUSIONS: Hyperglycemia in patients with COVID-19 is significantly associated with a prolonged ICU length of stay, higher need of mechanical ventilation, and increased risk of mortality in the critical care setting. Tighter blood glucose control (≤140 mg/dL) might improve outcomes in COVID-19 critically ill patients; evidence from ongoing clinical trials is needed.

A Multicenter Evaluation of Survival After In-Hospital Cardiac Arrest in Coronavirus Disease 2019 Patients.

IMPORTANCE: In-hospital cardiac arrest survival among coronavirus disease 2019 patients has been reported to range from 0% to 12%. These numbers are significantly lower than reported prepandemic in-hospital cardiac arrest survival rates of approximately 20-25% in the United States for non-coronavirus disease 2019 patients. OBJECTIVE: To assess the incidence of in-hospital cardiac arrest survival of coronavirus disease 2019 patients. DESIGN: A retrospective cohort study of adult patients with coronavirus disease 2019 subsequently found to have in-hospital cardiac arrest and underwent cardiopulmonary resuscitation (cardiopulmonary resuscitation). SETTING: Multiple hospitals of the Cleveland Clinic Health System. PATIENTS: All adult patients (age ≥ 18 yr) admitted to Cleveland Clinic Health System with a diagnosis of coronavirus disease 2019 who experienced in-hospital cardiac arrest requiring cardiopulmonary resuscitation. MEASUREMENTS AND MAIN RESULTS: From March 01, 2020 to October 15, 2020, 3,555 patients with coronavirus disease 2019 were hospitalized; 1,372 were admitted to the ICU; 58 patients had in-hospital cardiac arrest. Median age of this cohort was 66.5 years (interquartile range, 55.0-76.0 yr). Patients were predominantly male (62.5%), White (53.4%), with a median body mass index of 29.7 (interquartile range, 25.8-34.6). Most in-hospital cardiac arrests were in critical care environments (ICU), 51 of 58 (87.9%); seven of 58 (12.1%) were on ward locations. Thirty-four of 58 patients (58.6%) were on mechanical ventilation prior to in-hospital cardiac arrest with a median duration of mechanical ventilation of 9 days (interquartile range, 2-18 d). Twenty-four of 58 patients (44%) were on vasopressors prior to arrest. Initial arrest rhythm was pulseless electrical activity at (63.8%), asystole (29.3%), and pulseless ventricular tachycardia/fibrillation (6.9%). Of the 58 patients, 35 (60.3%) attained return of spontaneous circulation, and 13 of 58 (22.4%) were discharged alive. CONCLUSIONS: We report a 22% survival to discharge after in-hospital cardiac arrest in coronavirus disease 2019 patients, a survival rate similar to before the coronavirus disease 2019 pandemic.

Clinical characteristics and outcomes of critically Ill patients with COVID-19 in Northeast Ohio: low mortality and length of stay.

BACKGROUND: Published coronavirus disease 2019 (COVID-19) reports suggest higher mortality with increasing age and comorbidities. Our study describes the clinical characteristics and outcomes for all intensive care unit (ICU) patients admitted across the Cleveland Clinic enterprise, a 10-hospital health care system in Northeast Ohio, serving more than 2.7 million people. METHODS: We analyzed the quality data registry for clinical characteristics and outcomes of all COVID-19-confirmed ICU admissions. Differences in outcomes from other health care systems and published cohorts from other parts of the world were delineated. RESULTS: Across our health care system, 495 COVID-19 patients were admitted from March 15 to June 1, 2020. Mean patient age was 67.3 years, 206 (41.6%) were females, and 289 (58.4%) were males. Mean Acute Physiology Score was 45.3, and mean Acute Physiology and Chronic Health Evaluation III score was 60.5. In total, 215 patients (43.3%) were intubated for a mean duration of 9.2 days. Mean ICU and hospital length of stay were 7.4 and 13.9 days, respectively, while mean ICU and hospital mortality rates were 18.4% and 23.8%. CONCLUSIONS: Our health care system cohort is the fourth largest to be reported. Lower ICU and hospital mortality and length of stay were seen compared to most other published reports. Better preparedness and state-level control of the surge in COVID-19 infections are likely the reasons for these better outcomes. Future research is needed to further delineate differences in mortality and length of stay across health care systems and over time.

C-GRApH: A Validated Scoring System for Early Stratification of Neurologic Outcome After Out-of-Hospital Cardiac Arrest Treated With Targeted Temperature Management.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) results in significant morbidity and mortality, primarily from neurologic injury. Predicting neurologic outcome early post-OHCA remains difficult in patients receiving targeted temperature management. METHODS AND RESULTS: Retrospective analysis was performed on consecutive OHCA patients receiving targeted temperature management (32-34°C) for 24 hours at a tertiary-care center from 2008 to 2012 (development cohort, n=122). The primary outcome was favorable neurologic outcome at hospital discharge, defined as cerebral performance category 1 to 2 (poor 3-5). Patient demographics, pre-OHCA diagnoses, and initial laboratory studies post-resuscitation were compared between favorable and poor neurologic outcomes with multivariable logistic regression used to develop a simple scoring system (C-GRApH). The C-GRApH score ranges 0 to 5 using equally weighted variables: (C): coronary artery disease, known pre-OHCA; (G): glucose ≥200 mg/dL; (R): rhythm of arrest not ventricular tachycardia/fibrillation; (A): age >45; (pH): arterial pH ≤7.0. A validation cohort (n=344) included subsequent patients from the initial site (n=72) and an external quaternary-care health system (n=272) from 2012 to 2014. The c-statistic for predicting neurologic outcome was 0.82 (0.74-0.90, P<0.001) in the development cohort and 0.81 (0.76-0.87, P<0.001) in the validation cohort. When subdivided by C-GRApH score, similar rates of favorable neurologic outcome were seen in both cohorts, 70% each for low (0-1, n=60), 22% versus 19% for medium (2-3, n=307), and 0% versus 2% for high (4-5, n=99) C-GRApH scores in the development and validation cohorts, respectively. CONCLUSIONS: C-GRApH stratifies neurologic outcomes following OHCA in patients receiving targeted temperature management (32-34°C) using objective data available at hospital presentation, identifying patient subsets with disproportionally favorable (C-GRApH ≤1) and poor (C-GRApH ≥4) prognoses.

The impact of multidrug resistance on outcomes in ventilator-associated pneumonia.

Multidrug-resistant (MDR) organisms in ventilator-associated pneumonia were found in 49 of 107 patients and were associated with home antibiotics, pre-ventilator-associated pneumonia hospital stay, and health care exposure. Overall, MDR organisms were associated with increased mortality (P = .006). On multivariate analysis, MDR status was modulated by organism class. In nonfermenting gram-negative rods, no association between MDR and mortality was found, but, in all other organisms, MDR was associated with increased mortality risk (hazard ratio, 6.15; 95% confidence interval: 1.80-21.05, P = .004).