Late-afternoon communication and patient planning (CAPP) rounds: an intervention to allow early patient discharges.

OBJECTIVE: Measure effect of late-afternoon communication and patient planning (CAPP) rounds to increase early electronic discharge orders (EDO). METHODS: We enrolled 4485 patients discharged from six subspecialty medical services. We implemented late-afternoon CAPP rounds to identify patients who could have morning discharge the subsequent day. After an initial successful implementation of the intervention, we identified lack of sustainability. We made changes with sustained implementation of the intervention. This is a before-after study of a quality improvement intervention. PROGRAM EVALUATION: Primary measures of intervention effectiveness were percentage of patients who received EDO by 11 am and patients discharged by noon. Additional measure of effectiveness were percent of patients admitted to the correct ward, emergency department (ED)-to-ward transfer time compared between intervention and nonintervention periods. We compared the overall expected LOS and the average weekly discharges to assess for comparability across the control and intervention time periods. We used the readmission rate as balancing measure to ensure that the intervention was not have unintended negative patients consequences. RESULTS: Expected length of stay based upon discharge diagnosis/comorbidities and readmission rates were similar across the intervention and control time periods. The average weekly discharges were not statistically significant. Percentage of EDO by 11 am was higher in the first intervention period, second intervention period and combined intervention periods (28.9% vs. 21.8%, P < 0.001) compared with the respective control periods. Percent discharged before noon increased in the first intervention period, second intervention period and for the combined intervention periods (17 vs. 11.8%, P < 0.001). There was no difference in the percent admitted to the correct ward and ED-to-ward transfer time. CONCLUSION: Afternoon CAPP rounds to identify early patient discharges the following day led to increase in EDO entered by 11 am and discharges by noon without an adverse change in readmission rates and LOS.

Prospective Observational Study Comparing Sepsis-2 and Sepsis-3 Definitions in Predicting Mortality in Critically Ill Patients.

BACKGROUND: Sepsis definitions have evolved, but there is a lack of consensus over adoption of the most recent definition, Sepsis-3. We sought to compare Sepsis-2 and Sepsis-3 in the classification of patients with sepsis and mortality risk at 30 days. METHODS: We used the following definitions: Sepsis-2 (≥2 systemic inflammatory response syndrome criteria + infection), Sepsis-3 (prescreening by quick Sequential Organ Failure Assessment [qSOFA] of ≥2 of 3 criteria followed by the complete score change ≥2 + infection), and an amended Sepsis-3 definition, iqSOFA (qSOFA ≥2 + infection). We used χ 2 or Wilcoxon rank-sum tests, receiver-operator characteristic curves, and survival analysis. RESULTS: We enrolled 176 patients (95% in an intensive care unit, 38.6% female, median age 61.4 years). Of 105 patients classified by Sepsis-2 as having sepsis, 80 had sepsis per Sepsis-3 or iqSOFA (kappa = 0.72; 95% confidence interval [CI], 0.62-0.82). Twenty-five (14.8%) died (20 of 100 with sepsis per Sepsis-2 [20%], and 20 of 77 [26.0%] with sepsis per Sepsis-3 or iqSOFA). Results for Sepsis-3 and iqSOFA were identical. The area under the curve of receiver-operator characteristic (ROC) curves for identifying those who died were 0.54 (95% CI, 0.41-0.68) for Sepsis-2, 0.84 (95% CI, 0.74-0.93) for Sepsis-3, and 0.69 (95% CI, 0.60-0.79) for iqSOFA (P < .01). Hazard ratios for death associated with sepsis were greatest for sepsis or septic shock per Sepsis-3. CONCLUSIONS: Sepsis-3 and iqSOFA were better at predicting death than Sepsis-2. Using the SOFA score might add little advantage compared with the simpler iqSOFA score.

Characteristics and outcomes of neutropenia after orthotopic liver transplantation.

Neutropenia after orthotopic liver transplantation (LT) is relatively common, but the factors associated with its development remain elusive. We assessed possible predictors of neutropenia (absolute neutrophil count [ANC] ≤ 1000/mm(3) ) within the first year of LT in a cohort of 304 patients at a tertiary medical center between 1999 and 2009 using time-dependent survival analysis to identify risk factors for neutropenia. In addition, we analyzed neutropenia as a predictor of the clinical outcomes of death, bloodstream infection (BSI), invasive fungal infection, cytomegalovirus (CMV) disease, and graft rejection within the first year of LT. Of the 304 LT recipients, 73 (24%) developed neutropenia, 5 (7%) of whom had grade 4 neutropenia (ANC < 500/mm(3) ). The following were independent predictors for neutropenia: Child-Turcotte-Pugh score (hazard ratio [HR] 1.15; 95% confidence interval [CI], 1.03-1.30; P = 0.02), BSI (HR, 2.89; 95% CI, 1.63-5.11; P < 0.001), CMV disease (HR, 4.28; 95% CI, 1.55-11.81; P = 0.005), baseline tacrolimus trough level (HR, 1.02; 95% CI, 1.01-1.03; P = 0.007), and later era LT (2004-2009 versus 1999-2003; HR, 2.28; 95% CI, 1.43-3.65; P < 0.001). Moreover, neutropenia was found to be an independent predictor for mortality within the first year of LT (HR, 3.76; 95% CI, 1.84-7.68; P < 0.001). In conclusion, our data suggest that neutropenia within a year after LT is not unusual and is an important predictor of mortality.

Pretransplant lymphopenia is a novel prognostic factor in cytomegalovirus and noncytomegalovirus invasive infections after liver transplantation.

Infection after liver transplantation (LT) remains a leading cause of morbidity and mortality. The risk of infection after LT is highest in those who are most immunosuppressed, but to date, no standard blood marker of one's degree of immunosuppression or risk index has been established. The purpose of this study was to determine whether pretransplant lymphopenia (absolute lymphocyte count < 500 cells/mm3 within 24 hours before LT) is a candidate marker of immunosuppression and could be useful in predicting the risk of cytomegalovirus (CMV) disease and non-CMV invasive infections after LT. Data were extracted from medical records for all primary, solitary LT procedures performed at Tufts Medical Center from 1999 to 2009. Two hundred seventy-six patients had sufficient data to be included in the analysis. Among these patients, 52% developed CMV or non-CMV invasive infections within 5 years of LT. Within 2 years, 23 (8%) had CMV disease, and 103 (37%) at least 1 non-CMV invasive infection. More lymphopenic patients than nonlymphopenic patients developed CMV (21% versus 4%, P < 0.001) and non-CMV invasive infections (50% versus 33%, P = 0.02). In a multivariate survival analysis, pretransplant lymphopenia was the strongest independent predictor of CMV disease [hazard ratio (HR) = 5.52, 95% confidence interval (CI) = 2.31-13.1, P = 0.001] after adjustments for known risk factors, including CMV serostatus (HR = 4.72, 95% CI = 2.01-11.1, P < 0.001). Both pretransplant lymphopenia (HR = 1.64, 95% CI = 1.14-2.53, P = 0.03) and CMV (HR = 2.93, 95% CI = 1.23-6.92, P = 0.02) independently predicted non-CMV infections. Our results suggest that pretransplant lymphopenia is a novel independent predictor of both CMV disease and non-CMV invasive infections after LT and is a candidate marker of immunosuppression in LT recipients.

Risk factors for death after sepsis in patients immunosuppressed before the onset of sepsis.

Few studies have focused on sepsis in patients with pre-existing immunosuppression. Since the numbers and the incidence of sepsis are increasing, sepsis in immunosuppressed patients will increase in importance. We studied the epidemiology of sepsis and risk factors for 28-d mortality in patients immunosuppressed prior to the onset of sepsis using data from the Academic Medical Center Consortium's (AMCC) prospective observational cohort study of sepsis. We compared characteristics of immunosuppressed (n =412) and immunocompetent (n =754) patients. Immunosuppressed patients were younger and more likely to have underlying liver or lung disease, and nosocomial infection or bloodstream infection of unknown source when presenting with sepsis. They were also more likely to die within 28 d compared to immunocompetent patients (adjusted relative risk 1.62, 95% CI 1.38 - 1.91). Septic shock, hypothermia, cancer and invasive fungal infections were associated with increased mortality in immunosuppressed patients. Black race and the presence of rigors were independent predictors of survival in immunosuppressed patients. We conclude that sepsis among patients immunosuppressed prior to the onset of sepsis was associated with higher mortality than in immunocompetent patients. As the numbers of immunosuppressed patients continue to grow, more studies on the epidemiology of sepsis in this group will become increasingly important.

Daptomycin in the treatment of vancomycin-resistant Enterococcus faecium bacteremia in neutropenic patients.

OBJECTIVE: Vancomycin resistant enterococcal (VRE) blood stream infection (BSI) in neutropenic patients is associated with poor outcome. We report our experience in treating VRE BSI in febrile, neutropenic patients with daptomycin, a recently licensed lipopeptide with bactericidal activity against VRE. PATIENTS AND METHODS: Patients with fever, neutropenia and VRE BSI were treated with more than one dose of daptomycin (either 6 mg/kg/day or 4 mg/kg/day) in an open label, emergency-use trial. Patients were then assessed for clinical and microbiological cures and survival. MIC's of isolates to daptomycin were determined. RESULTS: Nine febrile, neutropenic patients with VRE BSI received daptomycin. Four of 9 courses (44%) had clinical and/or microbiologic cure. Two of the 5 who failed cure died within 3 days of initiation of daptomycin. Five subjects survived to 30 days after the onset of BSI. CONCLUSIONS: Use of daptomycin in neutropenic patients with VRE BSI deserves further study as a treatment for VRE BSI in neutropenic patients.

The clinical impact of ganciclovir prophylaxis on the occurrence of bacteremia in orthotopic liver transplant recipients.

BACKGROUND: Cytomegalovirus (CMV) infection or receipt of a CMV-seropositive donor liver has been shown to be an independent predictor of bacteremia in orthotopic liver transplant (OLT) recipients. However, prevention of CMV infection through use of intense CMV prophylaxis has not been examined to assess the impact on bacteremia in liver transplant recipients. METHODS: We analyzed the impact of CMV prophylaxis on rates of bacteremia by examining 192 consecutive OLT recipients during a 2-year follow-up period. RESULTS: There were 29 episodes of bacteremia. Univariate analysis of risk factors for bacteremia showed that invasive fungal disease, initial anti-lymphocyte immunosuppression, treatment for rejection, and use of solumedrol were significantly associated with increased risk. Receipt of >or=14 days of ganciclovir prophylaxis (hazard ratio [HR], 0.40; 95% CI [confidence interval], 0.18-0.87; P=.02), end-to-end biliary anastomosis, and receipt of <10 units of red blood cells (RBCs) were significantly associated with a decreased risk. Three-variable analysis controlling for end-to-end anastomosis and use of <10 units of RBCs, showed that use of >or=14 days of ganciclovir was still associated with a reduced risk of bacteremia (HR, 0.44; 95% CI, 0.20-0.98; P=.0437). CONCLUSIONS: Among factors associated with bacteremia, use of prophylactic ganciclovir is independently associated with a significant reduction of bacteremia in OLT recipients.