Multimodal Quality Initiatives in Sepsis Care: Assessing Impact on Core Measures and Outcomes.

ABSTRACT: Providing timely and effective care for patients with sepsis is challenging due to delays in recognition and intervention. The Surviving Sepsis Campaign has developed bundles that have been shown to reduce sepsis mortality. However, hospitals have not consistently adhered to these bundles, resulting in suboptimal outcomes. To address this, a multimodal quality improvement sepsis program was implemented from 2017 to 2022 in a large urban tertiary hospital. The aim of this program was to enhance the Severe Sepsis and Septic Shock Management Bundle compliance and reduce sepsis mortality. At baseline, the Severe Sepsis and Septic Shock Management Bundle compliance rates were low, at 25%, with a sepsis observed/expected mortality ratio of 1.14. Our interventions included the formation of a multidisciplinary committee, the appointment of sepsis champions, the implementation of sepsis alerts and order sets, the formation of a Code Sepsis team, real-time audits, and peer-to-peer education. By 2022, compliance rose to 62%, and the observed/expected mortality ratio decreased to 0.73. Our approach led to improved outcomes and hospital rankings. These findings underscore the efficacy of a comprehensive sepsis care initiative, emphasizing the importance of interdisciplinary collaboration. A multimodal hospital-wide sepsis performance program is feasible and can contribute to improved outcomes. However, further research is necessary to determine the specific impact of individual strategies on sepsis outcomes.

Clinical and echocardiographic outcomes with new-onset left bundle branch block after SAPIEN-3 transcatheter aortic valve replacement.

BACKGROUND: New-onset left bundle branch block (LBBB) can develop after transcatheter aortic valve replacement (TAVR) resulting in worse outcomes. AIMS: Describe clinical and echocardiographic outcomes with new-onset LBBB after TAVR. METHODS: We included consecutive patients who underwent transfemoral-TAVR with SAPIEN-3 (S3) valve between April 2015 and December 2018. Exclusion criteria included pre-existing LBBB, right BBB, left anterior hemiblock, left posterior hemiblock, wide QRS ≥ 120ms, prior permanent pacemaker (PPM), and nontransfemoral access. RESULTS: Among 612 patients, 11.4% developed new-onset LBBB upon discharge. The length of stay was longer with new-onset LBBB compared with no LBBB [3 (2-5) days versus 2 (1-3) days; p < 0.001]. New-onset LBBB was associated with higher rates of 30-day PPM requirement (18.6% vs. 5.4%; p < 0.001) and 1-year heart failure hospitalizations (10.7% vs. 4.4%; p = 0.033). There was no difference in 3-year mortality between both groups (30.9% vs. 30.6%; p = 0.829). Further, new-onset LBBB was associated with lower left ventricular ejection fraction (LVEF) at both 30 days (55.9 ± 11.4% vs. 59.3 ± 9%; p = 0.026) and 1 year (55 ± 12% vs. 60.1 ± 8.9%; p = 0.002). These changes were still present when we stratified patients according to baseline LVEF (≥50% or <50%). New-onset LBBBs were associated with a higher 1-year LV end-diastolic volume index (51.4 ± 18.6 vs. 46.4 ± 15.1 ml/m2 ; p = 0.036), and LV end-systolic volume index (23.2 ± 14.1 vs. 18.9 ± 9.7 ml/m2 ; p = 0.009). Compared with resolved new-onset LBBB, persistent new-onset LBBB was associated with worse LVEF and higher PPM at 1 year. CONCLUSIONS: New-onset LBBB after S3 TAVR was associated with higher PPM requirement, worse LVEF, higher LV volumes, and increased heart failure hospitalizations, with no difference in mortality.

Comparison of Outcomes of Transcatheter Aortic Valve Implantation in Patients With Versus Without Mitral Annular Calcium.

There are limited data regarding the impact of mitral annular calcium (MAC) on the outcomes of patients who underwent transcatheter aortic valve implantation (TAVI). We performed a retrospective analysis of patients who underwent TAVI in 2018 and divided them into 2 groups based on the presence or absence of MAC, using a validated MAC computed tomography-based scoring system. Among 468 patients who underwent TAVI in 2018, 271 patients (58%) had MAC present compared with 197 patients (42%) without MAC. Compared with patients without MAC, patients in the MAC group were older (81 vs 79, p = 0.012), had a higher body mass index (29.30 vs 28.05, p = 0.031), lower left ventricular end-diastolic diameter (4.47 vs 4.80, p <0.001), higher mitral valve mean gradient (4.54 vs 3.01, p = 0.031), and a higher Society of Thoracic Surgeons risk score (5.69 vs 4.91, p = 0.127). There was no significant difference in the with versus without MAC groups in the all-cause mortality (at 1 year: 9% vs 6%, p = 0.8; at 2 years: 15% vs 13%, p = 0.47), incidence of myocardial infarction (1% vs 2%, p = 0.417), stroke (1% vs 3%, p = 0.4), and major adverse cardiac and cerebrovascular events (17% vs 19%, p = 0.53) at 1 year. Although the rate of new-onset left bundle branch block was higher in patients with MAC, there was no significant difference between the 2 groups in the rates of complete atrioventricular block (5% vs 3%, p = 0.483) or the need for pacemaker implantation (6% vs 3%, p = 0.168). The post-TAVI peak aortic valve gradient was comparable between the groups with and without MAC (22.52 vs 22.60, p = 0.931). In conclusion, TAVI is a safe alternative for patients with severe aortic stenosis and concomitant MAC, with comparable outcomes to patients without MAC.

Impact of elevated left ventricular filling pressure on long-term outcomes after transcatheter aortic valve replacement.

BACKGROUND: Increase in left ventricular filling pressure (FP) and diastolic dysfunction are established consequences of progressive aortic stenosis (AS). However, the impact of elevated FP as detected by pretranscatheter aortic valve replacement (TAVR) echocardiogram on long-term outcomes after TAVR remains unclear. OBJECTIVE: To understand the impact of elevated FP in patients with severe AS who undergo TAVR. METHODS: This was a retrospective study of all patients who underwent TAVR between 1 January 2014 and 31 December 2017. The presence of elevated FP was determined in accordance with the latest guidelines using the last available comprehensive echocardiogram prior to TAVR. RESULTS: Of 983 patients who were included in our study, 422 patients (43%) were found to have elevated FP and 561 patients (57%) had normal FP prior to TAVR. Patients with elevated FP had a mean age of 81.2±8.6 years and were more likely to be males (62%), diabetic (41% vs 35%, p=0.046), and have a higher prevalence of atrial fibrillation (Afib) (53% vs 39%, p<0.001). The 5-year all-cause mortality after TAVR was significantly higher in patients with elevated FP when compared with patients with normal FP (32% vs 24%, p=0.006). The presence of elevated FP, history of Afib and prior PCI emerged as independent predictors of long-term mortality after TAVR. CONCLUSION: Elevated FP is associated with increased mortality in patients with severe AS undergoing TAVR. Assessment of FP should be incorporated into the risk assessment of AS patients to identify those who may benefit from early intervention.