Patients Who Decompensate and Trigger Rapid Response Immediately Upon Hospital Admission Have Higher Mortality Than Equivalent Patients Without Rapid Responses.

BACKGROUND: Rapid response teams (RRTs) have impacted the management of decompensating patients, potentially improving mortality. Few studies address the significance of RRT timing relative to hospital admission. We aimed to identify outcomes of adult patients who trigger immediate RRT activation, defined as within 4 hours of admission and compare with RRT later in admission or do not require RRT activation, and identify risk factors that predispose toward immediate RRT activation. METHODS: A retrospective case-control study was performed using an RRT activation database, comprising 201,783 adult inpatients at an urban, academic, tertiary care hospital. This group was subdivided by timing of RRT activation regarding admission: within the first 4 hours (immediate RRT), between 4 and 24 hours (early RRT), and after 24 hours (late RRT). The primary outcome was 28-day all-cause mortality. Individuals triggering an immediate RRT were compared with demographically matched controls. Mortality was adjusted for age, Quick Systemic Organ Failure Assessment score, intensive care unit admission, and Elixhauser Comorbidity Index. RESULTS: Patients with immediate RRT had adjusted 28-day all-cause mortality of 7.1% (95% confidence interval [CI], 5.6%-8.5%) and death odds ratio of 3.27 (95% CI, 2.5-4.3) compared with those who did not (mortality, 2.9%; 95%CI, 2.8%-2.9%; P < 0.0001). Patients triggering an immediate RRT were more likely to be Black, be older, and have higher Quick Systemic Organ Failure Assessment scores than those who did not trigger RRT activation. CONCLUSIONS: In this cohort, patients who require immediate RRT experienced higher 28-day all-cause mortality, potentially because of evolving or unrecognized critical illness. Further exploring this phenomenon may create opportunities for improved patient safety.

Blood Pressure Assessment and Treatment in the Observation Unit.

PURPOSE OF REVIEW: To review the pathophysiology, diagnosis, and the management of hypertension. Given the paucity of literature regarding the role of the observation unit in the management of hypertension, we will provide our recommendations based on our experience working in an observation unit. RECENT FINDINGS: Many patients have limited access to primary care, and hypertension diagnosis often relies on office-based measurements. We will describe situations where that is not necessary to make the diagnosis. We will discuss the current non-pharmacologic treatment guidelines, the education of which should be provided to patients both in the emergency department and observation units. We will provide the current recommendations on what anti-hypertension medications can be initiated in the emergency department and observation units. Hypertension is a leading cause of morbidity and mortality in the USA. The utility of an observation unit in the diagnosis and management of patients with hypertension is beneficial particularly for those with risk factors for atherosclerotic disease. An observation unit stay provides the opportunity to diagnosis hypertension, initiate lifestyle education and pharmacologic treatment if indicated, and help to arrange appropriate follow-up for ongoing management and treatment in individuals with limited access to care.

Preliminary Analysis of Excess Mortality in India During the COVID-19 Pandemic.

We studied all-cause mortality during the COVID-19 pandemic in 19 Indian states (population 1.27 billion). Excess mortality was calculated by comparison with years 2015 to 2019. The known COVID-19 deaths reported for a state were assumed to be accurate, unless excess mortality data suggested a higher toll. Data from one state were excluded due to anomalies. In several regions, fewer deaths were reported in 2020 than expected. Areas in Andhra Pradesh, Delhi, Haryana, Karnataka, Madhya Pradesh, Tamil Nadu, and West Bengal saw spikes in mortality in Spring 2021. The pandemic-related mortality through August 31, 2021, in 18 Indian states was estimated to be 198.7 per 100,000 population (range 146.1-263.8 per 100,000). If these rates apply nationally, then 2.69 million people (range 1.98 to 3.57 million) may have perished in India as a result of the pandemic by August 31, 2021.

The Effect of Body Mass Index and Weight-Adjusted Fluid Dosing on Mortality in Sepsis.

PURPOSE: The Surviving Sepsis Campaign guidelines recommend 30 mL/kg of fluids within 3 hours (30by3) of sepsis-induced hypoperfusion, but a national mandate released an allowance for dosing based on ideal instead of actual body weight (IBW/ABW) for obese patients. This study aims to determine the dose-effect of 30by3 for patients with severe sepsis or septic shock (SS/SS) with respect to body mass index (BMI) categories and secondarily, examine the clinical impact of IBW vs. ABW-based dosing. METHODS: Retrospective cohort study of adults (≥18 years; n = 1,032) with SS/SS presenting to an urban, tertiary-care emergency department. Models include MEDS score, antibiotic timing, lactate, renal and heart failure, among others. RESULTS: The cohort was 10.2% underweight and 28.7% obese. Overall mortality was 17.1% with 20.4% shock mortality. An exponential increase in mortality was observed for each 5 mL/kg under 30by3 for underweight (p = 0.02), but not obese patients. ABW vs IBW-30by3 dosing was reached in 80.0 vs 52.4% (underweight), 56.4 vs 56.9% (normal/overweight), and 23.3 vs 46.0% (obese). Across all BMI categories, there was increased mortality for not reaching ABW-based 30by3 dosing (OR 1.78, 95% CI 1.18-2.69) with no significant impact for IBW (OR 1.28, 95% CI 0.87 -1.91). The increased mortality for failing to reach ABW-dosed 30by3 remained for underweight patients ABW (OR 5.82, 95% CI 1.32-25.57) but not obese patients. Longer ICU stays were observed for not reaching 30by3 based on ABW (ß = 2.40, 95% CI 0.84-3.95) and IBW dosing (ß = 1.58, 95% CI 0.07-3.08) overall. This effect remained for obese and underweight (except IBW dosing) patients. CONCLUSIONS: An exponential, dose-effect increase in mortality was observed for underweight patients not receiving 30by3. Therefore, the mortality impact of under-dosing may be amplified using ABW for underweight patients. Fluid dosing did not impact mortality for obese patients, but we caution against deviation from guidelines without further studies.

The effect of delays in second-dose antibiotics on patients with severe sepsis and septic shock.

BACKGROUND: Early antibiotics are fundamental to sepsis management. Second-dose antibiotic delays were associated with increased mortality in a recent study. Study objectives include: 1) determine factors associated with delays in second-dose antibiotic administration; 2) evaluate if delays influence clinical outcomes. METHODS: ED-treated adults (≥18 years; n = 1075) with severe sepsis or septic shock receiving ≥2 doses of intravenous antibiotics were assessed, retrospectively, for second-dose antibiotic delays (dose time > 25% of recommended interval). Predictors of delay and impact on outcomes were determined, controlling for MEDS score, 30 mL/kg fluids and antibiotics within three hours of sepsis onset, lactate, and renal failure, among others. RESULTS: In total, 335 (31.2%) patients had delayed second-dose antibiotics. A total of 1864 second-dose antibiotics were included, with 354 (19.0%) delays identified by interval (delayed/total doses): 6-h (36/67) = 53.7%; 8-h (165/544) = 30.3%; 12-h (114/436) = 26.1%; 24-h (21/190) = 8.2%; 48-h (0/16) = 0%. In-hospital mortality in the timely group was 15.5% (shock-17.6%) and 13.7% in the delayed group (shock-16.9%). Increased odds of delay were observed for ED boarding (OR 2.54, 95% 1.81-3.55), shorter dosing intervals (6/8-h- OR 2.99, 95% CI 1.95-4.57; 12-h- OR 2.46, 95% CI 1.72-3.51), receiving 30 mL/kg fluids by three hours (OR 1.42, 95% CI 1.06-1.90), and renal failure (OR 2.57, 95% CI 1.50-4.39). Delays were not associated with increased mortality (OR 0.87, 95% CI 0.58-1.29) or other outcomes. CONCLUSIONS: Factors associated with delayed second-dose antibiotics include ED boarding, antibiotics requiring more frequent dosing, receiving 30 mL/kg fluid, and renal failure. Delays in second-dose administration were not associated with mortality or other outcomes.