Improved Outcomes After Regional Implementation of Sepsis Alert: A Novel Triage Model.

OBJECTIVES: To assess whether the triage model Sepsis Alert for Emergency Departments results in improved initial care of patients with severe infections. DESIGN: Interventional study comparing patient care before and after the start of a new triage model, including 90-day follow-up. SETTING: Eight emergency departments in Skåne County, Sweden. SUBJECTS: Patients with suspected severe infection. INTERVENTIONS: Patients with severely deviating vital signs and suspected infection were triaged into a designated sepsis line called Sepsis Alert, for rapid evaluation supported by an infectious disease specialist. Also, all emergency department staff participated in a designated sepsis education before the model was introduced. MEASUREMENTS AND MAIN RESULTS: Medical records were evaluated for a 3-month period 1 year before the triage system was started in 2016 and for a 3-month period 1 year after. Of 195,607 patients admitted to these emergency departments during two 3-month periods, a total of 5,321 patients presented severely abnormal vital signs. Of these, 1,066 patients who presented with fever greater thanor equal to 38°C or history of fever/chills were considered to be patients at risk of having severe sepsis. Among patients triaged according to Sepsis Alert, 89.3% received antibiotic treatment within 1 hour after arrival to the emergency department (median time to antibiotics, 26 min), which was significantly better than before the start of the new triage: 67.9% (median time to antibiotics, 37 min) (p < 0.001). Additionally, sepsis treatment quality markers were significantly improved after the introduction of Sepsis Alert, including number of blood cultures and lactate measurements taken, percentage of patients receiving IV fluids, and appropriate initial antibiotic treatment. There were no differences in 28- or 90-day mortality rates. CONCLUSIONS: The implementation of the new triage model Sepsis Alert with special attention to severe sepsis patients led to faster and more accurate antibiotic treatment and improved diagnostic procedures and supportive care.

Sources of Airborne Norovirus in Hospital Outbreaks.

BACKGROUND: Noroviruses are the major cause of viral gastroenteritis. Disease transmission is difficult to prevent and outbreaks in health-care facilities commonly occur. Contact with infected persons and contaminated environments are believed to be the main routes of transmission. However, noroviruses have recently been found in aerosols and airborne transmission has been suggested. The aim of our study was to investigate associations between symptoms of gastroenteritis and the presence of airborne norovirus, and to investigate the size of norovirus-carrying particles. METHODS: Air sampling was repeatedly performed close to 26 patients with norovirus infections. Samples were analyzed for norovirus RNA by reverse transcription quantitative polymerase chain reaction. The times since each patient's last episodes of vomiting and diarrhea were recorded. Size-separating aerosol particle collection was performed. RESULTS: Norovirus RNA was found in 21 (24%) of 86 air samples from 10 different patients. Only air samples during outbreaks, or before a succeeding outbreak, tested positive for norovirus RNA. Airborne norovirus RNA was also strongly associated with a shorter time period since the last vomiting episode (odds ratio 8.1; P = .04 within 3 hours since the last vomiting episode). The concentrations of airborne norovirus ranged from 5-215 copies/m3, and detectable amounts of norovirus RNA were found in particles <0.95 µm and >4.51 µm. CONCLUSIONS: The results suggest that recent vomiting is the major source of airborne norovirus and imply a connection between airborne norovirus and outbreaks. The presence of norovirus RNA in submicrometre particles indicates that airborne transmission can be an important transmission route.

Sepsis Alert - a triage model that reduces time to antibiotics and length of hospital stay.

OBJECTIVE: To study if a modified triage system at an Emergency Department (ED) combined with educational efforts resulted in reduced time to antibiotics and decreased length of hospital stay (LOS) for patients with severe infection. METHODS: A retrospective, observational study comparing patients before and after the start of a new triage model at the ED of a University Hospital. After the implementation of the model, patients with fever and abnormal vital signs were triaged into a designated sepsis line (Sepsis Alert) for rapid evaluation by the attending physician supported by a infectious diseases (IDs) specialist. Also, all ED staff participated in a designated sepsis education before Sepsis Alert was introduced. Medical records were evaluated for patients during a 3-month period after the triage system was started in 2012, and also during the corresponding months in 2010 and 2014. RESULTS: A total of 1837 patients presented with abnormal vital signs. Of these, 221 patients presented with fever and thus at risk of having severe sepsis. Among patients triaged according to the new model, median time to antibiotics was 58.5 at startup and 24.5 minutes at follow-up two years later. This was significantly less than for patients treated before the new model, 190 minutes. Also, median LOS was significantly decreased after introduction of the new triage model, from nine to seven days. CONCLUSIONS: A triage model at the ED with special attention to severe sepsis patients, led to sustained improvements of time to antibiotic treatment and LOS.

Sepsis Incidence: A Population-Based Study.

BACKGROUND: Although sepsis is a major health problem, data on sepsis epidemiology are scarce. The aim of this study was to assess the incidence of sepsis, based on clinical findings in all adult patients treated with intravenous antibiotic in all parts of all hospitals in an entire population. METHODS: This is a retrospective chart review of patients ≥18 years, living in 2 regions in Sweden, who were started on an intravenous antibiotic therapy on 4 dates, evenly distributed over the year of 2015. The main outcome was the incidence of sepsis with organ dysfunction. The mean population ≥18 years at 2015 in the regions was 1275753. Five hundred sixty-three patients living in the regions were started on intravenous antibiotic treatment on the dates of the survey. Patients who had ongoing intravenous antibiotic therapy preceding the inclusion dates were excluded, if sepsis was already present. RESULTS: Four hundred eighty-two patients were included in the study; 339 had a diagnosed infection, of those, 96 had severe sepsis according to the 1991/2001 sepsis definitions, and 109 had sepsis according to the sepsis-3. This is equivalent to an annual incidence of traditional severe sepsis of 687/100000 persons (95% confidence interval [CI], 549-824) or according to the sepsis-3 definition of 780/100000 persons (95% CI, 633-926). Seventy-four patients had sepsis according to both definitions. CONCLUSIONS: The incidence of sepsis with organ dysfunction is higher than most previous estimates independent of definition. The inclusion of all inpatients started on intravenous antibiotic treatment of sepsis in a population makes an accurate assessment of sepsis incidence possible.

A cost analysis of introducing an infectious disease specialist-guided antimicrobial stewardship in an area with relatively low prevalence of antimicrobial resistance.

BACKGROUND: Antimicrobial stewardship programs have been widely introduced in hospitals as a response to increasing antimicrobial resistance. Although such programs are commonly used, the long-term effects on antimicrobial resistance as well as societal economics are uncertain. METHODS: We performed a cost analysis of an antimicrobial stewardship program introduced in Malmö, Sweden in 20 weeks 2013 compared with a corresponding control period in 2012. All direct costs and opportunity costs related to the stewardship intervention were calculated for both periods. Costs during the stewardship period were directly compared to costs in the control period and extrapolated to a yearly cost. Two main analyses were performed, one including only comparable direct costs (analysis one) and one including comparable direct and opportunity costs (analysis two). An extra analysis including all comparable direct costs including costs related to length of hospital stay (analysis three) was performed, but deemed as unrepresentative. RESULTS: According to analysis one, the cost per year was SEK 161 990 and in analysis two the cost per year was SEK 5 113. Since the two cohorts were skewed in terms of size and of infection severity as a consequence of the program, and since short-term patient outcomes have been demonstrated to be unchanged by the intervention, the costs pertaining to patient outcomes were not included in the analysis, and we suggest that analysis two provides the most correct cost calculation. In this analysis, the main cost drivers were the physician time and nursing time. A sensitivity analysis of analysis two suggested relatively modest variation under changing assumptions. CONCLUSION: The total yearly cost of introducing an infectious disease specialist-guided, audit-based antimicrobial stewardship in a department of internal medicine, including direct costs and opportunity costs, was calculated to be as low as SEK 5 113.

Hydrogen Peroxide Vapor Decontamination in a Patient Room Using Feline Calicivirus and Murine Norovirus as Surrogate Markers for Human Norovirus.

OBJECTIVE: To determine whether hydrogen peroxide vapor (HPV) could be used to decontaminate caliciviruses from surfaces in a patient room. DESIGN: Feline calicivirus (FCV) and murine norovirus (MNV) were used as surrogate viability markers to mimic the noncultivable human norovirus. Cell culture supernatants of FCV and MNV were dried in triplicate 35-mm wells of 6-well plastic plates. These plates were placed in various positions in a nonoccupied patient room that was subsequently exposed to HPV. Control plates were positioned in a similar room but were never exposed to HPV. METHODS: Virucidal activity was measured in cell culture by reduction in 50% tissue culture infective dose titer for FCV and by both 50% tissue culture infective dose titer and plaque reduction for MNV. RESULTS: Neither viable FCV nor viable MNV could be detected in the test room after HPV treatment. At least 3.65 log reduction for FCV and at least 3.67 log reduction for MNV were found by 50% tissue culture infective dose. With plaque assay, measurable reduction for MNV was at least 2.85 log units. CONCLUSIONS: The successful inactivation of both surrogate viruses indicates that HPV could be a useful tool for surface decontamination of a patient room contaminated by norovirus. Hence nosocomial spread to subsequent patients can be avoided.

Do surface active parenteral formulations cause inflammation?

Local irritation and inflammation at the site of administration are a common side effect following administration of parenteral formulations. Biological effects of surface (interfacial) activity in solutions are less well investigated than effects caused by other physico-chemical parameters such as pH and osmolality. The interfacial activity in different systems, including human plasma, typical amphiphilic substances with fundamental biological relevance such as free fatty acids, anesthetic depot formulations and six different antibiotics was measured. The relative interfacial pressure, and/or concentration of active substance, required to obtain 50% of the maximal attainable effect in terms of interfacial pressure were calculated. The aim was to test the hypothesis that these parameters would allow comparison to biological effects reported in in vivo studies on the investigated substances. The highest interfacial activity was found in a triglyceride/plasma system. Among the antibiotic tested, the highest interfacial activities were found in erythromycin and dicloxacillin, which is in accordance with previous clinical findings of a high tendency of infusion phlebitis and cell toxicity. Independently of investigated system, biological effects were minimal below a 15% relative increase of interfacial activity. Above 35-45% the effects were severe. Interfacial activity in parenteral formulations may well cause damages to tissues followed by inflammation.

Design for the post-antibiotic era: experiences from a new building for infectious diseases in malmö, sweden.

OBJECTIVE: To describe the experience of planning and designing a new facility for infectious diseases in Sweden and to discuss underlying theories relating to infection prevention and evidence-based design. BACKGROUND: Departments of Infectious Diseases are common in healthcare facililties in Sweden. In 2005, a decision was made to build a new facility. The program required spacious single rooms, with a high ventilation standard, and anterooms. METHODS: In this article we present an analysis of the future of infectious diseases. Underlying theories are discussed. We also describe how a program was outlined using literature studies, including evidence-based healthcare design, focus groups of staff, and study visits. RESULTS: Active involvement of users and infection control specialists was important in the building process. A full-scale patient room mock-up was built with ventilation, electrical, and other systems. The mock-up was cost effective because it avoided costly mistakes during the building process. The mock-up also was a place where staff could assess and begin adapting to their future work environment. Separate ventilation and separate entrances to patient rooms from the building exterior allowed placement of isolation units in the main hospital area. CONCLUSIONS: Antimicrobial resistance, emerging diseases, healthcare associated infections, and outbreaks highlight the need for infection control measures in all hospital design. Infection control should be integrated in all hospital planning and be part of contracts. In this study we describe a specialized unit where a high degree of standardization and flexibility has made it possible to have a unique standard of preparedness for the post-antibiotic era. KEYWORDS: Design process, evidence-based design, infection control, planning, safety.

Perception of risk factors for infusion phlebitis among Swedish nurses: a questionnaire study.

This questionnaire study was set up to assess the perceptions of risk factors for infusion phlebitis among Swedish nurses, as their concepts of these factors may influence the incidence. A majority of the nurses believed that insertion of a peripheral venous catheter in the forearm and catheter rotation within 48 hours was protective. These measures are not supported in recent studies and guidelines. Surveillance of the educational level of staff, who insert peripheral venous catheters, is an important tool for reducing the incidence of infusion phlebitis.

Dicloxacillin and erythromycin at high concentrations increase ICAM-1 expression by endothelial cells: a possible factor in the pathogenesis of infusion phlebitis.

OBJECTIVES: Antimicrobial agents are important risk factors for infusion phlebitis, but the risk varies between different antibiotics. Erythromycin and dicloxacillin are known to induce phlebitis frequently, as well as to exert toxic effects on cultured endothelial cells. The pathogenesis of infusion phlebitis is unclear, but chemical toxicity is thought to lead to inflammation and subsequent thrombosis. In the present study, endothelial cells were exposed to antibiotics at the range of concentrations used for intravenous administration, followed by analysis of pro-inflammatory and pro-coagulant surface molecules. METHODS: Primary human umbilical vein endothelial cells (HUVEC) and the endothelial hybrid cell line EaHy926 were exposed to dicloxacillin, erythromycin, benzylpenicillin and cefuroxime (all at 6250 mg/L) for 60 min, followed by washing. After 5 or 24 h additional incubation, cells were analysed for E-selectin (CD62E), tissue factor (TF) or intercellular adhesion molecule 1 (ICAM-1, CD54) density by flow cytometry. RESULTS: Despite constitutive expression of ICAM-1 (34%) in HUVEC, 6250 mg/L of dicloxacillin or erythromycin significantly increased the number of cells with ICAM-1 expression by 37% and 30%, respectively. In contrast, cefuroxime and benzylpenicillin did not up-regulate ICAM-1 above background levels. A similar pattern was seen with the endothelial cell line EaHy926. The E-selectin and TF density were not affected by the antibiotics examined. CONCLUSIONS: The results of this study support the theory that endothelial cells that are affected by high concentrations of antibiotics may initiate an inflammatory response through expression of ICAM-1. This is a novel finding in the pathogenesis of infusion phlebitis.

Dicloxacillin: a higher risk than cloxacillin for infusion phlebitis.

Ever since dicloxacillin and cloxacillin were introduced in the 1960s, it has been known that they are associated with a high incidence of infusion phlebitis. Some in vitro studies and clinical experience have indicated that dicloxacillin is the more vessel-irritating of the 2 drugs. In this prospective observational study on 39 patients with 111 peripheral venous catheters (PVCs), the incidence of infusion phlebitis was compared between these 2 drugs. The incidence of phlebitis was 38% with dicloxacillin and 21% with cloxacillin; which, compared by logistic regression with other risk factors as covariates, was significant [odds ratio 5.06, 95% confidence interval (95% CI) 1.45-17.60]. Since the duration of catheterization is also an important risk factor, Cox regression was performed, and the difference between the 2 drugs was still significant (proportional hazard rate 3.48, 95%, CI 1.64-7.38). The only other significant risk factor found in the study was the insertion site; the risk was higher in PVCs inserted in the forearm/antecubital fossa than in the hand/wrist. The infusion time and dilution of the infusate were not significant risk factors.

[Multidisciplinary course in emergency medicine gives residents greater confidence]. / Multidisciplinär kurs i akutmedicin ger ST-läkare större säkerhet.

Lack of courses in emergency medicine for doctors under training is currently a problem in Sweden. Only 10 percent will have these courses early under their internship. The University hospital in Malmoe has therefore decided to create a course for doctors under training and to offer it early in their education. The curriculum is based on a problem-based learning concept using a modified case methodology that has been used since the 1920's at Harvard Business school in Boston. The course integrates doctors from different specialties with experienced nurses from the emergency ward. The five day course comprises; three theoretical days where cases from the emergency room are discussed with the case methodology, followed by two days of practical training. Our results from 100 participants over a period of two years is very encouraging, over 85 percent of the participants were very satisfied with the course. The multidisciplinary discussion about different cases was much appreciated. Our experience of this problem-based learning concept is very good, since it promotes deep rather than surface learning and promotes an in-depth collaboration between disciplines.

Antibiotics differ in their tendency to cause infusion phlebitis: a prospective observational study.

Intravenous administration of antibiotics is a known risk factor for infusion phlebitis. We have previously demonstrated differences in cell toxicity for 4 antibiotics. Clinical experience indicates that antibiotics differ in their tendency to cause phlebitis. The present study was done prospectively on 550 patients with 1386 peripheral venous catheters. The incidence of phlebitis was 18.5% with antibiotics and 8.8% without (odds ratio 2.34). Dicloxacillin (odds ratio 5.74) and erythromycin (odds ratio 5.33) had the greatest tendency to cause phlebitis in univariate, multivariate and Cox regression analyses. Benzylpenicillin, cefuroxime and cloxacillin were also associated with a greater risk of phlebitis, whereas ampicillin, imipenem/cilastatin, clindamycin, netilmicin and vancomycin were not. Other risk factors were the site of insertion and age 51-60 y. Medication with warfarin was found to be protective, but not with aspirin. Treatment with low molecular weight heparin reduced the risk of phlebitis, but the difference was not significant. With regard to when antibiotics were given, the day-specific risk increased between Days 1 and 2, but no further on subsequent days. The hypothesis that antibiotics differ in their tendency to cause phlebitis was confirmed.