The impact of obesity on sepsis mortality: a retrospective review.

BACKGROUND: Recent sepsis guidelines have focused on the early identification and risk stratification of patients on presentation. Obesity is associated with alterations in multiple inflammatory regulators similar to changes seen in sepsis, suggesting a potential interaction between the presence of obesity and the severity of illness in sepsis. METHODS: We performed a retrospective chart review of patients admitted with a primary billing diagnosis of sepsis at a single United States university hospital from 2007 to 2010. Seven hundred and ninety-two charts were identified meeting inclusion criteria. Obesity was defined as a body mass index (BMI) ≥ 30 kg/m2. The data recorded included age, race, sex, vital signs, laboratory values, length of stay, comorbidities, weight, height, and survival to discharge. A modified APACHE II score was calculated to estimate disease severity. The primary outcome variable was inpatient mortality. RESULTS: Survivors had higher average BMI than nonsurvivors (27.6 vs. 26.3 kg/m2, p = 0.03) in unadjusted analysis. Severity of illness and comorbid conditions including cancer were similar across BMI categories. Increased incidence of diabetes mellitus type 2 was associated with increasing BMI (p < 0.01) and was associated with decreased mortality, with an odds ratio of 0.53 compared with nondiabetic patients. After adjusting for age, gender, race, severity of illness, length of stay, and comorbid conditions, the trend of decreased mortality for increased BMI was no longer statistically significant, however diabetes continued to be strongly protective (odds ratio 0.52, p = 0.03). CONCLUSIONS: This retrospective analysis suggests obesity may be protective against mortality in septic inpatients. The protective effect of obesity may be dependent on diabetes, possibly through an unidentified hormonal intermediary. Further prospective studies are necessary to elaborate the specific mechanism of this protective effect.

Effect of standardized electronic discharge instructions on post-discharge hospital utilization.

BACKGROUND: Several physician organizations and the Centers for Medicare and Medicaid Services (CMS) support compliance measures for written discharge instructions. CMS has identified clear discharge instructions with specific attention to medication management as a necessary intervention. OBJECTIVE: We tested the hypothesis that implementing a standardized electronic discharge instructions document with embedded computerized medication reconciliation would decrease post-discharge hospital utilization. DESIGN: Retrospective pre- and post-implementation comparison cohort study. PATIENTS: Subjects were hospitalized patients age 18 and older discharged between November 1, 2005 and October 31, 2006 (n = 16,572) and between March 1, 2007 and February 28, 2008 (n = 17,516). INTERVENTION: Implementation of a standardized, templated electronic discharge instructions document with embedded computerized medication reconciliation on December 18, 2006. MAIN MEASURES: The primary outcome was a composite variable of readmission or Emergency Department (ED) visit within 30 days of discharge. Secondary outcomes were the individual variables of readmissions and ED visits within 30 days. KEY RESULTS: The implementation of standardized electronic discharge instructions with embedded computerized medication reconciliation was not associated with a change in the primary composite outcome (adjusted OR 1.04, 95% CI 0.98-1.10) or the secondary outcome of 30-day ED visits (adjusted OR 0.98, 95% CI 0.98-1.10). There was an unexpected small but statistically significant increase in 30-day readmissions (adjusted OR 1.08, 95% CI 1.01-1.16). CONCLUSIONS: Implementation of standardized electronic discharge instructions was not associated with reduction in post-discharge hospital utilization. More studies are needed to determine the reasons for post-discharge hospital utilization and to examine outcomes associated with proposed process-related recommendations.

Improving Outcomes in Patients With Sepsis.

Sepsis mortality may be improved by early recognition and appropriate treatment based on evidence-based guidelines. An intervention was developed that focused on earlier identification of sepsis, early antimicrobial administration, and an educational program that was disseminated throughout all hospital units and services. There were 1331 patients with sepsis during the intervention period and 1401 patients with sepsis during the control period. After controlling for expected mortality, patients in the intervention period had 30% lower odds of dying (odds ratio = 0.70, 95% confidence interval [CI] = 0.57 to 0.84). They also had 1.07 fewer days on average in the intensive care unit (95% CI = -1.98 to -0.16), 2.15 fewer hospital days (95% CI = -3.45 to -0.86), and incurred on average $1949 less in hospital costs, although the effect on costs was not statistically significant. Continued incremental improvement and sustainment is anticipated through organizational oversight, continued education, and initiation of an automated electronic sepsis alert function.

The effect of a provider-enhanced clinical decision support tool for guiding venous thromboembolism pharmacoprophylaxis in low-risk patients.

BACKGROUND: Computer-based tools to assess venous thromboembolism (VTE) risk have been shown to increase VTE pharmacoprophylaxis rates and decrease VTE incidence in high-risk hospitalized patients. However, VTE risk may be underestimated using computer-based tools alone. We tested the effect of a provider-enhanced clinical decision support (CDS) tool on VTE pharmacoprophylaxis and VTE incidence in patients who would have been deemed "low risk" using a computer-based risk-assessment tool alone. METHODS: The study sample was adult patients hospitalized during a 13-month period who were determined to be at low risk for VTE with a computer-based risk-assessment tool. The provider-enhanced CDS tool was implemented 4 months into the study period and required providers to stratify patients as being at high, moderate, or low risk for VTE. We compared rates of VTE pharmacoprophylaxis and VTE incidence before and after implementation of the provider-enhanced CDS tool. RESULTS: There were 1322 patients in the 4-month pre-implementation period and 3347 patients in the 9-month post-implementation period who were determined to be at low risk for VTE based on a computer-based risk-assessment tool. Using the provider-enhanced CDS tool, providers stratified 31% of these computer-assigned low-risk patients as being at moderate risk for VTE and 7% as being at high risk for VTE. The rate of VTE pharmacoprophylaxis increased from 27% to 34% (P < 0.01). The venous thromboprophylaxis rate decreased from 0.98% to 0.42% after implementation of the provider-enhanced CDS tool (P < 0.02). CONCLUSION: Patients identified as being at low risk for VTE solely by computer-based algorithms may include patients whom providers determine to be at risk for VTE. Provider-enhanced CDS tools may outperform computer-based VTE risk-stratification algorithms.