Effect of a machine learning-based severe sepsis prediction algorithm on patient survival and hospital length of stay: a randomised clinical trial.

IntroductionSeveral methods have been developed to electronically monitor patients for severe sepsis, but few provide predictive capabilities to enable early intervention; furthermore, no severe sepsis prediction systems have been previously validated in a randomised study. We tested the use of a machine learning-based severe sepsis prediction system for reductions in average length of stay and in-hospital mortality rate.MethodsWe conducted a randomised controlled clinical trial at two medical-surgical intensive care units at the University of California, San Francisco Medical Center, evaluating the primary outcome of average length of stay, and secondary outcome of in-hospital mortality rate from December 2016 to February 2017. Adult patients (18+) admitted to participating units were eligible for this factorial, open-label study. Enrolled patients were assigned to a trial arm by a random allocation sequence. In the control group, only the current severe sepsis detector was used; in the experimental group, the machine learning algorithm (MLA) was also used. On receiving an alert, the care team evaluated the patient and initiated the severe sepsis bundle, if appropriate. Although participants were randomly assigned to a trial arm, group assignments were automatically revealed for any patients who received MLA alerts.ResultsOutcomes from 75 patients in the control and 67 patients in the experimental group were analysed. Average length of stay decreased from 13.0 days in the control to 10.3 days in the experimental group (p=0.042). In-hospital mortality decreased by 12.4 percentage points when using the MLA (p=0.018), a relative reduction of 58.0%. No adverse events were reported during this trial.ConclusionThe MLA was associated with improved patient outcomes. This is the first randomised controlled trial of a sepsis surveillance system to demonstrate statistically significant differences in length of stay and in-hospital mortality.Trial registrationNCT03015454

Screening for Sepsis: A Key Strategy for Early Identification and Management of Septic Patients

Background: Sepsis, defined as a systemic inflammatory response to infection, is a life-threatening medical condition that rapidly progresses from severe sepsis (characterized by signs of organ dysfunction) to septic shock with fluid-refractory hypotension. Adherence to the Surviving Sepsis Campaign guidelines for the management of severe sepsis and septic shock have been associated with improved delivery of care and reduced mortality. Delays in recognition of sepsis has been identified as a barrier to achieving early goal-directed therapy targets. Purpose: To determine if a sepsis screening protocol could facilitate earlier identification of patients with sepsis Methods: A retrospective medical record review was conducted for adult patients with a primary or secondary diagnosis of sepsis using ICD-9 codes 038.9 (unspecified septicemia), 995.91 (sepsis), 995.92 (severe sepsis), and 785.52 (septic shock). A sepsis screening strategy was applied retrospectively to simulate implementation of a screening protocol. Application of the screening strategy was performed to quantify the interval between when clinicians first recognized sepsis and when patients first exhibited signs of systemic inflammatory response syndrome (SIRS). Results: The median interval of time between when a clinician recognized sepsis and when a patient first exhibited signs of sepsis was 222 minutes. A difference in time occurred in 22% of the cases. Duration of the interval was positively correlated with hospital length of stay (rs = .65, n = 17, p = .005). Conclusion: The interval between when patients with sepsis were first identified by a clinician (without screening) and when those patients could have been recognized utilizing a screening protocol was quantified. Results suggest that more than one in five patients would have been identified earlier using a screening protocol. A pilot study to further investigate the potential impact of sepsis screening on time to identification is warranted

Improved diagnosis and management of sepsis and bloodstream infection

Sepsis is a severe organ dysfunction triggered by infections, and a leading cause of hospitalization and death. Concurrent bloodstream infection (BSI) is common and around one third of sepsis patients have positive blood cultures. Prompt diagnosis and treatment is crucial, but there is a trade-off between the negative effects of over diagnosis and failure to recognize sepsis in time. The emerging crisis of antimicrobial resistance has made bacterial infections more difficult to treat, especially gram-negative pathogens such as Pseudomonas aeruginosa. The overall aim with this thesis was to improve diagnosis, assess the influence of time to antimicrobial treatment and explore prognostic bacterial virulence markers in sepsis and BSI. The papers are based on observational data from 7 cohorts of more than 100 000 hospital episodes. In addition, whole genome sequencing has been performed on approximately 800 invasive P. aeruginosa isolates collected from centers in Europe and Australia. Paper I showed that automated surveillance of sepsis incidence using the Sepsis-3 criteria is feasible in the non-ICU setting, with examples of how implementing this model generates continuous epidemiological data down to the ward level. This information can be used for directing resources and evaluating quality-of-care interventions. In Paper II, evidence is provided for using peripheral oxygen saturation (SpO2) to diagnose respiratory dysfunction in sepsis, proposing the novel thresholds 94% and 90% to get 1 and 2 SOFA points, respectively. This has important implications for improving sepsis diagnosis, especially when conventional arterial blood gas measurements are unavailable. Paper III verified that sepsis surveillance data can be utilized to develop machine learning screening tools to improve early identification of sepsis. A Bayesian network algorithm trained on routine electronic health record data predicted sepsis onset within 48 hours with better discrimination and earlier than conventional NEWS2 outside the ICU. The results suggested that screening may primarily be suited for the early admission period, which have broader implications also for other sepsis screening tools. Paper IV demonstrated that delays in antimicrobial treatment with in vitro pathogen coverage in BSI were associated with increased mortality after 12 hours from blood culture collection, but not at 1, 3, and 6 hours. This indicates a time window where clinicians should focus on the diagnostic workup, and proposes a target for rapid diagnostics of blood cultures. Finally, Paper V showed that the virulence genotype had some influence on mortality and septic shock in P. aeruginosa BSI, however, it was not a major prognostic determinant. Together these studies contribute to better understanding of the sepsis and BSI populations, and provide several suggestions to improve diagnosis and timing of treatment, with implications for clinical practice. Future works should focus on the implementation of sepsis surveillance, clinical trials of time to antimicrobial treatment and evaluating the prognostic importance of bacterial genotype data in larger populations from diverse infection sources and pathogens

Utilization of big data to improve management of the emergency departments. Results of a systematic review

Background. The emphasis on using big data is growing exponentially in several sectors including biomedicine, life sciences and scientific research, mainly due to advances in information technologies and data analysis techniques. Actually, medical sciences can rely on a large amount of biomedical information and Big Data can aggregate information around multiple scales, from the DNA to the ecosystems. Given these premises, we wondered if big data could be useful to analyze complex systems such as the Emergency Departments (EDs) to improve their management and eventually patient outcomes. Methods. We performed a systematic review of the literature to identify the studies that implemented the application of big data in EDs and to describe what have already been done and what are the expectations, issues and challenges in this field. Results. Globally, eight studies met our inclusion criteria concerning three main activities: the management of ED visits, the ED process and activities and, finally, the prediction of the outcome of ED patients. Although the results of the studies show good perspectives regarding the use of big data in the management of emergency departments, there are still some issues that make their use still difficult. Most of the predictive models and algorithms have been applied only in retrospective studies, not considering the challenge and the costs of a real-time use of big data. Only few studies highlight the possible usefulness of the large volume of clinical data stored into electronic health records to generate evidence in real time. Conclusion. The proper use of big data in this field still requires a better management information flow to allow real-time application

Improving Timely Sepsis Care through Staff Education within the Emergency Department

Problem: A sepsis protocol and bundle has been implemented in an urban Emergency Department to help screen patients and treat sepsis efficiently and effectively. The benchmarks from the bundle are not being met consistently every month and are below the targeted 90%. Context: A microsystem assessment and a gap survey sent out to nurses, helped determine that there is room to improve nurses’ knowledge and confidence about sepsis and the sepsis bundle workflow. Sepsis is one of the most expensive and burdensome conditions in U.S. hospitals. Literature supports staff education to improve sepsis bundle compliance. Intervention: A video was created and was sent out via the nurse manager to all the nurses in the unit. The video is a slide deck that was recorded with a voice over, including information about signs and symptoms of sepsis and the sepsis protocol. In addition, information posted in the staff break room was updated about sepsis, the protocol, and current compliance. Measures: Data from the first quarter of 2023 and the last quarter of 2022 was obtained for first vital to lactic acid results within 60 minutes, lactic acid results to antibiotic administration within 60 minutes, and antibiotic order to administration within 35 minutes. Results: The Post-Intervention results have not been obtained for this project due to time constraint. The recommendation is to obtain and analyze the 2023 second quarter data, and then compare it to the 2023 first quarter data and the 2022 last quarter data to determine if the benchmarks have been met consistently by 90% for each month in the 2023 second quarter. Conclusions: Providing nurses with the knowledge to help identify sepsis rapidly, as well as becoming more familiar with the sepsis protocol, helps them confidently enact the bundle. Second quarter data will evaluate if this project has improved the workflow and has saved time

Acute lung injury in paediatric intensive care: course and outcome

Introduction: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) carry a high morbidity and mortality (10-90%). ALI is characterised by non-cardiogenic pulmonary oedema and refractory hypoxaemia of multifactorial aetiology [1]. There is limited data about outcome particularly in children. Methods This retrospective cohort study of 85 randomly selected patients with respiratory failure recruited from a prospectively collected database represents 7.1% of 1187 admissions. They include those treated with High Frequency Oscillation Ventilation (HFOV). The patients were admitted between 1 November 1998 and 31 October 2000. Results: Of the 85, 49 developed acute lung injury and 47 had ARDS. There were 26 males and 23 females with a median age and weight of 7.7 months (range 1 day-12.8 years) and 8 kg (range 0.8-40 kg). There were 7 deaths giving a crude mortality of 14.3%, all of which fulfilled the Consensus I [1] criteria for ARDS. Pulmonary occlusion pressures were not routinely measured. The A-a gradient and PaO2/FiO2 ratio (median + [95% CI]) were 37.46 [31.82-43.1] kPa and 19.12 [15.26-22.98] kPa respectively. The non-survivors had a significantly lower PaO2/FiO2 ratio (13 [6.07-19.93] kPa) compared to survivors (23.85 [19.57-28.13] kPa) (P = 0.03) and had a higher A-a gradient (51.05 [35.68-66.42] kPa) compared to survivors (36.07 [30.2-41.94]) kPa though not significant (P = 0.06). Twenty-nine patients (59.2%) were oscillated (Sensormedics 3100A) including all 7 non-survivors. There was no difference in ventilation requirements for CMV prior to oscillation. Seventeen of the 49 (34.7%) were treated with Nitric Oxide including 5 out of 7 non-survivors (71.4%). The median (95% CI) number of failed organs was 3 (1.96-4.04) for non-survivors compared to 1 (0.62-1.62) for survivors (P = 0.03). There were 27 patients with isolated respiratory failure all of whom survived. Six (85.7%) of the non-survivors also required cardiovascular support.Conclusion: A crude mortality of 14.3% compares favourably to published data. The A-a gradient and PaO2/FiO2 ratio may be of help in morbidity scoring in paediatric ARDS. Use of Nitric Oxide and HFOV is associated with increased mortality, which probably relates to the severity of disease. Multiple organ failure particularly respiratory and cardiac disease is associated with increased mortality. ARDS with isolated respiratory failure carries a good prognosis in children

An interdisciplinary code sepsis team to improve sepsis bundle compliance in the emergency department

Purpose: Sepsis is one of the leading causes of mortality with over 700,000 hospitalizations and 200,000 deaths annually. Various tools exist to aid in the early identification and treatment of sepsis including electronic alert systems, standardized order sets, nurse-initiated protocols and specialty trained teams. Despite available guidelines, mortality rates for severe sepsis and septic shock are near 50%. Methods: The aims of this rapid cycle quality improvement project were 1) to develop and implement an interdisciplinary team to address early implementation of evidence-based sepsis bundles in the emergency department and 2) to compare sepsis bundle compliance three months pre-and three months’ post-intervention implementation. The population included all patients’ over 18 years of age presenting to the emergency department with clinical indications of sepsis, severe sepsis, or septic shock. Results: The pre-post intervention analysis shows an improvement in time to each bundle element except antibiotics. There was statistical significance in time to second lactate. Statistical significance was noted in the fluid resuscitation volume met (p=.000), initial lactate collected within 180 minutes (p=.001), and second lactate within 360 minutes (.000). Mortality rates in patients with sepsis on presentation showed a steady decline from 12.45% in the first month pre-intervention to 4.55% in the last month post intervention. Conclusion: Interdisciplinary teams can utilize existing knowledge, skills and tools to improve sepsis bundle compliance and mortality outcomes in sepsis patients presenting to the emergency department

Sepsis Screening Tool Increased the Usage of Sepsis Order Set

Introduction: The sepsis screening tool was launched to improve the usage of the sepsis order set. Objectives: The purposes of this study were to determine whether the sepsis screening tool increased the usage of sepsis order set and whether the tool improved the primary outcomes. This study assessed the association between using sepsis order set and the compliance of the SEP-1 measure (represented by achieving total perfect care), and the primary outcomes. Furthermore, this study assessed association between the compliance with SEP-1 and the primary outcomes. The primary outcomes were a) time zero to antibiotics, b) inpatient length of stay, and c) survival at discharge. Material and Methods: Retrospective study collected data 6 months before and 6 months after the launch of sepsis screening tool at a tertiary academic hospital. A total of 632 patients were studied. The sepsis screening tool was incorporated at the nurse station at triage. The sepsis order set contained treatment guidelines based on the SEP-1 measure. Results: Our findings confirmed that the sepsis screening tool increased the usage of the order set, raised an awareness of the emergency department personnel and improved the adherence to the treatment guidelines by showing that the usage of sepsis order set significantly increased in the postintervention group (p = 0.001). However, we did not find the association between the sepsis screening tool and the primary outcomes or the total perfect care. The utilization of sepsis order set streamlined and standardized the sepsis management, shortened time to antibiotic by 54 minutes (p = 0.001) and reduced length of stay by 1.8 days (p = 0.002). However, there was no significant difference in survival between the group that used the order set and the group that did not use the order set. There was a significant association between sepsis order set use and total perfect care (p \u3c 0.001), which indicated that the order set use increased the compliance with SEP-1 measure. The group that achieved total perfect care significantly associated with all primary outcomes; 102.4 minutes shorter average time zero to antibiotic (p \u3c 0.001), 1.5 days shorter average length of stay (p = 0.004), and better survival at discharge (p \u3c 0.001, 95% CI 0.02 – 0.206, OR 0.064) than the group that did not achieve total perfect care. Conclusions: Our study confirmed that adherence to the standard treatment guidelines improved the treatment outcomes. The sepsis screening tool increased the use of the sepsis order set. When the order set was used, the compliance with the SEP-1 measure increased. The group that used sepsis order set had a significantly shorter length of stay and shorter time to antibiotic. The group that met SEP-1 measure compliance significantly received antibiotics earlier, shorter stay as an inpatient, and better survival. However, we need more studies to confirm the significant association between compliance of SEP-1 measure and the outcomes because this study did not adjust for clinical characteristics and severity of illness

Reducing Sepsis Mortality: A Cloud-Based Alert Approach

The aim of this study is to examine the impact of a cloud-based CDS alerting system for SIRS, a precursor to sepsis, and sepsis itself, on adult patient and process outcomes at VCU Health System. The two main hypotheses are: 1) the implementation of cloud-based SIRS and sepsis alerts will lead to lower sepsis-related mortality and lower average length of stay, and 2) the implementation of cloud-based SIRS and sepsis alerts will lead to more frequent ordering of the Sepsis PowerPlan and more recording of sepsis diagnoses. To measure these outcomes, a pre-post study was conducted. A pre-implementation group diagnosed with sepsis within the year leading up to the alert intervention consisted of 1,551 unique inpatient visits, and the three-year post-implementation sample size was 9,711 visits, for a total cohort of 11,262 visits. Logistic regression and multiple linear regression were used to test the hypotheses. Study results showed that sepsis-related mortality was slightly higher after the implementation of SIRS alerts, but the presence of sepsis alerts did not have a significant relationship to mortality. The average length of stay and the total number of recorded sepsis diagnoses were higher after the implementation of both SIRS and sepsis alerts, while ordering of the Sepsis Initial Resuscitation PowerPlan was lower. There is preliminary evidence from this study that more sepsis diagnoses are made as a result of alert adoption, suggesting that clinicians can consider the implementation of these alerts in order to capture a higher number of sepsis diagnoses

Temporal Trends in Incidence, Sepsis-Related Mortality, and Hospital-Based Acute Care After Sepsis.

OBJECTIVES: A growing number of patients survive sepsis hospitalizations each year and are at high risk for readmission. However, little is known about temporal trends in hospital-based acute care (emergency department treat-and-release visits and hospital readmission) after sepsis. Our primary objective was to measure temporal trends in sepsis survivorship and hospital-based acute care use in sepsis survivors. In addition, because readmissions after pneumonia are subject to penalty under the national readmission reduction program, we examined whether readmission rates declined after sepsis hospitalizations related to pneumonia. DESIGN AND SETTING: Retrospective, observational cohort study conducted within an academic healthcare system from 2010 to 2015. PATIENTS: We used three validated, claims-based approaches to identify 17,256 sepsis or severe sepsis hospitalizations to examine trends in hospital-based acute care after sepsis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: From 2010 to 2015, sepsis as a proportion of medical and surgical admissions increased from 3.9% to 9.4%, whereas in-hospital mortality rate for sepsis hospitalizations declined from 24.1% to 14.8%. As a result, the proportion of medical and surgical discharges at-risk for hospital readmission after sepsis increased from 2.7% to 7.8%. Over 6 years, 30-day hospital readmission rates declined modestly, from 26.4% in 2010 to 23.1% in 2015, driven largely by a decline in readmission rates among survivors of nonsevere sepsis, and nonpneumonia sepsis specifically, as the readmission rate of severe sepsis survivors was stable. The modest decline in 30-day readmission rates was offset by an increase in emergency department treat-and-release visits, from 2.8% in 2010 to a peak of 5.4% in 2014. CONCLUSIONS: Owing to increasing incidence and declining mortality, the number of sepsis survivors at risk for hospital readmission rose significantly between 2010 and 2015. The 30-day hospital readmission rates for sepsis declined modestly but were offset by a rise in emergency department treat-and-release visits