72 research outputs found
Sepsis Education and Training in Medical School
Purpose: According to the National Institutes of Health, severe sepsis strikes more than one million Americans every year. Despite the extensive research that has gone into creating the different risk stratification tools for sepsis, there is still a fifteen to thirty percent mortality rate among patients diagnosed with sepsis. We believe this is due to a lack of robust education and training of medical students in sepsis identification, and thus, the purpose of this study was to determine the extent of training and education of medical students in the identification and treatment of sepsis.
Methods: This study is aimed at the first-year residents at emergency medicine programs nationwide. Using the Qualtrics software available on the Thomas Jefferson University commons, we created a twenty-one question survey that collected data on knowledge, skills, and attitudes of first-year residents towards sepsis diagnosis and treatment, based on what they have formally learned in medical school. Thus far, we are continuing to collect data. Once data has been collected, we will undergo quantitative and qualitative analysis.
Results and Conclusions: As of writing this abstract, we continue to collect data due to unforeseen circumstances. We will soon have data that can be analyzed. We believe the data will show a lack of robust curriculum at medical schools nationwide for the training of medical students in the diagnosing and treatment of sepsis. If this is proven true, programs can be created to add sepsis curriculum to formal medical education
Discrete Optimization for Interpretable Study Populations and Randomization Inference in an Observational Study of Severe Sepsis Mortality
Motivated by an observational study of the effect of hospital ward versus
intensive care unit admission on severe sepsis mortality, we develop methods to
address two common problems in observational studies: (1) when there is a lack
of covariate overlap between the treated and control groups, how to define an
interpretable study population wherein inference can be conducted without
extrapolating with respect to important variables; and (2) how to use
randomization inference to form confidence intervals for the average treatment
effect with binary outcomes. Our solution to problem (1) incorporates existing
suggestions in the literature while yielding a study population that is easily
understood in terms of the covariates themselves, and can be solved using an
efficient branch-and-bound algorithm. We address problem (2) by solving a
linear integer program to utilize the worst case variance of the average
treatment effect among values for unobserved potential outcomes that are
compatible with the null hypothesis. Our analysis finds no evidence for a
difference between the sixty day mortality rates if all individuals were
admitted to the ICU and if all patients were admitted to the hospital ward
among less severely ill patients and among patients with cryptic septic shock.
We implement our methodology in R, providing scripts in the supplementary
material
The association between hemoglobin concentration and neurologic outcome after cardiac arrest.
PURPOSE: The purpose of the study is to determine the association between hemoglobin concentration (Hgb) and neurologic outcome in postarrest patients.
METHODS: We conducted a retrospective cohort study using the Penn Alliance for Therapeutic Hypothermia (PATH) cardiac arrest registry. Inclusion criteria were resuscitated cardiac arrest (inhospital or out of hospital) and an Hgb value recorded within 24 hours of return of spontaneous circulation. The primary outcome was favorable neurologic status at hospital discharge. Survival to hospital discharge was a secondary outcome.
RESULTS: There were 598 eligible patients from 21 hospitals. Patients with favorable neurologic outcome had significantly higher median Hgb in the first 2 hours (12.7 vs 10.5 g/dL; P \u3c .001) and 6 hours (12.6 vs 10.6 g/dL; P \u3c .001) postarrest. Controlling for age, pulseless rhythm, etiology, location of arrest, receipt of targeted temperature management, hematologic or metastatic malignancy, or preexisting renal insufficiency, there was a significant relationship between Hgb and neurologic outcome within the first 6 hours after arrest (odds ratio, 1.23; 95% confidence interval, 1.09-1.38) and survival to hospital discharge (odds ratio, 1.20; 95% confidence interval, 1.08-1.34).
CONCLUSION: Higher Hgb after cardiac arrest is associated with favorable neurologic outcome, particularly within the first 6 hours. It is unclear if this effect is due to impaired oxygen delivery or if Hgb is a marker for more severe illness
Validation of an ICD code for accurately identifying emergency department patients who suffer an out-of-hospital cardiac arrest.
AIM: International classification of disease (ICD-9) code 427.5 (cardiac arrest) is utilized to identify cohorts of patients who suffer out-of-hospital cardiac arrest (OHCA), though the use of ICD codes for this purpose has never been formally validated. We sought to validate the utility of ICD-9 code 427.5 by identifying patients admitted from the emergency department (ED) after OHCA.
METHODS: Adult visits to a single ED between January 2007 and July 2012 were retrospectively examined and a keyword search of the electronic medical record (EMR) was used to identify patients. Cardiac arrest was confirmed; and ICD-9 information and location of return of spontaneous circulation (ROSC) were collected. Separately, the EMR was searched for patients who received ICD-9 code 427.5. The kappa coefficient (κ) was calculated, as was the sensitivity and specificity of the code for identifying OHCA.
RESULTS: The keyword search identified 1717 patients, of which 385 suffered OHCA and 333 were assigned the code 427.5. The agreement between ICD-9 code and cardiac arrest was excellent (κ = 0.895). The ICD-9 code 427.5 was both specific (99.4%) and sensitive (86.5%). Of the 52 cardiac arrests that were not identified by ICD-9 code, 33% had ROSC before arrival to the ED. When searching independently on ICD-9 code, 347 patients with ICD-9 code 427.5 were found, of which 320 were true arrests. This yielded a positive predictive value of 92% for ICD-9 code 427.5 in predicting OHCA.
CONCLUSIONS: ICD-9 code 427.5 is sensitive and specific for identifying ED patients who suffer OHCA with a positive predictive value of 92%
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
Factors associated with post-arrest withdrawal of life-sustaining therapy.
INTRODUCTION: Most successfully resuscitated cardiac arrest patients do not survive to hospital discharge. Many have withdrawal of life sustaining therapy (WLST) as a result of the perception of poor neurologic prognosis. The characteristics of these patients and differences in their post-arrest care are largely unknown.
METHODS: Utilizing the Penn Alliance for Therapeutic Hypothermia Registry, we identified a cohort of 1311 post-arrest patients from 26 hospitals from 2010 to 2014 who remained comatose after return of spontaneous circulation. We stratified patients by whether they had WLST post-arrest and analyzed demographic, arrest, and post-arrest variables.
RESULTS: In our cohort, 565 (43%) patients had WLST. In multivariate regression, patients who had WLST were less likely to go to the cardiac catheterization lab (OR 0.40; 95% CI: 0.26-0.62) and had shorter hospital stays (OR 0.93; 95% CI: 0.91-0.95). When multivariate regression was limited to patient demographics and arrest characteristics, patients with WLST were older (OR 1.18; 95% CI: 1.07-1.31 by decade), had a longer arrest duration (OR 1.14; 95% CI: 1.05-1.25 per 10min), more likely to be female (OR: 1.41; 95% CI: 1.01-1.96), and less likely to have a witnessed arrest (OR 0.65; 95% CI: 0.42-0.98).
CONCLUSION: Patients with WLST differ in terms of demographic, arrest, and post-arrest characteristics and treatments from those who did not have WLST. Failure to account for this variability could affect both clinical practice and the interpretation of research
Inter-rater reliability of post-arrest cerebral performance category (CPC) scores.
PURPOSE: Cerebral Performance Category (CPC) scores are often an outcome measure for post-arrest neurologic function, collected worldwide to compare performance, evaluate therapies, and formulate recommendations. At most institutions, no formal training is offered in their determination, potentially leading to misclassification.
MATERIALS AND METHODS: We identified 171 patients at 2 hospitals between 5/10/2005 and 8/31/2012 with two CPC scores at hospital discharge recorded independently - in an in-house quality improvement database and as part of a national registry. Scores were abstracted retrospectively from the same electronic medical record by two separate non-clinical researchers. These scores were compared to assess inter-rater reliability and stratified based on whether the score was concordant or discordant among reviewers to determine factors related to discordance.
RESULTS: Thirty-nine CPC scores (22.8%) were discordant (kappa: 0.66), indicating substantial agreement. When dichotomized into favorable neurologic outcome (CPC 1-2)/ unfavorable neurologic outcome (CPC 3-5), 20 (11.7%) scores were discordant (kappa: 0.70), also indicating substantial agreement. Patients discharged home (as opposed to nursing/other care facility) and patients with suspected cardiac etiology of arrest were statistically more likely to have concordant scores. For the quality improvement database, patients with discordant scores had a statistically higher median CPC score than those with concordant scores. The registry had statistically lower median CPC score (CPC 1) than the quality improvement database (CPC 2); p\u3c0.01 for statistical significance.
CONCLUSIONS: CPC scores have substantial inter-rater reliability, which is reduced in patients who have worse outcomes, have a non-cardiac etiology of arrest, and are discharged to a location other than home
Magnesium Depletion in Patients Treated with Therapeutic Hypothermia After Cardiac Arrest
Magnesium (Mg2+) depletion can have detrimental effects in postcardiac arrest patients through multiple potential mechanisms. Therapeutic hypothermia (TH) produces a Mg2+ diuresis, but the effects of postcardiac arrest TH on serum Mg2+ levels in patients with postcardiac arrest syndrome (PCAS) are yet to be systematically quantified. We conducted a retrospective chart review of 119 consecutive comatose PCAS patients treated with TH between 2005 and 2010 and compared them to 33 matched historic controls (HCs) seen at the same institution between 2002 and 2005 who were not treated with TH. We abstracted data from the first 96 hours postarrest, including date, time, and value of serum Mg2+ levels and date, time, and amount of Mg2+ repletion, along with outcomes at discharge. The median Mg2+ level of TH patients was 2.0?mg/dL [interquartile range (IQR), 1.9?2.2?mg/dL] (0.82 mmol/L [IQR, 0.78?0.90 mmol/L]) versus 2.2?mg/dL [IQR, 1.9?2.4?mg/dL] (0.90 mmol/L [IQR, 0.82?0.99 mmol/L]) (p=0.2) in HCs. In addition, 42.9% (520/1214) of Mg2+ levels in TH patients versus 31.9% (43/135) (p=0.014) in HC patients were below 2.0?mg/dL [0.82 mmol/L]. The average number of times the Mg2+ level was checked in TH patients was 10.2 (range 1?18) versus 4.1 (range 1?10) in HCs. The TH patients were more likely to receive supplemental Mg2+ than HCs (81.5% [97/119] vs. 27.3% [9/33] [p<0.01]). The mean supplemental Mg2+ dose was 1.9?g for TH patients versus 0.5?g for HC patients. Mortality in patients treated with TH was 53.1% (60/113) versus 78.6% (22/28) (p=0.014) in HCs. Low serum Mg2+ levels with subsequent Mg2+ supplementation were more common in comatose patients with PCAS treated with TH compared to normothermic HC patients. The effect of untreated hypomagnesemia on postcardiac arrest outcomes remains to be determined.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140255/1/ther.2014.0012.pd
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