Severe Sepsis: Variation in Resource and Therapeutic Modality use Among Academic Centers

Background: Treatment of severe sepsis is expensive, often encompassing a number of discretionary modalities. The objective of the present study was to assess intercenter variation in resource and therapeutic modality use in patients with severe sepsis. Methods: We conducted a prospective cohort study of 1028 adult admissions with severe sepsis from a stratified random sample of patients admitted to eight academic tertiary care centers. The main outcome measures were length of stay (LOS; total LOS and LOS after onset of severe sepsis) and total hospital charges. Results: The adjusted mean total hospital charges varied from $69 429 to US$237 898 across centers, whereas the adjusted LOS after onset varied from 15.9 days to 24.2 days per admission. Treatments used frequently after the first onset of sepsis among patients with severe sepsis were pulmonary artery catheters (19.4%), ventilator support (21.8%), pressor support (45.8%) and albumin infusion (14.4%). Pulmonary artery catheter use, ventilator support and albumin infusion had moderate variation profiles, varying 3.2-fold to 4.9-fold, whereas the rate of pressor support varied only 1.92-fold across centers. Even after adjusting for age, sex, Charlson comorbidity score, discharge diagnosis-relative group weight, organ dysfunction and service at onset, the odds for using these therapeutic modalities still varied significantly across centers. Failure to start antibiotics within 24 hours was strongly correlated with a higher probability of 28-day mortality (r2 = 0.72). Conclusion: These data demonstrate moderate but significant variation in resource use and use of technologies in treatment of severe sepsis among academic centers. Delay in antibiotic therapy was associated with worse outcome at the center level

Severe sepsis: variation in resource and therapeutic modality use among academic centers

BACKGROUND: Treatment of severe sepsis is expensive, often encompassing a number of discretionary modalities. The objective of the present study was to assess intercenter variation in resource and therapeutic modality use in patients with severe sepsis. METHODS: We conducted a prospective cohort study of 1028 adult admissions with severe sepsis from a stratified random sample of patients admitted to eight academic tertiary care centers. The main outcome measures were length of stay (LOS; total LOS and LOS after onset of severe sepsis) and total hospital charges. RESULTS: The adjusted mean total hospital charges varied from $69 429 to US$237 898 across centers, whereas the adjusted LOS after onset varied from 15.9 days to 24.2 days per admission. Treatments used frequently after the first onset of sepsis among patients with severe sepsis were pulmonary artery catheters (19.4%), ventilator support (21.8%), pressor support (45.8%) and albumin infusion (14.4%). Pulmonary artery catheter use, ventilator support and albumin infusion had moderate variation profiles, varying 3.2-fold to 4.9-fold, whereas the rate of pressor support varied only 1.92-fold across centers. Even after adjusting for age, sex, Charlson comorbidity score, discharge diagnosis-relative group weight, organ dysfunction and service at onset, the odds for using these therapeutic modalities still varied significantly across centers. Failure to start antibiotics within 24 hours was strongly correlated with a higher probability of 28-day mortality (r(2 )= 0.72). CONCLUSION: These data demonstrate moderate but significant variation in resource use and use of technologies in treatment of severe sepsis among academic centers. Delay in antibiotic therapy was associated with worse outcome at the center level

A new class of non-linear stochastic population models with mass conservation.

We study the effects of random feeding, growing and dying in a closed nutrient-limited producer/consumer system, in which nutrient is fully conserved, not only in the mean, but, most importantly, also across random events. More specifically, we relate these random effects to the closest deterministic models, and evaluate the importance of the various times scales that are involved. These stochastic models differ from deterministic ones not only in stochasticity, but they also have more details that involve shorter times scales. We tried to separate the effects of more detail from that of stochasticity. The producers have (nutrient) reserve and (body) structure, and so a variable chemical composition. The consumers have only structure. so a constant chemical composition. The conversion efficiency from producer to consumer, therefore, varies. The consumers use reserve and structure of the producers as complementary compounds, following the rules of Dynamic Energy Budget theory. Consumers die at constant specific rate and decompose instantaneously. Stochasticity is incorporated in the behaviour of the consumers, where the switches to handling and searching, as well as dying are Poissonian point events. We show that the stochastic model has one parameter more than the deterministic formulation without time scale separation for conversions between searching and handling consumers, which itself has one parameter more than the deterministic formulation with time scale separation for these conversions. These extra parameters are the contributions of a single individual producer and consumer to their densities, and the ratio of the two, respectively. The tendency to oscillate increases with the number of parameters. The focus bifurcation point has more relevance for the asymptotic behaviour of the stochastic model than the Hopf bifurcation point, since a randomly perturbed damped oscillation exhibits a behaviour similar to that of the stochastic limit cycle particularly near this bifurcation point. For total nutrient values below the focus bifurcation point, the system gradually becomes more confined to the direct neighbourhood of the isocline for which the producers do not change. (C) 2007 Elsevier Inc. All rights reserved

Implementation issues influencing the decision to adopt postponement

Purpose - Postponement (also known as delayed product differentiation) has been shown to be an effective supply chain strategy from an inventory-reduction, service-level improvement standpoint. However, there has been relatively little empirical research on identifying the drivers and/or obstacles to a successful implementation of a postponement strategy. This study aims to identify the importance of several managerial issues surrounding the implementation of such a strategy. Design/methodology/approach - Exploratory depth interviews with company managers were conducted to identify and examine issues that may affect a successful implementation. Borrowing from the concept of triangulation, the findings are integrated with results reported elsewhere in the literature to understand the interrelated aspects of postponement implementation issues. This approach provides insights that would not be had if the results of each study were viewed independently of one another. Findings - The identification of managerial issues implies that there is more to implementing a partial postponement strategy than the repositioning of inventories prescribed by a mathematical inventory model. Several issues that may influence a postponement implementation are identified and discussed including product integrity, operations scheduling, and organizational readiness. Research limitations/implications - The depth interview process is an empirical methodology subject to the limitations of judgmental conclusions, interpreter bias and small sample size. The results of this exploratory study provide a more in-depth understanding of drivers and obstacles to implementing this supply chain strategy. The findings suggest the need for further investigation of the issues surrounding the decision to adopt postponement. Practical implications - The findings have broad implications for manufacturing managers regarding the impact of adopting a postponement strategy on several aspects of the operations function. Originality/value - Although principally exploratory in nature, the investigation demonstrates the need for researchers to identify and better understand the managerial issues surrounding an attempt to implement a specific partial postponement strategy. © Emerald Group Publishing Limited

Service systems engineering: New course development – Service systems operations

A new curriculum in Service Systems Engineering, which consists of eight new courses, is being established. Four courses were developed in the first year. One of the courses was Service Systems Operations (SSO). Since most OM authors have integrated the production of goods and services in single text, with much emphasis still on manufacturing operations, coupled with the lack of emphasis on co-creation or co-production, the course developers experienced pedagogical and contextual challenges in creating the course. This paper will outline the comparison of traditional OM with service systems operations to highlight the similarities and differences between the two. Additionally the course objectives and pedagogy that will be used in instruction of the course will be shared. Also presented will be the link between the program and course objectives to position the course and curriculum for ABET accreditation. Course Development The Service Systems Operations course was designed and developed to provide the foundation in several areas: (a) Continue from the fundamentals course, Introduction to Service System

MRSA nares swab is a more accurate predictor of MRSA wound infection compared with clinical risk factors in emergency department patients with skin and soft tissue infections

Objectives Skin and soft tissue infections (SSTI) caused by methicillin-resistant Staphylococcus aureus (MRSA) are prevalent in the emergency department (ED). We determined whether MRSA nasal carriage better identifies patients with MRSA wound infection than clinical risk factors or emergency medicine (EM) provider’s choice of discharge prescriptions. Methods Adult patients presenting to a large academic medical centre ED in the USA with SSTI between May 2010 and November 2011 were screened. Research assistants administered a questionnaire regarding MRSA risk factors, and MRSA nares swab PCR testing, wound culture results and information on antibiotics prescribed at discharge were collected. Measures of classification accuracy for nares swab, individual risk factors and physician’s prescription for MRSA coverage were compared with gold standard wound culture. Results During the study period, 116 patients with SSTI had both wound cultures and nares swabs for MRSA. S. aureus was isolated in 59.5%, most often MRSA (75.4%). Thirty patients (25.9%) had a positive MRSA nares swab and culture for a sensitivity of 57.7% and specificity of 92.2%. Positive predictive value (PPV) for MRSA nares swab was 85.7% and positive likelihood ratio was 7.4, while negative predictive value was 72.8% and negative likelihood ratio 0.5. None of the individual risk factors nor EM provider’s prescription for MRSA coverage had a PPV or positive likelihood ratio higher than nares swabs. Conclusions MRSA nares swab is a more accurate predictor of MRSA wound infection compared with clinical risk factors or EM provider’s choice of antibiotics. MRSA nares swab may be a useful tool in the ED

sepsis: variation in resource and therapeutic modality use among academic centers. Crit Care 2003

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