Outcome of Immediate Versus Early Antibiotics in Severe Sepsis and Septic Shock: A Systematic Review and Meta-analysis.

STUDY OBJECTIVE: Debate exists about the mortality benefit of administering antibiotics within either 1 or 3 hours of sepsis onset. We performed this meta-analysis to analyze the effect of immediate (0 to 1 hour after onset) versus early (1 to 3 hours after onset) antibiotics on mortality in patients with severe sepsis or septic shock. METHODS: This review was consistent with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Searched databases included PubMed, EMBASE, Web of Science, and Cochrane Library, as well as gray literature. Included studies were conducted with consecutive adults with severe sepsis or septic shock who received antibiotics within each period and provided mortality data. Data were extracted by 2 independent reviewers and pooled with random effects. Two authors independently assessed quality of evidence across all studies with Cochrane's Grading of Recommendations Assessment, Development and Evaluation methodology and risk of bias within each study, using the Newcastle-Ottawa Scale. RESULTS: Thirteen studies were included: 5 prospective longitudinal and 8 retrospective cohort ones. Three studies (23%) had a high risk of bias (Newcastle-Ottawa Scale). Overall, quality of evidence across all studies (Grading of Recommendations Assessment, Development and Evaluation) was low. Pooling of data (33,863 subjects) showed no difference in mortality between patients receiving antibiotics in immediate versus early periods (odds ratio 1.09; 95% confidence interval 0.98 to 1.21). Analysis of severe sepsis studies (8,595 subjects) found higher mortality in immediate versus early periods (odds ratio 1.29; 95% confidence interval 1.09 to 1.53). CONCLUSION: We found no difference in mortality between immediate and early antibiotics across all patients. Although the quality of evidence across studies was low, these findings do not support a mortality benefit for immediate compared with early antibiotics across all patients with sepsis.

Derivation of a screen to identify severe sepsis and septic shock in the ED-BOMBARD vs. SIRS and qSOFA.

STUDY OBJECTIVE: To predict severe sepsis/septic shock in ED patients. METHODS: We conducted a retrospective case-control study of patients ≥18 admitted to two urban hospitals with a combined ED census of 162,000. Study cases included patients with severe sepsis/septic shock admitted via the ED. Controls comprised admissions without severe sepsis/septic shock. Using multivariate logistic regression, a prediction rule was constructed. The model's AUROC was internally validated using 1000 bootstrap samples. RESULTS: 143 study and 286 control patients were evaluated. Features predictive of severe sepsis/septic shock included: SBP ≤ 110 mm Hg, shock index/SI ≥ 0.86, abnormal mental status or GCS < 15, respirations ≥ 22, temperature ≥ 38C, assisted living facility residency, disabled immunity. Two points were assigned to SI and temperature with other features assigned one point (mnemonic: BOMBARD). BOMBARD was superior to SIRS criteria (AUROC 0.860 vs. 0.798, 0.062 difference, 95% CI 0.022-0.102) and qSOFA scores (0.860 vs. 0.742, 0.118 difference, 95% CI 0.081-0.155) at predicting severe sepsis/septic shock. A BOMBARD score ≥ 3 was more sensitive than SIRS ≥ 2 (74.8% vs. 49%, 25.9% difference, 95% CI 18.7-33.1) and qSOFA ≥ 2 (74.8% vs. 33.6%, 41.2% difference, 95% CI 33.2-49.3) at predicting severe sepsis/septic shock. A BOMBARD score ≥ 3 was superior to SIRS ≥ 2 (76% vs. 45%, 32% difference, 95% CI 10-50) and qSOFA ≥ 2 (76% vs. 29%, 47% difference, 95% CI 25-63) at predicting sepsis mortality. CONCLUSION: BOMBARD was more accurate than SIRS and qSOFA at predicting severe sepsis/septic shock and sepsis mortality.

Use of electronic health record documentation by healthcare workers in an acute care hospital system.

Acute care clinicians spend significant time documenting patient care information in electronic health records (EHRs). The documentation is required for many reasons, the most important being to ensure continuity of care. This study examined what information is used by clinicians, how this information is used for patient care, and the amount of time clinicians perceive they review and document information in the EHR. A survey administered at a large, multisite healthcare system was used to gather this information. Findings show that diagnostic results and physician documents are viewed more often than documentation by nurses and ancillary caregivers. Most clinicians use the information in the EHR to understand the patient's overall condition, make clinical decisions, and communicate with other caregivers. The majority of respondents reported they spend 1 to 2 hours per day reviewing information and 2 to 4 hours documenting in the EHR. Bedside nurses spend 4 hours per day documenting, with much of this time spent completing detailed forms seldom viewed by others. Various flow sheets and forms within the EHR are rarely viewed. Organizations should provide ongoing education and awareness training for hospital clinical staff on available forms and best practices for effective and efficient documentation. New forms and input fields should be added sparingly and in collaboration with informatics staff and clinical team members to determine the most useful information when developing documentation systems.