Implementing a collaborative sepsis protocol on the time to antibiotics in an emergency department of a saudi hospital: quasi randomized study.

Background. The objective of this study is to evaluate the impact of an ED sepsis protocol on the time to antibiotics for emergency department (ED) patients with severe sepsis. Methods. Quasiexperimental prospective study was conducted at the emergency department. Consecutive patients with severe sepsis were included before and after the implementation of a sepsis protocol. The outcome measures were time from recognition of severe sepsis/septic shock to first antibiotic dose delivery and the appropriateness of initial choice of antibiotics based on the presumed source of infection. Results. There were 47 patients in preintervention group and 112 patients in postintervention group. Before implementation, mean time from severe sepsis recognition to delivery of antibiotics was 140 ± 97 minutes. During the intervention period, the mean time was 68 ± 67 minutes, with an overall reduction of 72 minutes. The protocol resulted in an overall improvement of 37% in the compliance, as 62% received appropriate initial antibiotics for the presumed source of infection as compared to 25% before the start of protocol. Conclusion. Implementation of ED sepsis protocol improved the time from recognition of severe sepsis/septic shock to first antibiotic dose delivery as well as the appropriateness of initial antibiotic therapy.

Chronic obstructive pulmonary disease: hospital and intensive care unit outcomes in the Kingdom of Saudi Arabia.

BACKGROUND: There is little data surrounding the survival of patients with chronic obstructive pulmonary disease (COPD) who are admitted to the critical care unit with exacerbation of symptoms. We conducted a study to measure the in-hospital and intensive care unit (ICU) outcomes of patients admitted with COPD exacerbation, and identified the related prognostic factors. METHOD: We performed a retrospective cohort study of patients who were admitted to the adult ICU between January 2006 and July 2011 for COPD exacerbation in King Abdulaziz National Guard Hospital, Al-Hasa, Saudi Arabia. RESULTS: During the study period, a total of 119 patients were admitted to the ICU with acute respiratory failure attributed to COPD exacerbation. The mean age was 72 ± 13 years, and 44 (37%) were females. The main cause of respiratory failure was infection, which occurred in 102 (86%) patients. Thirty-nine (33%) of the admitted patients were mechanically ventilated, and the median duration was 2.6 (1-42) days. The median lengths of the ICU and hospital stays were 3 (1-40) and 9 (2-43) days, respectively. The ICU mortality was 6%, and hospital mortality was 11%. Low Glasgow Coma Scale on admission, intubation, duration of mechanical ventilation, current smoking, tracheostomy, cardiopulmonary arrest, and the development of acute renal failure were associated with higher hospital mortality. CONCLUSION: Early ICU and hospital mortality is low for COPD patients who have been admitted to the ICU with exacerbation. Low Glasgow Coma Scale scores on admission, intubation, prolonged use of mechanical ventilation, and the development of acute renal failure were identified as risk factors associated with increased hospital mortality.

Impact of 6-hour sepsis resuscitation bundle compliance on hospital mortality in a saudi hospital.

Purpose. To assess the effect of improved compliance with 6-hour sepsis resuscitation bundle on mortality in patients with severe sepsis and septic shock. Materials and Methods. A quasi-experimental prospective study was conducted at a 10-bedded combined medical and surgical intensive care unit. The historical group included all consecutive patients with severe sepsis and septic shock admitted from January 2008 to March 2009. Intervention included evidence-based written sepsis pathway, antibiotic recommendations, and an educational program.The post-intervention group included all consecutive patients admitted from July 2009 to June 2011. The primary outcome measures were the overall compliance to seven 6-hour sepsis resuscitation bundle elements and 30-day hospital mortality. There were 99 patients in the historical group and 199 in the post-intervention group. Results. The baseline patients' characteristics were similar. Overall compliance to all seven sepsis resuscitation bundle elements in historical group was 5.1% [95% confidence interval (CI), 2.1-11.3] which improved after intervention to 23.6% (95% CI, 17.9-30.1); P < 0.001. The overall compliance to 6-hour sepsis resuscitation bundle elements was associated with improved survival [odds ratio (OR), 5.8 (95% CI, 2.2-15.1; P < 0.001)]. 30-day hospital mortality reduced from 31.3% in the historical group to 21.1% in the intervention group; P = 0.05. Conclusion. Improvement in compliance to 6-hour sepsis resuscitation bundle was associated with a reduction in 30-day hospital mortality.

Venous thromboembolism risk and prophylaxis in a Saudi hospital.

OBJECTIVE: To evaluate the risk factors and physician's compliance to American College of Chest Physicians (ACCP) guidelines recommendations for venous thromboembolism (VTE) prevention at our hospital. METHODS: This retrospective cohort study was conducted at King Abdulaziz Hospital, Al-Ahsa, Saudi Arabia from November 2009 to December 2009. We used the American College of Chest Physicians (ACCP) 2008 guidelines and Caprini's scores to assess VTE risk and to determine whether patients had received recommended prophylaxis. All hospital in-patients aged 15 years or above were assessed for risk of VTE by reviewing the hospital chart. A data sheet was developed to obtain the data on demographics, VTE prophylaxis medication, dose, route, duration, and associated risk factors. The primary endpoint was the rate of appropriate thromboprophylaxis. RESULTS: Nine hundred and sixty-eight patients were included. The mean age was 40 +/- 18.7 years, and 647 (66.8%) were women. According to the ACCP criteria, 547 (56.5%) patients were at risk for VTE. Of 210 patients that qualified for prophylaxis, 117 (55.7%) received some form of prophylaxis. However, 46 (39.3%) of them received ACCP-recommended VTE prophylaxis. In contrast, 25.6% of patients with no risk, according to Caprini score, had thromboprophylaxis prescribed. CONCLUSION: This study demonstrates that only a small proportion of eligible patients received the recommended VTE prophylaxis. Efforts should be made to develop strategies to improve patient safety practices.

Pain management of children and adolescents with sickle cell disease presenting to the emergency department.

OBJECTIVE: To show and characterize our practice in the initial management of children and adolescents with sickle cell disease (SCD) presenting in acute painful crises, and to identify if there is a delay in patients getting the initial analgesics compared with standard guidelines. METHODS: This retrospective cohort study was conducted at the Emergency Department (ED) of King Abdulaziz Hospital, Al-Ahsa, Kingdom of Saudi Arabia. The study participants were patients who visited the ED with acute painful crises related to SCD between July 2006 and July 2007. Exclusion criteria included age younger than 5 years and those older than 18 years old. A structured medical records review was used to abstract the data. The data was then computed using the Statistical Package for Social Sciences (SPSS, Chicago, IL, USA) for Windows version 16. RESULTS: There were 270 patient visits made by 43 patients. The time to administration of initial analgesic drugs was 42.2 ± 20.4 minutes. Two hundred thirty-seven (87.7%) visits were discharged from ED after an average length of stay of 183.9 ± 129.3 minutes. The 3 most common initial analgesics used were morphine sulphate, voltaren, and paracetamol. The routes frequently used were intravenous, oral, and intramuscular. CONCLUSION: There was a delay in the administration of the initial analgesic and approximately a fifth of patients received their analgesics via an unrecommended intramuscular route.

Central venous catheter practice in an adult intensive care setting in the eastern province of Saudi Arabia.

OBJECTIVE: To study the standard central venous catheter (CVC) practice in an adult intensive care unit (ICU) for potential improvement. METHODS: This is a prospective descriptive study conducted in an adult ICU of the 300-bedded King Abdul- Aziz Hospital, Al-Ahsa, Saudi Arabia. All consecutive patients admitted over 18 months (April 2007 to September 2008) were included. Details of CVCs, indications, complications, and patients' demographic information were recorded daily until CVCs were removed. RESULTS: Overall, 379 patients had 474 CVCs, which accounted for 3024 catheter-days, with a mean duration of 6.35 +/- 4.7 days (95% confidence intervals: 5.92-6.78). The most common site of insertion was the internal jugular vein (230 [48.5%]); 192 (40.5%) subclavian catheters, and 52 (11%) femoral. The CVC utilization ratio was 0.64. The catheter related local infection (CRLI) rate was 4.6 per 1000 catheter-day (the highest in the femoral site) and the catheter-related bloodstream infection (CRBSI) rate was 1.98 per 1000 catheter-day (the highest for the jugular route). There were only a few mechanical complications including 2 pneumothoraces, 5 arterial cannulations, and a single significant catheter dislodgement causing respiratory failure. CONCLUSION: Our results suggest that the current CVC practice enabled us to keep the rate of complications low, which is comparable to international standards.

Pain practices in a Saudi emergency department.

OBJECTIVE: To describe analgesic practices among adults presenting to the emergency department (ED), and to determine factors affecting the timeliness and adequacy of analgesia. METHODS: A retrospective cohort study with descriptive and comparable data analysis was conducted on 2,199 patient visits. This included a structured medical records review for all adult patients (over 14 years old) from August 1, 2006 to October 31, 2006 that presented to the Emergency Department (ED) of King Abdul-Aziz Hospital, Al-Ahsa, Kingdom of Saudi Arabia. Patients with acute pain episode associated with sickle cell disease, headache, backache, renal colic, and trauma (specific isolated injuries) were included. Patients quantified their pain on arrival by using 2 scales. RESULTS: There were 2199 patient visits during the study period that included 1190 males (54.1%). The mean age was 24.4 10.6 years. One quarter of all the patients did not receive any analgesia in the ED. The median time to administration of initial analgesic was 54 minutes. Approximately one fourth of all patients were sent home with no analgesics. Data identified female patients and low triage level as the predictors for longer time to initial analgesia. CONCLUSION: Our data illustrate that adults with painful conditions in our ED often receive inadequate or no analgesic treatment.

Testing psychiatric stigma in a general hospital in Saudi Arabia.

OBJECTIVE: To measure the stigma of psychiatric illness in a general hospital setting, and to test the connection between common ideas people have of patients with psychiatric illness (personal responsibility, and dangerousness), and the generation of discriminatory behavior. METHODS: A cross-sectional survey through internal mail was carried out in all the hospital staff of King Abdulaziz Hospital in Al-Ahsa, Kingdom of Saudi Arabia. The questionnaire was distributed on the 1st of February, and the study was finished on the 12th of March 2008. The sample size of 860 staff members was included for the study. This study was approved by the Eastern Region National Guard's Health Affairs Research and Ethical Committee. RESULTS: Hospital staff had high scores (6.8/9) for caring attitude for patients with psychiatric illness. They had medium scores for fear (4/9), avoidance (4.8/9), and dangerousness (4.3/9). They had low scores (3.1/9) for anger feelings toward these patients. Discriminatory behavior was found to be the result of feeling that these patients are dangerous, but not because they were held responsible for their illness. CONCLUSION: Our staff had a caring attitude towards patients with psychiatric illness. The idea that the patients with psychiatric illness are to blame for their illness did not hold, while the idea that these patients are dangerous showed positive relationship with discriminatory behavior.

Extended spectrum beta-lactamase producing Escherichia coli and Klebsiella pneumoniae bacteremia. Risk factors and outcome in the eastern region of Saudi Arabia.

OBJECTIVE: To study the risk factors for bacteremia caused by Escherichia coli (E. coli) or Klebsiella pneumoniae (K. pneumoniae) producing extended-spectrum beta-lactamase (ESBL) and their outcome. METHODS: A case-control study was conducted in King Abdul-Aziz National Guard Hospital, Al-Ahsa, Kingdom of Saudi Arabia from January 2006 through December 2007. All adult patients for whom culture results were positive for E. coli or K. pneumoniae were eligible. Twenty-nine patients with ESBL producing bacteremia (cases) were compared with 80 patients with non-ESBL producing bacteremia controls. Hospital mortality was the primary end point. Univariable and multivariable logistic regression were performed to analyze risk factors for ESBL bacteremia and its 30-day mortality. RESULTS: A total of 109 patients with bacteremia were enrolled that included 29 cases and 80 controls. Forty-nine percent of the patients were male. The mean age was 60.2+/-21.1 years. Nosocomial infection was the only independent risk factor for bacteremia due to ESBL-producing pathogens (odds ratio [OR] 3.40, 95% confidence interval [CI] 1.14-8.44, p=0.02). Overall 30-day mortality was 22%, and was similar in both groups. The nosocomial infection (OR 3.20, 95% CI 1.48-6.94, p=0.01), presentation with septic shock (OR 48.88, 95% CI 6.01-397.32, p=0.004), and intensive care unit care (OR 7.40, 95% CI 1.94 -28.34, p=0.001) were the independent risk factors for 30-day mortality. CONCLUSION: The ESBL rate is high in our study among the bacteremic patients. Nosocomial infection is identified both as a risk factor for ESBL bacteremia and mortality.