Overcultured? Blood cultures on discharged ED patients were ordered more frequently after the SEP-1 bundle initiation.

INTRODUCTION: In 2015, the Severe Sepsis and Early Septic Shock Management Bundle (SEP-1) tied hospital reimbursement to performance on a series of time sensitive indicators, including ordering blood cultures on patients with severe sepsis or septic shock. This metric could have broadly shaped ordering practices in the Emergency Department (ED), including for patients who did not have severe sepsis or septic shock. In this study, we sought to evaluate whether the frequency of blood culture orders on adult patients discharged from the ED changed after the SEP-1 metric, whether the rates of positivity for pathogens or contaminants changed after the SEP-1 metric, and whether similar changes were seen in orders for other laboratory tests. METHODS: This was a retrospective evaluation of blood culture orders from discharged adult ED patients from a suburban academic hospital between January 1, 2012 and June 30, 2019. We compared the number of blood cultures per discharged adult patient before and after the SEP-1 metric. We categorized each culture that grew an organism as a pathogen or a contaminant, and we compared rates of pathogen and contaminant growth before and after SEP-1. We compared rates of orders of blood cultures and lactates as labs related to SEP-1 with rates of orders of D-dimers, lipases, human chorionic gonadotropins (HCGs), and brain natriuretic peptides (BNPs) as labs unrelated to SEP-1 before and after the implementation of the SEP-1 metric. RESULTS: There were 144,343 adult patients discharged from the ED during the study period. A total of 6754 blood cultures were drawn from 3827 of those patient visits. The rate increased from 43.1 cultures per 1000 discharged patients before the SEP-1 metric to 75.9 blood cultures per 1000 discharged patients, an increase of 76.2% (p < 0.001). The cultures had a decreased rate of positivity (from 3.93% before SEP-1 to 3.03% after SEP-1, p = 0.044) and an unchanged rate of blood cultures resulting in a contaminant (2.49% to 1.85%, p = 0.071). Overall, orders of the labs unrelated to SEP-1 increased by an average of 16.8% after the SEP-1 metric and orders of the labs related to SEP-1 increased by an average of 81.0%. CONCLUSION: After the SEP-1 bundle, blood cultures were ordered more frequently on discharged ED patients. These cultures had a lower rate of positivity for pathogens and an unchanged rate of growth of contaminants. This increase was not matched by a similar increase in other labs. Taken together, these findings suggest that the SEP-1 metric had the unintended consequence of increasing orders of blood cultures on patients healthy enough to be discharged from the ED.

Acute venous thromboembolism after initiation of voxelotor for treatment of sickle cell disease.

Sickle Cell Disease (SCD) is the most common genetic disease in the United States. Symptoms result from formation of sickle hemoglobin (HbS), which polymerizes and obstructs vasculature. Voxelotor, a HbS polymerization inhibitor, was granted accelerated approval by the Food and Drug Administration in 2019 for chronic treatment of SCD. While voxelotor may offer a disease-modifying approach to SCD, little is known about long-term safety profile. Venous thromboembolism (VTE) is a potential adverse effect (AE) that rarely occurred during clinical trials. While pulmonary embolism (PE) is listed as a potential AE, the pathophysiologic mechanism has yet to be elucidated. We report a patient with SCD presenting to the emergency department (ED) with acute onset shortness of breath, tachycardia, and hypotension in the setting of newly initiated voxelotor twenty days prior to arrival. Computed tomography pulmonary angiography showed multiple acute subsegmental PEs. Lower extremity doppler showed acute bilateral DVTs. Voxelotor, which was suspected to have provoked the VTEs, was discontinued indefinitely. The patient's reaction scored a 5 on the Naranjo Adverse Drug Reaction Probability Scale, indicating probable causal relationship between the VTEs and voxelotor. Although listed as an AE on its drug label, the only reports of voxelotor-associated VTE are in the results of clinical trials. To our knowledge, we present the first case of VTE likely provoked by voxelotor. While voxelotor offers a promising therapeutic option for SCD, emergency medicine physicians should be aware of severe AEs that may necessitate ED visits.

Vaginal cuff dehiscence - A potential surgical emergency.

Vaginal cuff dehiscence is a rare, but potentially morbid, complication of a total hysterectomy. Bowel evisceration can lead to serious sequelae and is considered a surgical emergency however there is a paucity of information on it in the Emergency Medicine literature. We present the case of a 40 year old female with a chief complaint of vaginal bleeding and severe abdominal pain after sexual intercourse. She was s/p total laparoscopic hysterectomy 3 months earlier. The history and physical exam were concerning for vaginal cuff dehiscence (VCD). The patient underwent an Exam Under Anesthesia (EUA) and subsequent laparoscopic repair of the vaginal cuff defect and fully recovered.

BundlED Up: A Narrative Review of Antimicrobial Stewardship Initiatives and Bundles in the Emergency Department.

Antimicrobial stewardship (ASP) is becoming an increasingly high priority worldwide, yet the emergency department (ED) is an area where stewardship is often neglected. Implementing care bundles, guidelines, and protocols appears to be a rational strategy for ED stewardship given the inherently dynamic and hectic environment of care. Multiple questions still exist such as whether to target certain disease states, optimal implementation of ASP interventions in the ED, and the benefit of unique ED-specific guidelines and protocols. A narrative review was performed on interventions, guidelines, and bundles implemented in the ED setting, in an effort to improve ASP or management of infectious diseases. This review is meant to serve as a framework for the reader to implement these practices at their own institution. We examined various studies related to ASP interventions or care bundles in the ED which included: CNS infections (one study), skin and soft-tissue infections (one study), respiratory infections (four studies), urinary tract infections and sexually transmitted infections (eight studies), sepsis (two studies), culture follow-up programs (four studies), and stewardship in general or multiple infection types (five studies). The interventions in this review were diverse, yet the majority showed a benefit in clinical outcomes or a decrease in antimicrobial use. Care bundles, guidelines, and antimicrobial stewardship interventions can streamline care and improve the management of common infectious diseases seen in the ED.

Early recognition of sepsis through emergency medical services pre-hospital screening.

BACKGROUND: The Surviving Sepsis Campaign implemented a 3-hour bundle including blood cultures, lactate, intravenous fluids, and antibiotics to improve mortality in sepsis. Though difficult to achieve, bundle compliance is associated with decreased hospital mortality. We predict that the implementation of an Emergency Medical Services (EMS) sepsis screening tool will improve 3-hour bundle compliance. OBJECTIVES: To determine if pre-hospital sepsis screening improves 3-hour bundle compliance. METHODS: Prospective implementation of an EMS sepsis screening tool (June 2016-November 2016) was compared to a historical control (August 2015-March 2016). The protocol was facilitated via communication between nurses and EMS personnel. The primary outcome was 3-hour bundle compliance. Secondary outcomes included time to individual bundle components. RESULTS: Of 135 patients screened, 20 were positive and included in the study, and subsequently compared to 43 control patients. Baseline demographics were similar, except median Sequential Organ Failure Assessment (SOFA) score was higher for the pre-EMS tool group (5 [interquartile range (IQR) 2-8] vs. 2 [IQR 1-4], p < 0.01). Three-hour bundle compliance was significantly higher in the EMS tool group (80% vs. 44.2%, p < 0.01). The pre-EMS tool group had lower median time to lactate (15 [IQR 0-35] vs. 46 min [IQR 34-57], p < 0.001), 30 mL/kg IV fluids (6.5 [IQR 0-38] vs. 46 min [IQR 27.5-72], p < 0.001), and, although not significant, antibiotics (63.5 [IQR 44-92] vs. 72 min [IQR 59.5-112], p = 0.26). CONCLUSION: Implementation of an EMS sepsis screening tool resulted in improved 3-hour bundle compliance compared to retrospective control.

Intravenous Lidocaine for Acute Pain: A Systematic Review.

This systematic review evaluates the safety and efficacy of intravenous (IV) lidocaine for the treatment of acute pain in adult patients. The PubMed database was searched for randomized controlled trials, retrospective cohort studies, case series, and case reports evaluating the use of IV lidocaine for the treatment of acute pain in adult patients, published between January 1970 and January 2018. The primary outcome was pain reduction via the Visual Analog Scale, Verbal Rating Scale, or Numeric Rating Scale among patients treated with IV lidocaine and placebo or active controls. Safety outcomes included both nonserious and serious adverse events. A total of 347 titles and abstracts were screened, and after full-text review, 13 studies met the inclusion criteria involving 512 patients. The four active controls studied were IV morphine, IV ketorolac, IV dihydroergotamine (DHE), and IV chlorpromazine (CPZ). The dosing of IV lidocaine varied among studies between a weight-based dose of a 1- to 2-mg/kg bolus, a fixed-bolus dose of 50-100 mg, and a 1-mg/kg/hour continuous infusion. Monitoring of serum lidocaine concentrations was not done routinely. Intravenous lidocaine had superior efficacy to morphine for renal colic and critical limb ischemia, superior efficacy to DHE for acute migraine, and equivalent efficacy to ketorolac for acute radicular lower back pain. However, lidocaine was less effective than CPZ for the treatment of acute migraine. The most common adverse event reported among all studies were neurologic effects such as altered mental status and slurred speech. Due to the inconsistency in dosing, length of administration, and lack of serum monitoring, the absolute safety of IV lidocaine for acute pain is unknown. Larger, prospective studies are needed before the routine use of IV lidocaine can be recommended for all types of acute pain.

Time Spent in the Emergency Department and Outcomes in Patients With Severe Sepsis and Septic Shock.

A majority of patients with severe sepsis and septic shock are first evaluated in the emergency department (ED). Methods such as screening tools have proven advantageous in earlier identification, allowing for timely initiation of treatment. Delay in symptom presentation and ED overcrowding contribute to deferment of sepsis bundle components and admission. To examine the impact of time from ED arrival to inpatient admission on mortality and length of stay (LOS) in patients with severe sepsis or septic shock. A retrospective analysis of adult patients with severe sepsis or septic shock was completed for those presenting between January 2013 and December 2014. Patients were dichotomized on the basis of the length of time from completed triage in the ED to intensive care unit (ICU) admission (at less than 6 hr and at 6 hr or more). Of the 294 patients screened, 172 patients (58.5%) met inclusion criteria (n = 70 cases at less than 6 hr; n = 102 at 6 hr or more). Mean wait time from ED arrival to ICU admission was 470.7 ± 333.9 min (range = 84-2,390 min). Groups were similar in baseline, disease severity, and bundle characteristics. There were no differences in the less than 6-hr group compared with the 6-hr-or-more group in rates of 30-day mortality (37.1% vs. 32.4%; p = 0.52), as well as in-hospital (27.1% vs. 23.5%; p = 0.59) or 90-day mortality (42.9% vs. 34.3%; p = 0.26). There were also no differences in hospital or ICU LOS. Timing of transfer from the ED to the ICU was not found to impact mortality or LOS. These results suggest that the ED can provide similar sepsis care to that in the ICU when transfer is delayed in patients with sepsis.

Emergency department sepsis screening tool decreases time to antibiotics in patients with sepsis.

Recent literature has highlighted the importance of early identification and treatment of sepsis; however, limited data exists to help recognize sepsis in the emergency department (ED) through use of a screening tool. The purpose of this study was to evaluate the impact of a sepsis screening tool implemented in an academic medical center ED on compliance with the 3-hour sepsis bundle. This was a retrospective cohort study that included a total of 115 patients, of which 58 were in the pre-tool group and 57 were in the post-tool group. There was no difference in 3-hour bundle compliance between groups (36.2% vs. 47.4%, P = 0.26). There was no difference in the following bundle components: lactate (79.3% vs. 80.7%, P = 0.85), blood cultures (86.2% vs. 96.5%, P = 0.09), blood cultures before administering antibiotics (91.4% vs. 100%, P = 0.57) and adequate fluids administration (44.7% vs. 41.9%, P = 0.820). A significantly higher number of patients received antibiotics within 3 h in the post-tool group (58.6% vs. 89.5%, P < 0.001). Statistically significant secondary outcomes included average time to antibiotics (P = 0.04), administering antibiotics within an hour (P > 0.001), and ICU length of stay (P = 0.03). There was no difference in 30-day mortality, however mortality was numerically lower in the post-tool group (36.2% vs. 26.3%, P = 0.25). Although implementation of an ED sepsis screening tool did not increase 3-hour bundle compliance, it did increase the proportion of patients receiving timely antimicrobial therapy and demonstrated a trend towards decreased mortality.

Early Recognition and Treatment of Sepsis After the Addition of Lactate to the Laboratory's Critical Result Call List.

PURPOSE: Screening of patients with sepsis is needed to increase recognition and allow for earlier interventions. There is no consensus on whether the addition of lactate to the critical result laboratory's call list should be a standard practice. MATERIALS AND METHODS: This was a retrospective cohort study that compared management and outcomes of patients with sepsis having lactate ≥4 mmol/L before (group 1) and after (group 2) the addition of a critical result threshold of lactate of ≥4 mmol/L to the critical result laboratory's call list and its effects on time to antibiotics and intravenous fluids (IVFs). RESULTS: One hundred twenty-one patients were included. Lactate was higher in group 1 (7.0 ± 4.3 vs 5.6 ± 2.0, P = 0.03). More patients in group 2 received hydrocortisone (1.9% vs 22.4%, P = .001). Hospital mortality, 30-day mortality, and 90-day mortality were significantly lower in group 2 (59.3% vs 32.8%, P = .003; 68.5% vs 37.3%, P ≤ .001; 68.5% vs 41.8%, P = .002). There were no significant differences in total volume of IVFs (2400.8 ± 1720.0 vs 2483.7 ± 2155.7, P = 0.83), time to start IVFs (184.0 ± 283.2 vs 115.6 ± 190.5, P = 0.27), or antibiotics (184.8 ± 187.1 vs 133.7 ± 137.4, P = 0.16). CONCLUSION: Addition of lactate to the critical result laboratory's call list did not lead to a statistically significant improvement in time to IVFs or antibiotics, although the average time to antibiotics and IVFs decreased by 51.1 and 68.4 minutes, respectively. Hospital mortality, 30-day mortality, and 90-day mortality were lower in group 2, which may be, in part, due to increased recognition of severe sepsis by critical result notification and earlier intervention.

Risk factors for mortality in septic patients who received etomidate.

PURPOSE: To characterize risk factors for mortality in septic patients who received etomidate for rapid sequence intubation. MATERIALS AND METHODS: This study was a retrospective cohort conducted at a large, tertiary, urban, academic medical center that included patients with severe sepsis or septic shock who received etomidate between January 1, 2010, and December 31, 2012. RESULTS: A total of 169 patients were included with similar baseline characteristics. There were more men in the nonsurvivor group than in the survivor group (67.1% vs 50.6%, P=.03). Septic shock occurred in 91.5% of nonsurvivors and 69% of survivors (P<.01). Nonsurvivors also had a higher initial lactate of (5.1±4.3 mmol/L vs 3.6±3.4 mmol/L, P=.02) and more vasopressor therapy (91.5% vs 69%, P<.01), required a higher number of vasopressors (2.2±1.1 vs 1.3±1, P<.01), and were administered hydrocortisone (53.7% vs 34.5%, P=.01). Abdominal source of sepsis (P=.048) and number of vasopressors (P=.01) were predictive of 30-day mortality. CONCLUSION: An alternative sedative induction agent may be considered for use in rapid sequence intubation in patients on multiple vasopressors or with abdominal source of infection.

A descriptive analysis of 1251 solid organ transplant visits to the emergency department.

BACKGROUND: As solid organ transplants become more common, recipients present more frequently to the emergency department (ED) for care. METHODS: We performed a retrospective medical record review of ED visits of all patients who received an organ transplant at our medical center from 2000-2004, and included all visits following the patients' transplant surgery through December 2005 or until failed graft, lost to follow up, or death. Clinically relevant demographic variables, confounding and outcome variables were recorded. Kidney, liver and combined kidney with other organ transplant recipients were included. RESULTS: Five hundred ninety-three patients received kidney (395), liver (161), or combined renal (37) organ transplants during the study period, resulting in 1,251 ED visits. This represents 3.15 ED visits/patient followed over a mean of 30.8 months. Abdominal pain/gastrointestinal (GI) symptoms (31.3%) and infectious complaints (16.7%) were the most common presentations. The most common ED discharge diagnoses were fever/infection (36%), GI/Genitourinary (GU) pathology (20.4%) and dehydration (15%). Renal transplant recipients were diagnosed with infectious processes most often, despite time elapsed from transplant. Liver transplant patients had diagnoses of fever/infection most often in their first 30 days post transplant. Thereafter they were more likely to develop GI/GU pathology. After the first year of transplantation, cardiopulmonary and musculoskeletal pathology become more common in all transplant organ groups. Of the 1,251 ED visits, 762 (60.9%) resulted in hospitalization. Chief complaints of abdominal pain/GI symptoms, infectious complaints, cardiovascular and neurologic symptoms, and abnormal laboratory studies were significantly likely to result in hospitalization. CONCLUSIONS: This study demonstrates a significant utilization of the ED by transplant recipients, presenting with a wide variety of symptoms and diagnoses, and with a high hospitalization rate. As the transplant-recipient population grows, these complex patients continue to present diagnostic and treatment challenges to primary care and emergency physicians.