Admission characteristics predictive of in-hospital death from hospital-acquired sepsis: A comparison to community-acquired sepsis.

PURPOSE: Healthcare associated (HA) sepsis is associated with increased resource utilization and mortality compared with community acquired (CA) sepsis. The purpose of this study was to identify independent predictors of in-hospital mortality from HA-sepsis. MATERIALS AND METHODS: Retrospective study of adult patients admitted with HA or CA-sepsis. Predictors were identified using logistic regression. RESULTS: There were 3917 sepsis encounters, of which 3186 were CA and 731 were HA. History of stroke (83/731, 11%) and myocardial infarction (70/731, 10%) were higher in HA than CA-sepsis (stroke: 258/3186, 8%, p = .005; myocardial infarction: 213/3186, 7%, p = .007). HA-sepsis patients required more mechanical ventilation (153/731, 21%) than CA-patients (218/3186, 7%, p < .001) and had a higher rate of vasopressor use (334/731, 46%) than CA patients (832/3186, 26%, p < .001). The HA group had longer ICU lengths of stay (LOS) than CA patients did at 9 days and 2.8 days, respectively (p < .0001). Moderate to severe liver disease (OR = 27, 95%CI 1.4, 513, p = .031) and congestive heart failure (CHF, 5.81, 95% CI 1.3, 26, p = .025) were predictive of in-hospital mortality from HA-sepsis. CONCLUSIONS: Liver disease and CHF were independent predictors of in-hospital mortality in HA-sepsis. HA-sepsis patients had increased prevalence of previous stroke, myocardial infarction, and liver disease.

Managing sepsis: Electronic recognition, rapid response teams, and standardized care save lives.

PURPOSE: Sepsis can lead to poor outcomes when treatment is delayed or inadequate. The purpose of this study was to evaluate outcomes after initiation of a hospital-wide sepsis alert program. MATERIALS AND METHODS: Retrospective review of patients ≥18years treated for sepsis. RESULTS: There were 3917 sepsis admissions: 1929 admissions before, and 1988 in the after phase. Mean age (57.3 vs. 57.1, p=0.94) and Charlson Comorbidity Scores (2.52 vs. 2.47, p=0.35) were similar between groups. Multivariable analyses identified significant reductions in the after phase for odds of death (OR 0.62, 95% CI 0.39-0.99, p=0.046), mean intensive care unit LOS (2.12days before, 95%CI 1.97, 2.34; 1.95days after, 95%CI 1.75, 2.06; p<0.001), mean overall hospital LOS (11.7days before, 95% CI 10.9, 12.7days; 9.9days after, 95% CI 9.3, 10.6days, p<0.001), odds of mechanical ventilation use (OR 0.62, 95% CI 0.39, 0.99, p=0.007), and total charges with a savings of $7159 per sepsis admission (p=0.036). There was no reduction in vasopressor use (OR 0.89, 95% CI 0.75, 0.1.06, p=0.18). CONCLUSION: A hospital-wide program utilizing electronic recognition and RRT intervention resulted in improved outcomes in patients with sepsis.

Impact of prescription drug-monitoring program on controlled substance prescribing in the ED.

OBJECTIVE: In 2009, Florida initiated a statewide prescription drug-monitoring program (PDMP) to encourage safer prescribing of controlled substances and reduce drug abuse and diversion. Data supporting the utility of such programs in the emergency department (ED) is scarce. This study sought to determine the effect of PDMP data on controlled substance prescribing from the ED. METHODS: In this pre-post study utilizing a historical control, pharmacists in the ED provided prescribers with a summary of the PDMP data for their patients. The number of controlled substances prescribed in the intervention group was compared with that prescribed in the historical control to determine if the intervention resulted in a change in the average number of controlled substance prescribed. RESULTS: Among the 710 patients evaluated, providing prescribers with PDMP data did not alter the average number of controlled substance per patient prescribed (0.23 controlled substances per patient in the historical control compared with 0.28 controlled substances per patient in the intervention group; 95% confidence interval [CI], -0.016 to 0.116; P = .125). All prescribers surveyed indicated that having PDMP data altered their controlled substance prescribing and felt more comfortable prescribing controlled substances. CONCLUSIONS: Although the results did not demonstrate a change in the average number of controlled substances prescribed when prescribers were provided with PDMP data, results from the survey indicate that prescribers felt the data altered their prescribing of controlled substances, and thus were more contented prescribing controlled substances.

Impact of an abbreviated cardiac enzyme protocol to aid rapid discharge of patients with cocaine-associated chest pain in the clinical decision unit.

INTRODUCTION: In 2007 there were 64,000 visits to the emergency department (ED) for possible myocardial infarction (MI) related to cocaine use. Prior studies have demonstrated that low- to intermediate-risk patients with cocaine-associated chest pain can be safely discharged after 9-12 hours of observation. The goal of this study was to determine the safety of an 8-hour protocol for ruling out MI in patients who presented with cocaine-associated chest pain. METHODS: We conducted a retrospective review of patients treated with an 8-hour cocaine chest pain protocol between May 1, 2011 and November 30, 2012 who were sent to the clinical decision unit (CDU) for observation. The protocol included serial cardiac biomarker testing with Troponin-T, CK-MB (including delta CK-MB), and total CK at 0, 2, 4, and 8 hours after presentation with cardiac monitoring for the observation period. Patients were followed up for adverse cardiac events or death within 30 days of discharge. RESULTS: There were 111 admissions to the CDU for cocaine chest pain during the study period. One patient had a delta CK-MB of 1.6 ng/ml, but had negative Troponin-T at all time points. No patient had a positive Troponin-T or CK-MB at 0, 2, 4 or 8 hours, and there were no MIs or deaths within 30 days of discharge. Most patients were discharged home (103) and there were 8 inpatient admissions from the CDU. Of the admitted patients, 2 had additional stress tests that were negative, 1 had additional cardiac biomarkers that were negative, and all 8 patients were discharged home. The estimated risk of missing MI using our protocol is, with 99% confidence, less than 5.1% and with 95% confidence, less than 3.6% (99% CI, 0-5.1%; 95% CI, 0-3.6%). CONCLUSION: Application of an abbreviated cardiac enzyme protocol resulted in the safe and rapid discharge of patients presenting to the ED with cocaine-associated chest pain.

The prosecution of sexual assault cases: correlation with forensic evidence.

STUDY OBJECTIVE: We sought to determine the association between historical and physical evidence with judicial outcome in sexual assault cases. METHODS: A population-based, retrospective review of forensic evidence was conducted for all sexual assault cases reported in Duval County, FL, during a 2-year period. Variables examined included age, race of victim, evidence of trauma (body, genital, or both), presence of spermatozoa at the time of the forensic examination, weapon use, and whether the victim knew the assailant. In cases in which an arrest was made, logistic regression was used to estimate the strength of association with the outcome of conviction in sexual assault cases. RESULTS: During the study period, 821 sexual assaults were reported, and 801 forensic examinations were performed. The victims were predominantly female (776; 97%), with 409 (51%) being black, 376 (47%) white, and 16 (2%) other minorities. A suspect was identified in 355 (44%) of the 801 cases for which a sexual assault forensic examination was conducted. No suspect was identified in 446 (56%) of these cases. There were 271 arrests made. The police did not have enough evidence to arrest a suspect after detention in 84 cases. For those cases in which a suspect was arrested, 153 had charges dropped, 89 were found guilty, 2 were found not guilty, and 27 cases were still pending or the files were sealed and unavailable for review. There was evidence of trauma in 202 (57%) of the examinations, and spermatozoa were found at the time of the forensic examination in 110 (31%) of the cases in which a suspect was identified. Logistic regression found that victims aged younger than 18 years, the presence of trauma, and the use of a weapon by the assailant were significantly associated with successful prosecution. There was a trend toward conviction if the victim was white. CONCLUSION: Emergency physicians have an obligation to provide care for victims of sexual assault cases. This care includes a possible legal defense. To that end, emergency physicians should be vigilant in the documentation of the history of the event (eg, weapon use) and in the documentation of traumatic injuries because these factors can assist in a successful prosecution.