ICU Utilization After Implementation of Minor Severe Pneumonia Criteria in Real-Time Electronic Clinical Decision Support.

OBJECTIVES: To determine if the implementation of automated clinical decision support (CDS) with embedded minor severe community-acquired pneumonia (sCAP) criteria was associated with improved ICU utilization among emergency department (ED) patients with pneumonia who did not require vasopressors or positive pressure ventilation at admission. DESIGN: Planned secondary analysis of a stepped-wedge, cluster-controlled CDS implementation trial. SETTING: Sixteen hospitals in six geographic clusters from Intermountain Health; a large, integrated, nonprofit health system in Utah and Idaho. PATIENTS: Adults admitted to the hospital from the ED with pneumonia identified by: 1) discharge International Classification of Diseases , 10th Revision codes for pneumonia or sepsis/respiratory failure and 2) ED chest imaging consistent with pneumonia, who did not require vasopressors or positive pressure ventilation at admission. INTERVENTIONS: After implementation, patients were exposed to automated, open-loop, comprehensive CDS that aided disposition decision (ward vs. ICU), based on objective severity scores (sCAP). MEASUREMENTS AND MAIN RESULTS: The analysis included 2747 patients, 1814 before and 933 after implementation. The median age was 71, median Elixhauser index was 17, 48% were female, and 95% were Caucasian. A mixed-effects regression model with cluster as the random effect estimated that implementation of CDS utilizing sCAP increased 30-day ICU-free days by 1.04 days (95% CI, 0.48-1.59; p < 0.001). Among secondary outcomes, the odds of being admitted to the ward, transferring to the ICU within 72 hours, and receiving a critical therapy decreased by 57% (odds ratio [OR], 0.43; 95% CI, 0.26-0.68; p < 0.001) post-implementation; mortality within 72 hours of admission was unchanged (OR, 1.08; 95% CI, 0.56-2.01; p = 0.82) while 30-day all-cause mortality was lower post-implementation (OR, 0.71; 95% CI, 0.52-0.96; p = 0.03). CONCLUSIONS: Implementation of electronic CDS using minor sCAP criteria to guide disposition of patients with pneumonia from the ED was associated with safe reduction in ICU utilization.

Survival Analysis of Cancer Patients With FIGO Stage IIIA Endometrial Cancer.

OBJECTIVE: Endometrial cancer patients with positive serosa and/or adnexae (FIGO stage IIIA) have a variable prognosis and are at a significant risk for recurrence. We investigated how tumor characteristics and adjuvant treatments influence the overall survival (OS) and recurrence patterns in these patients and patients with positive cytology alone (previously classified as stage IIIA before 2009). MATERIALS AND METHODS: This multi-institution retrospective study reviewed 55 patients with positive serosa and/or adnexae and 18 patients with positive cytology only, surgically staged from 1990 to 2010. The study cohort was evaluated using the Kaplan-Meier estimates of OS and Cox proportional hazards modeling. RESULTS: The 5-year OS for all IIIA patients was 55%. Administration of adjuvant therapy was associated with improved OS when compared with surgery alone (P=0.0018). The 5-year OS was 20% for patients treated with surgery alone (n=10), 55% with surgery and radiation therapy (n=26), 75% with surgery and chemotherapy (n=7), and 79% with surgery followed by both radiation therapy and chemotherapy (n=12; P=0.005). The tumor characteristics showed that nonendometrioid histology (P=0.0143) and lymph vascular space invasion (P=0.0483) had a poorer OS. Recurrence occurred in 29% of IIIA patients, with 9% locoregional failures and 20% distant failures. Patients with positive cytology only had a similar OS to patients with positive serosa and/or adnexae (76% vs. 55%; P=0.104) and recurrence rate (22% vs. 29%; P=0.4101). CONCLUSIONS: This retrospective study suggests benefit from the use of adjuvant radiotherapy and chemotherapy for stage IIIA patients. We recommend further investigation of adjuvant therapies for IIIA patients in prospective studies and randomized clinical trials.