Identifying which septic patients have increased mortality risk using severity scores: a cohort study.

BACKGROUND: Early aggressive therapy can reduce the mortality associated with severe sepsis but this relies on prompt recognition, which is hindered by variation among published severity criteria. Our aim was to test the performance of different severity scores in predicting mortality among a cohort of hospital inpatients with sepsis. METHODS: We anonymously linked routine outcome data to a cohort of prospectively identified adult hospital inpatients with sepsis, and used logistic regression to identify associations between mortality and demographic variables, clinical factors including blood culture results, and six sets of severity criteria. We calculated performance characteristics, including area under receiver operating characteristic curves (AUROC), of each set of severity criteria in predicting mortality. RESULTS: Overall mortality was 19.4% (124/640) at 30 days after sepsis onset. In adjusted analysis, older age (odds ratio 5.79 (95% CI 2.87-11.70) for ≥80y versus <60y), having been admitted as an emergency (OR 3.91 (1.31-11.70) versus electively), and longer inpatient stay prior to sepsis onset (OR 2.90 (1.41-5.94) for >21d versus <4d), were associated with increased 30 day mortality. Being in a surgical or orthopaedic, versus medical, ward was associated with lower mortality (OR 0.47 (0.27-0.81) and 0.26 (0.11-0.63), respectively). Blood culture results (positive vs. negative) were not significantly association with mortality. All severity scores predicted mortality but performance varied. The CURB65 community-acquired pneumonia severity score had the best performance characteristics (sensitivity 81%, specificity 52%, positive predictive value 29%, negative predictive value 92%, for 30 day mortality), including having the largest AUROC curve (0.72, 95% CI 0.67-0.77). CONCLUSIONS: The CURB65 pneumonia severity score outperformed five other severity scores in predicting risk of death among a cohort of hospital inpatients with sepsis. The utility of the CURB65 score for risk-stratifying patients with sepsis in clinical practice will depend on replicating these findings in a validation cohort including patients with sepsis on admission to hospital.

Immediately postoperative B-type natriuretic peptide and its predictive value.

BACKGROUND: Major vascular surgery involves a high risk of major cardiovascular morbidity and mortality. A method of predicting perioperative myocardial events is required. Preoperative B-type natriuretic peptide (BNP) has been evaluated for this purpose. The aims of this study were to determine the postoperative course of BNP levels and correlate these levels with the outcome. METHODS: The present study included 45 patients undergoing major vascular surgery. These patients further underwent serial venous blood sampling for troponin-T and BNP and serial electrocardiograms, pre- and postoperatively (immediately postoperatively and at days 1 through 4). RESULTS: Of the 45 patients, seven suffered myocardial damage, as defined by troponin-T. An immediate postoperative BNP (cutoff, 171 pg/mL) was better able to predict cardiac damage (p = 0.027) than BNP levels preoperatively (cutoff, 281 pg/mL, p = 0.042) and on day 1 postoperatively (cutoff, 182 pg/mL, p = 0.032). Only the preoperative BNP levels showed an effect on survival. Patients with a preoperative BNP >281 pg/mL had a mean survival of 12.7 months, as compared with 17.6 months for patients with a BNP <281 pg/mL, p = 0.044. CONCLUSION: Preoperative BNP is an accurate determinant of postoperative cardiac morbidity and all cause survival, with BNP in the immediate postoperative period being an even more accurate predictor of cardiac events. An immediate postoperative BNP might help risk stratify patients for the next 72 hours in the perioperative period (and maybe longer).

Reducing prescribing errors: can a well-designed electronic system help?

RATIONALE, AIMS AND OBJECTIVES: In this study, the aim was to investigate if an electronic prescribing system designed specifically to reduce errors would lead to fewer errors in prescribing medicines in a secondary care setting. METHOD: The electronic system was compared with paper prescription charts on 16 intensive care patients to assess any change in the number of prescribing errors. RESULTS: The overall level of compliance with nationally accepted standards was significantly higher with the electronic system (91.67%) compared with the paper system (46.73%). Electronically generated prescriptions were found to contain significantly fewer deviations (28 in 329 prescriptions, 8.5%) than the written prescriptions (208 in 408 prescriptions, 51%). CONCLUSION: Taking an interdisciplinary approach to work on the creation of a system designed to minimize the risk of error has resulted in a favoured system that significantly reduces the number of errors made.