Blood Culture Ordering After Sepsis Alerts and Subsequent Patient Outcomes: An Electronic Health Record-Based Study.

Sepsis is a global health priority associated with high mortality. Clinical decision support systems have been developed to support clinicians with sepsis management. Ordering blood cultures (BCs) for suspected sepsis patients are strongly recommended by clinical guidelines. However, limited evidence exists investigating BC ordering following sepsis alerts and subsequent patient outcomes. This study aimed to investigate this issue using electronic health record data from an acute care hospital in Australia. Of 4,092 patients, only 16.6% had a BC ordered following a sepsis alert. The median time from the first sepsis alert to a BC order was 15.3 hours. Patients had 5.89 times higher odds of being diagnosed with sepsis if a BC was ordered following a sepsis alert than those without BC ordered (p<0.0001). Further investigation is needed to understand reasons behind the delay or failure to order a BC despite receiving electronic sepsis alerts and how decision support can be optimized to improve patient outcomes.

Injection Drug Use Frequency Before and After Take-Home Naloxone Training.

Importance: Concerns that take-home naloxone (THN) training may lead to riskier drug use (as a form of overdose risk compensation) remain a substantial barrier to training implementation. However, there was limited good-quality evidence in a systematic review of the association between THN access and subsequent risk compensation behaviors. Objective: To assess whether THN training is associated with changes in overdose risk behaviors, indexed through injecting frequency, in a cohort of people who inject drugs. Design, Setting, and Participants: This cohort study used prospectively collected self-reported behavioral data before and after THN training of participants in The Melbourne Injecting Drug User Cohort Study (SuperMIX). Annual interviews were conducted in and around Melbourne, Victoria, Australia, from 2008 to 2021. SuperMIX participants were adults who regularly injected heroin or methamphetamine in the 6 months preceding their baseline interview. The current study included only people who inject drugs who reported THN training and had participated in at least 1 interview before THN training. Exposure: In 2017, the SuperMIX baseline or follow-up survey began asking participants if and when they had received THN training. The first THN training date that was recorded was included as the exposure variable. Subsequent participant interviews were excluded from analysis. Main Outcomes and Measures: Injecting frequency was the primary outcome and was used as an indicator of overdose risk. Secondary outcomes were opioid injecting frequency, benzodiazepine use frequency, and the proportion of the time drugs were used alone. Fixed-effects generalized linear (Poisson) multilevel modeling was used to estimate the association between THN training and the primary and secondary outcomes. Time-varying covariates included housing status, income, time in study, recent opioid overdose, recent drug treatment, and needle and syringe coverage. Findings were expressed as incidence rate ratios (IRRs) with 95% CIs. Results: There were 1328 participants (mean [SD] age, 32.4 [9.0] years; 893 men [67.2%]) who completed a baseline interview in the SuperMIX cohort, and 965 participants completed either a baseline or follow-up interview in or after 2017. Of these 965 participants, 390 (40.4%) reported THN training. A total of 189 people who inject drugs had pretraining participant interviews with data on injecting frequency and were included in the final analysis (mean [SD] number of interviews over the study period, 6.2 [2.2]). In fixed-effects regression analyses adjusted for covariates, there was no change in the frequency of injecting (IRR, 0.91; 95% CI, 0.69-1.20; P = .51), opioid injecting (IRR, 0.95; 95% CI, 0.74-1.23; P = .71), benzodiazepine use (IRR, 0.96; 95% CI, 0.69-1.33; P = .80), or the proportion of reported time of using drugs alone (IRR, 1.04; 95% CI, 0.86-1.26; P = .67) before and after THN training. Conclusions and Relevance: This cohort study of people who inject drugs found no evidence of an increase in injecting frequency, along with other markers of overdose risk, after THN training and supply. The findings suggest that THN training should not be withheld because of concerns about risk compensation and that advocacy for availability and uptake of THN is required to address unprecedented opioid-associated mortality.

The impacts of COVID-19 measures on drug markets and drug use among a cohort of people who use methamphetamine in Victoria, Australia.

BACKGROUND AND AIMS: Few studies of the impacts of the coronavirus disease 2019 (COVID-19) public health measures on drug markets and drug use patterns have used longitudinal data. We aimed to examine whether COVID-19 measures were associated with increases in methamphetamine price, decreases in methamphetamine use frequency and subsequent changes in secondary outcomes of other drug use frequency in metropolitan Melbourne and regional Victoria. DESIGN: Longitudinal analysis framework was used from a longitudinal cohort of people who use methamphetamine. SETTING: Victoria state, Australia. PARTICIPANTS: One hundred eighty-five VMAX study participants who reported a methamphetamine purchase after the onset of the pandemic were used for the price paid analysis. Methamphetamine or other drug use frequency analysis was performed using 277 participants who used methamphetamine during the pandemic or in the year before the pandemic. MEASUREMENTS: Price paid per gram of methamphetamine derived from the most recent purchase price and most recent purchase quantity. Frequency of methamphetamine and other drug use measured as the average number of days per week used in the last month. FINDINGS: Compared with pre-COVID-19 period, methamphetamine prices increased by AUD351.63 (P value <0.001) and by AUD456.51 (P value <0.001) in Melbourne and regional Victoria, respectively, during the period in which the most intense public health measures were implemented in Victoria. Although prices decreased after harder restrictions were lifted (by AUD232.84, P value <0.001 and AUD263.68, P value <0.001, in Melbourne and regional Victoria, respectively), they remained higher than pre-COVID-19 levels. A complementary 76% decrease was observed in relation to methamphetamine use frequency in regional Victoria (P value = 0.006) that was not offset by any changes in the frequency of use of other drugs such as alcohol, tobacco or other illicit drugs. CONCLUSION: COVID-19 public health measures in Victoria state, Australia, appear to have been associated with major price changes in the methamphetamine market and decreased frequency of use of the drug.

Medication use and hospital-acquired acute kidney injury: an electronic health record-based study.

BACKGROUND AND AIMS: Medications remain an important contributor to the development of acute kidney injury (AKI). This study aimed to examine associations between (i) administration of medications known to reduce glomerular filtration rate (GFR), that is, GFR modifiers and subsequent hospital-acquired AKI; and (ii) potentially medication-related AKI and patient adverse outcomes. METHODS: A retrospective cohort study utilising electronic health record data of patients admitted to a tertiary hospital in Australia in 2015. Timing of medication administration was compared with timing of AKI development. AKI cases were identified using an algorithm based on serum creatinine level changes. Multilevel regression models were applied with adjustment for relevant demographic and clinical factors. RESULTS: Among 11 503 admissions, AKI was identified in 955 patients (8.3%) and 637 (66.7% of 955) were preceded by administration of a GFR modifier. Patients without prior AKI were 17% more likely to develop AKI after administration of these medications (adjusted odds ratio 1.17, 95% confidence interval (CI) 1.003-1.37). Older age and comorbidity with diabetes, acute myocardial infarction, peripheral vascular disease, liver cirrhosis and multiple myeloma were also significant predictors. Patients with potentially medication-related AKI were 11.69 times more likely to die in hospital (95% CI 7.84-17.43) and stayed 3.49 times longer in hospital (95% CI 3.26-3.73), compared with those without AKI. CONCLUSIONS: Administration of medications contributing to the reduction of GFR is associated with an increased risk of hospital-acquired AKI and worse patient outcomes. Caution is required when prescribing these medications to patients at risk of developing AKI, and monitoring patients for deterioration is needed if administered.

Comparison of the quick Sepsis-related Organ Failure Assessment and adult sepsis pathway in predicting adverse outcomes among adult patients in general wards: a retrospective observational cohort study.

BACKGROUND: Quick Sepsis-related Organ Failure Assessment (qSOFA) is recommended for use by the most recent international sepsis definition taskforce to identify suspected sepsis in patients outside the intensive care unit (ICU) at risk of adverse outcomes. Evidence of its comparative effectiveness with existing sepsis recognition tools is important to guide decisions about its widespread implementation. AIM: To compare the performance of qSOFA with the adult sepsis pathway (ASP), a current sepsis recognition tool widely used in NSW hospitals and systemic inflammatory response syndrome criteria in predicting adverse outcomes in adult patients on general wards. METHODS: A retrospective observational cohort study was conducted which included all adults with suspected infections admitted to a Sydney teaching hospital between December 2014 and June 2016. The primary outcome was in-hospital mortality with two secondary composite outcomes. RESULTS: Among 2940 patients with suspected infection, 217 (7.38%) died in-hospital and 702 (23.88%) were subsequently admitted to ICU. The ASP showed the greatest ability to correctly discriminate in-hospital mortality and secondary outcomes. The area under the receiver-operating characteristic curve for mortality was 0.76 (95% confidence interval (CI): 0.74-0.78), compared to 0.64 for the qSOFA tool (95% CI: 0.61-0.67, P < 0.0001). Median time from the first ASP sepsis warning to death was 8.21 days (interquartile range (IQR): 2.29-16.75) while it was 0 days for qSOFA (IQR: 0-2.58). CONCLUSIONS: The ASP demonstrated both greater prognostic accuracy and earlier warning for in-hospital mortality for adults on hospital wards compared to qSOFA. Hospitals already using ASP may not benefit from switching to the qSOFA tool.

An experimental investigation of the impact of alert frequency and relevance on alert dwell time.

AIM: This study aimed to determine the impact of alert frequency and relevance on alert dwell time. METHOD: A 2 × 3 design was used where 127 university students completed 60 prescribing tasks and were presented with a variable frequency of computerized alerts (low, medium and high) with variable relevance (low and high). Participants were instructed to override an alert if it was not relevant to their prescription, and to cancel the order if the alert signalled an error in their order. RESULTS: Participants presented with a small number of alerts spent more time attending to alert content than participants presented with a medium or high number of alerts (respectively median 15.6 s vs 10.8 vs 10.2 s). Alert relevance had no impact on alert dwell time. Alerts requiring an override response were 4.5 times more likely to be correctly actioned than alerts requiring the order to be cancelled. DISCUSSION: Dwell time was influenced by alert frequency, with greater exposure to alerts associated with shorter dwell times. We hypothesize that this was because participants came to learn that spending time on alert information was unnecessary. We propose that when users experience no consequences or feedback from overriding alerts they quickly learn that this action is more efficient and so more rewarding than taking any other action.

Improving the Performance of Clinical Decision Support for Early Detection of Sepsis: A Retrospective Observational Cohort Study.

Sepsis remains a significant global health problem. It is a life-threatening, but poorly defined and recognized condition. Early recognition and intervention are essential to optimize patient outcomes. Automated clinical decision support systems (CDS) may be particularly beneficial for early detection of sepsis. The aim of this study was to use retrospective data to develop and evaluate seven revised versions of an electronic sepsis alert rule to assess their performance in detecting sepsis cases and patient deterioration (in-hospital mortality or ICU admission). Four revised options had higher sensitivity but lower specificity than the original rule. After discussion with clinical experts, two revised options with the highest sensitivity were selected. Further analysis on the number of alerts and time intervals between alerts and patient outcomes was conducted to decide the option to be implemented. This study has provided a data-driven approach to improve the CDS on early detection of sepsis.