Feasibility of using an automated call service to collect quality of life and functional outcome data in trauma patients.

Objectives: Following up trauma patients after discharge, to evaluate their subsequent quality of life and functional outcomes, is notoriously difficult, time consuming, and expensive. Automated systems are a conceptually attractive solution. We prospectively assessed the feasibility of using a series of automated phone calls administered by Emmi Patient Engagement to survey trauma patients after discharge. Methods: Recruitment into the study was incorporated into the patient discharge process by nursing staff. For this pilot, we included trauma patients discharging home and who were able to answer phone calls. A script was created to evaluate the Extended Glasgow Outcome Scale and the EuroQol EQ-5D to assess functional status and quality of life, respectively. Call attempts were made at 6 weeks, 3 months, 6 months, and 1 year after discharge. Results: A total of 110 patients initially agreed to participate. 368 attempted patient encounters (calls or attempted calls) took place, with 104 (28.3%) patients answering a least one question in the study. 21 unique patients (19.1% of those enrolled) completed 27 surveys. Conclusions: Automated, scripted phone calls to survey patients after discharge are not a feasible way of collecting functional and quality of life data. Level of evidence: Level II/prospective.

Physician documentation of sepsis syndrome is associated with more aggressive treatment.

INTRODUCTION: Timely recognition and treatment of sepsis improves survival. The objective is to examine the association between recognition of sepsis and timeliness of treatments. METHODS: We identified a retrospective cohort of emergency department (ED) patients with positive blood cultures from May 2007 to January 2009, and reviewed vital signs, imaging, laboratory data, and physician/nursing charts. Patients who met systemic inflammatory response syndrome (SIRS) criteria and had evidence of infection available to the treating clinician at the time of the encounter were classified as having sepsis. Patients were dichotomized as RECOGNIZED if sepsis was explicitly articulated in the patient record or if a sepsis order set was launched, or as UNRECOGNIZED if neither of these two criteria were met. We used median regression to compare time to antibiotic administration and total volume of fluid resuscitation between groups, controlling for age, sex, and sepsis severity. RESULTS: SIRS criteria were present in 228/315 (72.4%) cases. Our record review identified sepsis syndromes in 214 (67.9%) cases of which 118 (55.1%) had sepsis, 64 (29.9%) had severe sepsis, and 32 (15.0%) had septic shock. The treating team contemplated sepsis (RECOGNIZED) in 123 (57.6%) patients. Compared to the UNRECOGNIZED group, the RECOGNIZED group had a higher use of antibiotics in the ED (91.9 vs.75.8%, p=0.002), more patients aged 60 years or older (56.9 vs. 33.0%, p=0.001), and more severe cases (septic shock: 18.7 vs. 9.9%, severe sepsis: 39.0 vs.17.6%, sepsis: 42.3 vs.72.5%; p<0.001). The median time to antibiotic (minutes) was lower in the RECOGNIZED (142) versus UNRECOGNIZED (229) group, with an adjusted median difference of -74 minutes (95% CI [-128 to -19]). The median total volume of fluid resuscitation (mL) was higher in the RECOGNIZED (1,600 mL) compared to the UNRECOGNIZED (1,000 mL) group. However, the adjusted median difference was not statistically significant: 262 mL (95% CI [ -171 to 694 mL]). CONCLUSION: Patients whose emergency physicians articulated sepsis syndrome in their documentation or who launched the sepsis order set received antibiotics sooner and received more total volume of fluid. Age <60 and absence of fever are factors associated with lack of recognition of sepsis cases.

Would earlier microbe identification alter antibiotic therapy in bacteremic emergency department patients?

BACKGROUND: Although debate exists about the treatment of sepsis, few disagree about the benefits of early, appropriately targeted antibiotic administration. STUDY OBJECTIVES: To determine the appropriateness of empiric antimicrobial therapy and the extent to which therapy would be altered if the causative organism for sepsis was known at the time of administration. METHODS: This was a retrospective cohort study, conducted in an academic Emergency Department (ED), on consecutive positive blood cultures between November 1, 2008 and February 1, 2009. Blood cultures and the appropriateness of administered antimicrobial therapy were evaluated. Therapy choices were categorized based on whether or not a physician, complying with antimicrobial guidelines, would have made changes to empiric antibiotic therapy had the causative organism initially been known. RESULTS: There were 90 positive blood cultures obtained from 84 patients. Of these, 21.1% (n=19) were considered contaminants. The final categorization of empiric antibiotics given in the ED for the remaining blood culture results were: 1) therapy would be changed to narrower-spectrum antibiotics (n=34, 55.7%); 2) therapy would be changed because the organism was not covered (n=13, 21.3%); and 3) therapy would remain the same (n=14, 23.0%). There was 90.2% inter-rater agreement for these classifications (p<0.0001), with a kappa of 0.84. Polymerase chain reaction analysis had a statistically significant advantage (p<0.0001) over Infectious Disease Society of America protocols in facilitating accurate antimicrobial therapies. CONCLUSION: This study confirms the need for more rapid and accurate laboratory methods for bloodstream pathogen identification.