Regina Makdissi, MD

Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?

Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.

Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.

Setting: Fifty-six National Health Service EDs in the United Kingdom.

Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.

Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.

Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.

Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.

Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?

Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.

Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.

Setting: Fifty-six National Health Service EDs in the United Kingdom.

Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.

Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.

Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.

Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.

Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?

Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.

Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.

Setting: Fifty-six National Health Service EDs in the United Kingdom.

Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.

Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.

Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.

Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.

Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?

Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.

Study design: Systemic literature review and meta-analysis.

Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.

Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.

Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?

Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.

Study design: Systemic literature review and meta-analysis.

Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.

Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.

Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?

Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.

Study design: Systemic literature review and meta-analysis.

Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.

Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.

Clinical question: What is the influence of patient complexities on providers’ decisions to prescribe antibiotics in three common hospital-based clinical vignettes?

Background: Antibiotic treatment decisions for medically complex patients are complicated, because the risk of undertreatment may be severe, while overtreatment may be associated with adverse effects and the emergence of resistant pathogens. It is believed that physicians are more likely than not to prescribe antibiotics for complex patients.

Study design: Hospital-based, physician survey.

Setting: Three urban academic medical centers in Los Angeles County, Calif.

Synopsis: Physicians were presented with three clinical vignettes, with variations by age, comorbidity, functional status, and follow-up, and asked to choose the best antibiotic regimen. Of the 874 invited physicians, 255 (29%) responded to the survey; 245 physicians were eligible for the study.

Study results showed 28% to 49% of physicians recommended antibiotics that were inconsistent with national guidelines. This percentage increased to 48% to 63% for medically complex patients, defined as those with older age, high medical comorbidity burden, poor functional status, or limited follow-up after hospital discharge (P<0.01). Resident physicians (n=183) were more likely than attending physicians (n=57) to have recommended antibiotics in the baseline vignettes (43% vs. 34%, P<0.05) and in all four vignettes with patient complexities.

Bottom line: Inappropriate antibiotic use was prevalent and occurred more often for patients with medical complexities.

Citation: Wooten D, Kahn K, Grein JD, Eells SJ, Miller LG. The association of patient complexities with antibiotic ordering. J Hosp Med. 2015;10:1-7.

Clinical question: What is the influence of patient complexities on providers’ decisions to prescribe antibiotics in three common hospital-based clinical vignettes?

Background: Antibiotic treatment decisions for medically complex patients are complicated, because the risk of undertreatment may be severe, while overtreatment may be associated with adverse effects and the emergence of resistant pathogens. It is believed that physicians are more likely than not to prescribe antibiotics for complex patients.

Study design: Hospital-based, physician survey.

Setting: Three urban academic medical centers in Los Angeles County, Calif.

Synopsis: Physicians were presented with three clinical vignettes, with variations by age, comorbidity, functional status, and follow-up, and asked to choose the best antibiotic regimen. Of the 874 invited physicians, 255 (29%) responded to the survey; 245 physicians were eligible for the study.

Study results showed 28% to 49% of physicians recommended antibiotics that were inconsistent with national guidelines. This percentage increased to 48% to 63% for medically complex patients, defined as those with older age, high medical comorbidity burden, poor functional status, or limited follow-up after hospital discharge (P<0.01). Resident physicians (n=183) were more likely than attending physicians (n=57) to have recommended antibiotics in the baseline vignettes (43% vs. 34%, P<0.05) and in all four vignettes with patient complexities.

Bottom line: Inappropriate antibiotic use was prevalent and occurred more often for patients with medical complexities.

Citation: Wooten D, Kahn K, Grein JD, Eells SJ, Miller LG. The association of patient complexities with antibiotic ordering. J Hosp Med. 2015;10:1-7.

Clinical question: What is the influence of patient complexities on providers’ decisions to prescribe antibiotics in three common hospital-based clinical vignettes?

Background: Antibiotic treatment decisions for medically complex patients are complicated, because the risk of undertreatment may be severe, while overtreatment may be associated with adverse effects and the emergence of resistant pathogens. It is believed that physicians are more likely than not to prescribe antibiotics for complex patients.

Study design: Hospital-based, physician survey.

Setting: Three urban academic medical centers in Los Angeles County, Calif.

Synopsis: Physicians were presented with three clinical vignettes, with variations by age, comorbidity, functional status, and follow-up, and asked to choose the best antibiotic regimen. Of the 874 invited physicians, 255 (29%) responded to the survey; 245 physicians were eligible for the study.

Study results showed 28% to 49% of physicians recommended antibiotics that were inconsistent with national guidelines. This percentage increased to 48% to 63% for medically complex patients, defined as those with older age, high medical comorbidity burden, poor functional status, or limited follow-up after hospital discharge (P<0.01). Resident physicians (n=183) were more likely than attending physicians (n=57) to have recommended antibiotics in the baseline vignettes (43% vs. 34%, P<0.05) and in all four vignettes with patient complexities.

Bottom line: Inappropriate antibiotic use was prevalent and occurred more often for patients with medical complexities.

Citation: Wooten D, Kahn K, Grein JD, Eells SJ, Miller LG. The association of patient complexities with antibiotic ordering. J Hosp Med. 2015;10:1-7.

Clinical question: Which parameters predict emergency CAP, defined as the requirement for mechanical ventilation (MV), vasopressor support (VS), or death within three to seven days?

Background: Major causes of short-term mortality in CAP include respiratory failure, septic shock, and decompensated co-morbidity. Studies have demonstrated that immediate interventions can have a substantial impact on outcomes; improving prognosis will require early recognition of CAP as a medical emergency.

Study design: Retrospective evaluation of prospective cohort study.

Setting: Hospitalized patients recruited from the multicenter, German Competence Network for the study of CAP (CAPNETZ).

Synopsis: Investigators included 3,427 patients; those who required immediate mechanical ventilation or presented in septic shock had significantly lower mortality rates than those who presented without immediate need for MV or VS. Using multivariate Cox regression, independent predictors for the development of emergency CAP within 72 hours were determined. The study also evaluated the ATS/IDA 2007 nine minor criteria for severe pneumonia in predicting emergency CAP.

Bottom line: Emergency CAP is rare but carries important prognostic considerations. Identifying those patients at risk for clinical deterioration could help in early identification and management of this subgroup of patients. Altered mental status and vital signs (hypotension, tachypnea, tachycardia, hypothermia), acute organ dysfunction, home O2, and multilobar infiltrates have been found to be independent predictors of emergency CAP. Regular evaluation of these parameters, coupled with established scores such as the ATS/IDSA 2007 minor criteria, should help guide management.

Citation: Kolditz, M, Ewig S, Klapdor B, et al. Community-acquired pneumonia as medical emergency: predictors of early deterioration. Thorax. 2015;70(6):551-558. doi:10.1136/thoraxjnl-2014-206744.

Clinical question: Which parameters predict emergency CAP, defined as the requirement for mechanical ventilation (MV), vasopressor support (VS), or death within three to seven days?

Background: Major causes of short-term mortality in CAP include respiratory failure, septic shock, and decompensated co-morbidity. Studies have demonstrated that immediate interventions can have a substantial impact on outcomes; improving prognosis will require early recognition of CAP as a medical emergency.

Study design: Retrospective evaluation of prospective cohort study.

Setting: Hospitalized patients recruited from the multicenter, German Competence Network for the study of CAP (CAPNETZ).

Synopsis: Investigators included 3,427 patients; those who required immediate mechanical ventilation or presented in septic shock had significantly lower mortality rates than those who presented without immediate need for MV or VS. Using multivariate Cox regression, independent predictors for the development of emergency CAP within 72 hours were determined. The study also evaluated the ATS/IDA 2007 nine minor criteria for severe pneumonia in predicting emergency CAP.

Bottom line: Emergency CAP is rare but carries important prognostic considerations. Identifying those patients at risk for clinical deterioration could help in early identification and management of this subgroup of patients. Altered mental status and vital signs (hypotension, tachypnea, tachycardia, hypothermia), acute organ dysfunction, home O2, and multilobar infiltrates have been found to be independent predictors of emergency CAP. Regular evaluation of these parameters, coupled with established scores such as the ATS/IDSA 2007 minor criteria, should help guide management.

Citation: Kolditz, M, Ewig S, Klapdor B, et al. Community-acquired pneumonia as medical emergency: predictors of early deterioration. Thorax. 2015;70(6):551-558. doi:10.1136/thoraxjnl-2014-206744.

Clinical question: Which parameters predict emergency CAP, defined as the requirement for mechanical ventilation (MV), vasopressor support (VS), or death within three to seven days?

Background: Major causes of short-term mortality in CAP include respiratory failure, septic shock, and decompensated co-morbidity. Studies have demonstrated that immediate interventions can have a substantial impact on outcomes; improving prognosis will require early recognition of CAP as a medical emergency.

Study design: Retrospective evaluation of prospective cohort study.

Setting: Hospitalized patients recruited from the multicenter, German Competence Network for the study of CAP (CAPNETZ).

Synopsis: Investigators included 3,427 patients; those who required immediate mechanical ventilation or presented in septic shock had significantly lower mortality rates than those who presented without immediate need for MV or VS. Using multivariate Cox regression, independent predictors for the development of emergency CAP within 72 hours were determined. The study also evaluated the ATS/IDA 2007 nine minor criteria for severe pneumonia in predicting emergency CAP.

Bottom line: Emergency CAP is rare but carries important prognostic considerations. Identifying those patients at risk for clinical deterioration could help in early identification and management of this subgroup of patients. Altered mental status and vital signs (hypotension, tachypnea, tachycardia, hypothermia), acute organ dysfunction, home O2, and multilobar infiltrates have been found to be independent predictors of emergency CAP. Regular evaluation of these parameters, coupled with established scores such as the ATS/IDSA 2007 minor criteria, should help guide management.

Citation: Kolditz, M, Ewig S, Klapdor B, et al. Community-acquired pneumonia as medical emergency: predictors of early deterioration. Thorax. 2015;70(6):551-558. doi:10.1136/thoraxjnl-2014-206744.

Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?

Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.

Study design: Systemic literature review and meta-analysis.

Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.

Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.

Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?

Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.

Study design: Systemic literature review and meta-analysis.

Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.

Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.

Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?

Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.

Study design: Systemic literature review and meta-analysis.

Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.

Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.

Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?

Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.

Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.

Setting: Fifty-six National Health Service EDs in the United Kingdom.

Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.

Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.

Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.

Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.

Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?

Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.

Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.

Setting: Fifty-six National Health Service EDs in the United Kingdom.

Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.

Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.

Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.

Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.

Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?

Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.

Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.

Setting: Fifty-six National Health Service EDs in the United Kingdom.

Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.

Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.

Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.

Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.

Clinical question: Among patients presenting to the ED with sepsis, who will progress to septic shock within 48 hours of arrival?

Background: This study describes patient characteristics present within four hours of ED arrival associated with developing septic shock between four and 48 hours after arrival.

Study design: Retrospective chart review.

Setting: ED patients hospitalized at two large academic institutions.

Synopsis: A total of 18,100 patients were admitted from the ED, of which 3,960 patients had two or more systemic inflammatory response syndrome criteria, and 1,316 patients had sepsis within four hours of arrival. One hundred eleven patients with sepsis (8.4%) progressed to septic shock between four to 48 hours of ED arrival.

Characteristics associated with the progression included female gender (odds ratio, 1.59; 95% CI, 1.02-2.47), nonpersistent hypotension (odds ratio, 6.24; 95% CI, 3.58-10.86), bandemia at least 10% (odds ratio, 2.60; 95% CI, 1.50-4.51), lactate of at least 4.0 mmol/L (odds ratio, 5.30; 95% CI, 2.59-10.84), and past medical history of coronary artery disease (odds ratio, 2.01; 95% 1.26-3.44).

Bottom line: Although everyone presenting with sepsis should be treated aggressively, special consideration should be given to patients who are “high risk” to develop septic shock, using the predictors delineated above.

Citation: Capp R, Horton CL, Takhar SS, et al. Predictors of patients who present to the emergency department with sepsis and progress to septic shock between 4 and 48 hours of emergency department arrival. Crit Care Med. 2015;43(5):983-988.

Clinical question: Among patients presenting to the ED with sepsis, who will progress to septic shock within 48 hours of arrival?

Background: This study describes patient characteristics present within four hours of ED arrival associated with developing septic shock between four and 48 hours after arrival.

Study design: Retrospective chart review.

Setting: ED patients hospitalized at two large academic institutions.

Synopsis: A total of 18,100 patients were admitted from the ED, of which 3,960 patients had two or more systemic inflammatory response syndrome criteria, and 1,316 patients had sepsis within four hours of arrival. One hundred eleven patients with sepsis (8.4%) progressed to septic shock between four to 48 hours of ED arrival.

Characteristics associated with the progression included female gender (odds ratio, 1.59; 95% CI, 1.02-2.47), nonpersistent hypotension (odds ratio, 6.24; 95% CI, 3.58-10.86), bandemia at least 10% (odds ratio, 2.60; 95% CI, 1.50-4.51), lactate of at least 4.0 mmol/L (odds ratio, 5.30; 95% CI, 2.59-10.84), and past medical history of coronary artery disease (odds ratio, 2.01; 95% 1.26-3.44).

Bottom line: Although everyone presenting with sepsis should be treated aggressively, special consideration should be given to patients who are “high risk” to develop septic shock, using the predictors delineated above.

Citation: Capp R, Horton CL, Takhar SS, et al. Predictors of patients who present to the emergency department with sepsis and progress to septic shock between 4 and 48 hours of emergency department arrival. Crit Care Med. 2015;43(5):983-988.

Clinical question: Among patients presenting to the ED with sepsis, who will progress to septic shock within 48 hours of arrival?

Background: This study describes patient characteristics present within four hours of ED arrival associated with developing septic shock between four and 48 hours after arrival.

Study design: Retrospective chart review.

Setting: ED patients hospitalized at two large academic institutions.

Synopsis: A total of 18,100 patients were admitted from the ED, of which 3,960 patients had two or more systemic inflammatory response syndrome criteria, and 1,316 patients had sepsis within four hours of arrival. One hundred eleven patients with sepsis (8.4%) progressed to septic shock between four to 48 hours of ED arrival.

Characteristics associated with the progression included female gender (odds ratio, 1.59; 95% CI, 1.02-2.47), nonpersistent hypotension (odds ratio, 6.24; 95% CI, 3.58-10.86), bandemia at least 10% (odds ratio, 2.60; 95% CI, 1.50-4.51), lactate of at least 4.0 mmol/L (odds ratio, 5.30; 95% CI, 2.59-10.84), and past medical history of coronary artery disease (odds ratio, 2.01; 95% 1.26-3.44).

Bottom line: Although everyone presenting with sepsis should be treated aggressively, special consideration should be given to patients who are “high risk” to develop septic shock, using the predictors delineated above.

Citation: Capp R, Horton CL, Takhar SS, et al. Predictors of patients who present to the emergency department with sepsis and progress to septic shock between 4 and 48 hours of emergency department arrival. Crit Care Med. 2015;43(5):983-988.

Clinical question: Does developing individualized care plans in the inpatient setting reduce unnecessary ED visits, hospital readmissions, and hospital costs for frequent users of hospital services?

Background: High utilizers of healthcare services are recognized as medically and psychosocially complex and are at risk for adverse outcomes. Although they make up a small fraction of the patient population (1%), they have high rates of ED visits and hospital admissions and account for 21% of national healthcare spending and hospital costs.

Study design: QI intervention with retrospective pre-/post-intervention analysis.

Setting: Inpatient, tertiary academic medical center.

Synopsis: A multidisciplinary team integrated individualized care plans for 24 high utilizer patients into the EHR from August 1, 2012, to August 31, 2013. These plans summarized medical, psychiatric, and social histories, hospital utilization patterns, and management strategies, including connecting individuals to appropriate services. Outcomes were measured six and 12 months after implementation.

Hospital admissions decreased by 56% (P<0.001) and 50.5% (P>0.003); 30-day readmission decreased by 66% (P<0.001) and 51.5% (P<0.002); ED costs, ED visits, and inpatient length of stay did not change significantly. Inpatient variable direct costs were reduced by 47.7% and 35.8% (P=0.052) at six- and 12-month analysis, respectively.

Bottom line: Individualized care plans developed by a multidisciplinary team and integrated into the EHR at the time of hospitalization can reduce hospital admissions, 30-day readmissions, and hospital costs for high-utilizing patients.

Citation: Mercer T, Bae J, Kipnes J, Velazquez M, Thomas S, Setji N. The highest utilizers of care: individualized care plans to coordinate care, improve healthcare service utilization, and reduce costs at an academic tertiary care center [published online ahead of print April 9, 2015]. J Hosp Med. doi 10.1002/jhm.2351

Clinical question: Does developing individualized care plans in the inpatient setting reduce unnecessary ED visits, hospital readmissions, and hospital costs for frequent users of hospital services?

Background: High utilizers of healthcare services are recognized as medically and psychosocially complex and are at risk for adverse outcomes. Although they make up a small fraction of the patient population (1%), they have high rates of ED visits and hospital admissions and account for 21% of national healthcare spending and hospital costs.

Study design: QI intervention with retrospective pre-/post-intervention analysis.

Setting: Inpatient, tertiary academic medical center.

Synopsis: A multidisciplinary team integrated individualized care plans for 24 high utilizer patients into the EHR from August 1, 2012, to August 31, 2013. These plans summarized medical, psychiatric, and social histories, hospital utilization patterns, and management strategies, including connecting individuals to appropriate services. Outcomes were measured six and 12 months after implementation.

Hospital admissions decreased by 56% (P<0.001) and 50.5% (P>0.003); 30-day readmission decreased by 66% (P<0.001) and 51.5% (P<0.002); ED costs, ED visits, and inpatient length of stay did not change significantly. Inpatient variable direct costs were reduced by 47.7% and 35.8% (P=0.052) at six- and 12-month analysis, respectively.

Bottom line: Individualized care plans developed by a multidisciplinary team and integrated into the EHR at the time of hospitalization can reduce hospital admissions, 30-day readmissions, and hospital costs for high-utilizing patients.

Citation: Mercer T, Bae J, Kipnes J, Velazquez M, Thomas S, Setji N. The highest utilizers of care: individualized care plans to coordinate care, improve healthcare service utilization, and reduce costs at an academic tertiary care center [published online ahead of print April 9, 2015]. J Hosp Med. doi 10.1002/jhm.2351

Clinical question: Does developing individualized care plans in the inpatient setting reduce unnecessary ED visits, hospital readmissions, and hospital costs for frequent users of hospital services?

Background: High utilizers of healthcare services are recognized as medically and psychosocially complex and are at risk for adverse outcomes. Although they make up a small fraction of the patient population (1%), they have high rates of ED visits and hospital admissions and account for 21% of national healthcare spending and hospital costs.

Study design: QI intervention with retrospective pre-/post-intervention analysis.

Setting: Inpatient, tertiary academic medical center.

Synopsis: A multidisciplinary team integrated individualized care plans for 24 high utilizer patients into the EHR from August 1, 2012, to August 31, 2013. These plans summarized medical, psychiatric, and social histories, hospital utilization patterns, and management strategies, including connecting individuals to appropriate services. Outcomes were measured six and 12 months after implementation.

Hospital admissions decreased by 56% (P<0.001) and 50.5% (P>0.003); 30-day readmission decreased by 66% (P<0.001) and 51.5% (P<0.002); ED costs, ED visits, and inpatient length of stay did not change significantly. Inpatient variable direct costs were reduced by 47.7% and 35.8% (P=0.052) at six- and 12-month analysis, respectively.

Bottom line: Individualized care plans developed by a multidisciplinary team and integrated into the EHR at the time of hospitalization can reduce hospital admissions, 30-day readmissions, and hospital costs for high-utilizing patients.

Citation: Mercer T, Bae J, Kipnes J, Velazquez M, Thomas S, Setji N. The highest utilizers of care: individualized care plans to coordinate care, improve healthcare service utilization, and reduce costs at an academic tertiary care center [published online ahead of print April 9, 2015]. J Hosp Med. doi 10.1002/jhm.2351

Clinical question: Did revision of guidelines recommending computerized tomography (CT) scan before lumbar puncture (LP) reduce delayed treatment of acute bacterial meningitis (ABM)?

Background: Guidelines were introduced in Sweden in 2004 identifying patients at risk for LP-induced brain herniation. They were revised in 2009 to exclude moderate to severe mental status impairment and new seizures as contraindications to LP. This study evaluates the effects of the revision.

Study design: Retrospective.

Setting: Inpatient; two to six months post-discharge.

Synopsis: Data from the Swedish Quality Registry for Community-Acquired Acute Bacterial Meningitis from 2005 to 2009 (394 patients) was compared to data from 2010 to 2012 (318 patients). Mortality and neurological deficits were analyzed, as were effects of LP-CT sequence on time to treatment and outcome.

Treatment was started 1.18 hours earlier (95%CI, .46-1.90 hours, P<0.01) in 2010-2012. After adjusting for confounding factors, there was a nonsignificant reduction in mortality. Treatment delay was significantly associated with increased mortality of 12.6% per hour (95% CI, 3.4%-14.4%; P<0.01). There was significant reduction of neurological sequelae during 2010-2012.

CT performed before LP was associated with a treatment delay of 1.6 hours. In patients with impaired mental status in whom LP was done before CT, mortality was similar and the risk of neurological sequelae was lower.

The study is limited by its retrospective design, nonspecific criteria for diagnosing ABM, and frequent use of meropenem between 2010-2012.

Bottom line: The 2009 revision of Swedish guidelines resulted in earlier treatment of ABM, lower mortality, and fewer unfavorable results, suggesting further revision of international guidelines.

Citation: Glimåker M, Johansson B, Grindborg Ö, Bottai M, Lindquist L, Sjölin J. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin Infect Dis. 2015;60(8):1162-1169.

Clinical question: Did revision of guidelines recommending computerized tomography (CT) scan before lumbar puncture (LP) reduce delayed treatment of acute bacterial meningitis (ABM)?

Background: Guidelines were introduced in Sweden in 2004 identifying patients at risk for LP-induced brain herniation. They were revised in 2009 to exclude moderate to severe mental status impairment and new seizures as contraindications to LP. This study evaluates the effects of the revision.

Study design: Retrospective.

Setting: Inpatient; two to six months post-discharge.

Synopsis: Data from the Swedish Quality Registry for Community-Acquired Acute Bacterial Meningitis from 2005 to 2009 (394 patients) was compared to data from 2010 to 2012 (318 patients). Mortality and neurological deficits were analyzed, as were effects of LP-CT sequence on time to treatment and outcome.

Treatment was started 1.18 hours earlier (95%CI, .46-1.90 hours, P<0.01) in 2010-2012. After adjusting for confounding factors, there was a nonsignificant reduction in mortality. Treatment delay was significantly associated with increased mortality of 12.6% per hour (95% CI, 3.4%-14.4%; P<0.01). There was significant reduction of neurological sequelae during 2010-2012.

CT performed before LP was associated with a treatment delay of 1.6 hours. In patients with impaired mental status in whom LP was done before CT, mortality was similar and the risk of neurological sequelae was lower.

The study is limited by its retrospective design, nonspecific criteria for diagnosing ABM, and frequent use of meropenem between 2010-2012.

Bottom line: The 2009 revision of Swedish guidelines resulted in earlier treatment of ABM, lower mortality, and fewer unfavorable results, suggesting further revision of international guidelines.

Citation: Glimåker M, Johansson B, Grindborg Ö, Bottai M, Lindquist L, Sjölin J. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin Infect Dis. 2015;60(8):1162-1169.

Clinical question: Did revision of guidelines recommending computerized tomography (CT) scan before lumbar puncture (LP) reduce delayed treatment of acute bacterial meningitis (ABM)?

Background: Guidelines were introduced in Sweden in 2004 identifying patients at risk for LP-induced brain herniation. They were revised in 2009 to exclude moderate to severe mental status impairment and new seizures as contraindications to LP. This study evaluates the effects of the revision.

Study design: Retrospective.

Setting: Inpatient; two to six months post-discharge.

Synopsis: Data from the Swedish Quality Registry for Community-Acquired Acute Bacterial Meningitis from 2005 to 2009 (394 patients) was compared to data from 2010 to 2012 (318 patients). Mortality and neurological deficits were analyzed, as were effects of LP-CT sequence on time to treatment and outcome.

Treatment was started 1.18 hours earlier (95%CI, .46-1.90 hours, P<0.01) in 2010-2012. After adjusting for confounding factors, there was a nonsignificant reduction in mortality. Treatment delay was significantly associated with increased mortality of 12.6% per hour (95% CI, 3.4%-14.4%; P<0.01). There was significant reduction of neurological sequelae during 2010-2012.

CT performed before LP was associated with a treatment delay of 1.6 hours. In patients with impaired mental status in whom LP was done before CT, mortality was similar and the risk of neurological sequelae was lower.

The study is limited by its retrospective design, nonspecific criteria for diagnosing ABM, and frequent use of meropenem between 2010-2012.

Bottom line: The 2009 revision of Swedish guidelines resulted in earlier treatment of ABM, lower mortality, and fewer unfavorable results, suggesting further revision of international guidelines.

Citation: Glimåker M, Johansson B, Grindborg Ö, Bottai M, Lindquist L, Sjölin J. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin Infect Dis. 2015;60(8):1162-1169.

Clinical question: Can a multifaceted intervention decrease the frequency of unnecessary labs?

Background: Implementation of a multifaceted QI intervention within a large, community-based hospitalist group to decrease ordering of common labs.

Study design: QI project.

Setting: Large, community-based hospitalist group.

Synopsis: QI intervention was composed of academic detailing, audit and feedback, and transparent reporting of the frequency with which common labs were ordered daily. Researchers performed a pre-post analysis, comparing a cohort of patients during the 10-month baseline period before the QI intervention and the seven-month intervention period. The baseline (n=7,824) and intervention (n=5,759) cohorts were similar in their demographics.

Adjusting for age, sex, and principle discharge diagnosis, the number of common labs ordered per patient-day decreased by 0.22 (10.7%) during the intervention period compared with baseline (95% confidence interval [CI], 0.34 to 0.11; P<0.01). No effect was seen on length of stay or readmission rate. The intervention decreased hospital direct costs by an estimated $16.19 per admission or $151,682 annualized (95% CI, $119,746 to $187,618).

Bottom line: A community-based, hospitalist-led, QI intervention focused on daily labs can be effective in safely reducing healthcare waste without compromising quality of care.

Citation: Corson AH, Fan VS, White T, et al. A multifaceted hospitalist quality improvement intervention: decreased frequency of common labs. J Hosp Med. 2015;10(6):390-395.

Clinical question: Can a multifaceted intervention decrease the frequency of unnecessary labs?

Background: Implementation of a multifaceted QI intervention within a large, community-based hospitalist group to decrease ordering of common labs.

Study design: QI project.

Setting: Large, community-based hospitalist group.

Synopsis: QI intervention was composed of academic detailing, audit and feedback, and transparent reporting of the frequency with which common labs were ordered daily. Researchers performed a pre-post analysis, comparing a cohort of patients during the 10-month baseline period before the QI intervention and the seven-month intervention period. The baseline (n=7,824) and intervention (n=5,759) cohorts were similar in their demographics.

Adjusting for age, sex, and principle discharge diagnosis, the number of common labs ordered per patient-day decreased by 0.22 (10.7%) during the intervention period compared with baseline (95% confidence interval [CI], 0.34 to 0.11; P<0.01). No effect was seen on length of stay or readmission rate. The intervention decreased hospital direct costs by an estimated $16.19 per admission or $151,682 annualized (95% CI, $119,746 to $187,618).

Bottom line: A community-based, hospitalist-led, QI intervention focused on daily labs can be effective in safely reducing healthcare waste without compromising quality of care.

Citation: Corson AH, Fan VS, White T, et al. A multifaceted hospitalist quality improvement intervention: decreased frequency of common labs. J Hosp Med. 2015;10(6):390-395.

Clinical question: Can a multifaceted intervention decrease the frequency of unnecessary labs?

Background: Implementation of a multifaceted QI intervention within a large, community-based hospitalist group to decrease ordering of common labs.

Study design: QI project.

Setting: Large, community-based hospitalist group.

Synopsis: QI intervention was composed of academic detailing, audit and feedback, and transparent reporting of the frequency with which common labs were ordered daily. Researchers performed a pre-post analysis, comparing a cohort of patients during the 10-month baseline period before the QI intervention and the seven-month intervention period. The baseline (n=7,824) and intervention (n=5,759) cohorts were similar in their demographics.

Adjusting for age, sex, and principle discharge diagnosis, the number of common labs ordered per patient-day decreased by 0.22 (10.7%) during the intervention period compared with baseline (95% confidence interval [CI], 0.34 to 0.11; P<0.01). No effect was seen on length of stay or readmission rate. The intervention decreased hospital direct costs by an estimated $16.19 per admission or $151,682 annualized (95% CI, $119,746 to $187,618).

Bottom line: A community-based, hospitalist-led, QI intervention focused on daily labs can be effective in safely reducing healthcare waste without compromising quality of care.

Citation: Corson AH, Fan VS, White T, et al. A multifaceted hospitalist quality improvement intervention: decreased frequency of common labs. J Hosp Med. 2015;10(6):390-395.