Sepsis, cardiac arrest, and more

Research summaries from ACP Hospitalist Weekly.

Score predicts sepsis survivors' risk of unplanned rehospitalization or death in first year after discharge

A score uses eight predictors to prognosticate sepsis survivors' risk of unplanned rehospitalization or death in the first year after hospital discharge.

Researchers derived and validated the parsimonious prognostic score in a recent cohort study of adult sepsis survivors, defined as patients surviving to hospital discharge after a critical care unit admission for sepsis meeting Sepsis-3 criteria. They used data from the Intensive Care National Audit & Research Centre Case Mix Programme database on sepsis survivors identified from consecutive critical care admissions to 192 adult general critical care units in England between April 1, 2009, and March 31, 2014 (derivation cohort), and between April 1, 2014, and March 31, 2015 (validation cohort). The score was calculated using the following predictors: generic characteristics (age, sex, race/ethnicity, 2015 Index of Multiple Deprivation [IMD2015] in England quintiles, preadmission dependence, previous hospitalizations in the year preceding index sepsis admission, comorbidity, admission type, Acute Physiology and Chronic Health Evaluation II physiology score, hospital length of stay, worst blood lactate and blood hemoglobin concentrations, and type of hospital) and sepsis-specific characteristics (site of infection, number of organ dysfunctions, and organ support) at the index sepsis admission. Results were published on Sept. 14 by JAMA Network Open.

The derivation cohort included 94,748 patients (54.0% men; mean age, 61.3 years), and the validation cohort included 24,669 patients (53.7% men; mean age, 62.1 years). Unplanned rehospitalization or death in the first year after discharge occurred in 48,594 patients (51.3%) in the derivation cohort and in 13,129 patients (53.2%) in the validation cohort. The researchers identified and weighted a final set of eight independent predictors to generate a prognostic score for every patient: previous hospitalizations, age in 10-year increments, socioeconomic status using IMD2015 in England quintiles, preadmission dependence, number of comorbidities, admission type, blood hemoglobin level, and site of infection. The total prognostic score ranged from 0 to 22 points, with lower scores indicating a lower risk of the outcome. The derivation and validation cohorts had similar rates of prognostic scores of 0 to 4 points (30.5% and 27.3%, respectively) and of 11 points or more (72.7% and 72.3%, respectively). The discrimination of the score was moderate, with an area under the receiver-operating characteristic curve of 0.675 (95% CI, 0.672 to 0.679). A decision curve analysis, which informs clinicians when to intervene selectively and where data on treatment effectiveness and patient preferences do not exist, highlighted an optimal score cutoff of 7 points or more.

Limitations of the study include that its population was limited to patients who survived to discharge after a critical care unit admission for sepsis and that the model predicts one-year risk, not necessarily risk at specific time points during follow-up, the authors noted. In addition, they lacked information on patient preferences (e.g., desire to seek care, limitations of care).

The authors concluded, “This study validated a simple and internationally feasible prognostic score for [the] composite outcome, which could inform prognosis discussions, trial design, and follow-up care of sepsis survivors.”

Low-performing hospitals can improve quality for in-hospital cardiac arrest over time

Risk-standardized survival rates (RSSRs) for in-hospital cardiac arrest remained generally steady from 2012 to 2013 versus 2016 to 2017 but improved substantially in some low-performing hospitals, according to a recent study.

Image by Getty Images
Image by Getty Images

Researchers used data from hospitals that continuously participated in Get With The Guidelines–Resuscitation to determine RSSRs during a baseline period from 2012 to 2013 and two follow-up periods, 2014 to 2015 and 2016 to 2017. Hospitals were classified at baseline as top-, middle-, and bottom-performing if they ranked in the top 25%, the middle 50%, and the bottom 25%, respectively, for RSSR during 2012 to 2013. The study's primary outcome was each hospital's RSSR, representing rate of survival to discharge for patients with in-house cardiac arrest over a given time period. RSSRs are adjusted for each patient's illness severity to allow survival comparisons across sites. Results of the study were published Sept. 10 by Circulation: Cardiovascular Quality and Outcomes.

Data from 84,089 patients at 166 hospitals were included in the analysis. At baseline, the mean age of the study population was 64.8 years, 58.7% were men, and 24% were Black. Forty-two hospitals were categorized as top-performing, 82 were categorized as middle-performing, and 42 were categorized as bottom-performing. Median RSSRs were 31.7%, 24.6%, and 18.7%, respectively. More than 70% of top-performing hospitals ranked in the top 50% of RSSRs during both follow-up periods. During 2014 to 2015 and 2016 to 2017, respectively, 54.6% and 40.4% remained in the top 25% of RSSRs. Among bottom-performing hospitals, almost 75% remained in the bottom 50% of RSSRs during both follow-up periods. During 2014 to 2015 and 2016 to 2017, 50.0% and 40.5%, respectively, were in the bottom 25% of RSSRs. Percentile rankings remained generally consistent over time at 45.2% of the study hospitals. However, 21.4% of bottom-performing hospitals exhibited substantial improvements in percentile rankings over time and 23.7% of top-performing hospitals showed large declines in percentile rankings versus baseline.

Among other limitations, the study included only hospitals that had at least 20 cases of in-hospital cardiac arrest in any given year and continuous participation in the Get with the Guidelines–Resuscitation program, and the results could have been affected by residual confounding, the authors noted. They concluded that the RSSR metric for in-hospital cardiac arrest during a baseline period will generally be consistent for most hospitals during subsequent follow-up. “However, percentile rankings did change markedly at a small proportion of bottom-performing hospitals during the follow-up period, suggesting the opportunity to improve survival outcomes,” they wrote. “Future studies are needed to identify strategies and care innovations that were adopted by these bottom-performing hospitals.”

CMS sepsis measure associated with increases in antibiotic use

A CMS sepsis bundle implemented in 2015 was associated with increases in antibiotic use, including those used for hospital-onset and multidrug-resistant organisms, a recent study found.

The Sepsis Bundle Core Performance Measure for hospitals participating in Inpatient Quality Reporting (SEP-1), which was implemented by CMS in October 2015, calls for antibiotics to be administered to patients with severe sepsis or septic shock within three hours of diagnosis. Researchers performed a quasi-experimental investigation at the hospital level to examine the effect of SEP-1 implementation on use of broad-spectrum antibiotics and occurrence of Clostridioides difficile infection. Four antibiotic categories for adults at 111 hospitals were evaluated from October 2014 to September 2015, before SEP-1, and from October 2015 to June 2017, after SEP-1. The categories were agents used primarily for prophylaxis against surgical-site infection, broad-spectrum agents used primarily for community-acquired infections, broad-spectrum agents used primarily for hospital-onset/multidrug-resistant organisms, and agents used primarily against methicillin-resistant Staphylococcus aureus (MRSA). Changes in antibiotic category use and rates of C. diff infection were evaluated in interrupted time-series analyses. The study results were published Aug. 22 by Clinical Infectious Diseases.

Of the 111 hospitals included in the study, 22.5% were located in the Northeast, 29.7% were located in the South, 30.6% were located in the Midwest, and 17.1% were located in the West. During the study period, there were 40,908,558 patient-days from 7,353,968 inpatient admissions, including 293,665 sepsis cases, with a median of 1,198 cases of severe sepsis and 1,204 cases of septic shock per hospital. After SEP-1 was implemented, an immediate increase of 2.3% in use of broad-spectrum agents for hospital-onset/multidrug resistant organisms was seen at the hospital level (P=0.0375), as was a long-term trend of an increase of 0.4% per month (P=0.0273). Overall antibiotic use also increased immediately by 1.4% (P=0.0293). Rates of C. diff infection, however, decreased 7.8% immediately after SEP-1 was implemented. When only patients with sepsis were included in the analyses, an immediate increase was seen for all antibiotic categories after implementation, including an 88.9% increase in overall antibiotic use, a 64.7% increase in anti-MRSA agents, and a 284% increase in antimicrobial agents for surgical prophylaxis.

The researchers noted that all of the hospitals included in the study were large academic medical centers and that some may have implemented sepsis protocols before SEP-1 went into effect, among other limitations. They concluded that their findings support continued observation of antibiotic use after implementation of SEP-1. “Meeting the 3-hour . . . [time to first antibiotic dose] is an important element of SEP-1; however, these data suggest that antimicrobial stewardship programs should apply postprescription audit and feedback strategies among sepsis patients to ensure that antibiotic de-escalation is occurring appropriately,” the authors wrote. They called for additional studies on the relationship between increased use of broad-spectrum antibiotics and rates of C. diff infection and antibiotic resistance.

Substance use problems in the U.S. exacerbated by pandemic, studies indicate

Two recent studies described how COVID-19 has exacerbated substance use problems, and a perspective offered hospitalists advice on handling substance use disorder during the pandemic.

One analysis, published as a research letter by JAMA on Sept. 18, compared a random sample of 75,000 urine drug tests taken before COVID-19 with 75,000 taken from March 13 to July 10. It found that the proportion of specimens testing positive increased from 3.59% to 4.76% for cocaine, from 3.80% to 7.32% for fentanyl, from 1.29% to 2.09% for heroin, and from 5.89% to 8.16% for methamphetamine. The authors cautioned that the study had limitations, including that patients being tested during the pandemic may be at inherently higher risk, but concluded that urine drug test positivity increased significantly for all of the studied drugs in a population with or at risk of substance use disorders.

Another study, also published as a research letter by JAMA on Sept. 18, looked at nonfatal opioid overdose visits to a single ED in Virginia. They increased from 102 between March and June 2019 to 227 between March and June 2020. In addition to the overall increase, the study found that a higher proportion of overdose patients were Black in 2020 (63% vs. 80%). Slightly more than half of the patients received a naloxone prescription in either period and 44% of 2019 patients and 68% of 2020 patients received treatment resources and/or a referral at discharge. However, less than a tenth of the admitted patients received an addiction medicine consult in either time period.

Taken together, the studies “suggest that substance use and opioid overdoses in the COVID-19 era may be increasing, consistent with media reports,” said an accompanying editorial. It noted that recent pandemic-motivated policy changes, including expanding Medicaid, easing restrictions on methadone dispensing, and allowing more telemedicine, could help, but more efforts will be needed.

The perspective, published Sept. 23 by the Journal of Hospital Medicine and appearing in the October issue, offered these recommendations to improve care for inpatients with substance use during the pandemic and beyond:

  • Identify and treat acute withdrawal.
  • Manage acute pain, including providing high-dose opioids if needed.
  • Encourage hospitals to provide patients with tablets or other means to communicate, and refer patients to virtual peer support and recovery meetings.
  • Initiate medication for addiction during admission and refer to addiction treatment after discharge.
  • Assess mental health and suicide risks.
  • Discuss relapse prevention.
  • Assess overdose risk and promote harm reduction.
  • Consider high-risk transitions (such as discharge of people experiencing homelessness) that may be exacerbated by COVID-19.

The authors noted that hospitals' and hospitalists' ability to address these issues as recommended will vary based on their time and resources. They encouraged collaboration with addiction consult services, if available, as well as social workers, care managers, and other members of the health care team.