Objective: The purpose of this study was to examine the outcome implications of implementing a severe sepsis bundle in an emergency department as a quality indicator set with feedback to modify physician behavior related to the early management of severe sepsis and septic shock. Design: Two-year prospective observational cohort. Setting: Academic tertiary care facility. Patients: Patients were 330 patients presenting to the emergency department who met criteria for severe sepsis or septic shock. Interventions: Five quality indicators comprised the bundle for severe sepsis management in the emergency department: a) initiate central venous pressure (CVP)/central venous oxygen saturation (Scvo₂) monitoring within 2 hrs; b) give broad-spectrum antibiotics within 4 hrs; c) complete early goal-directed therapy at 6 hrs; d) give corticosteroid if the patient is on vasopressor or if adrenal insufficiency is suspected; and e) monitor for lactate clearance. Measurements and Main Results: Patients had a mean age of 63.8 ± 18.5 yrs, Acute Physiology and Chronic Health Evaluation II score 29.6 ± 10.6, emergency department length of stay 8.5 ± 4.4 hrs, hospital length of stay 11.3 ± 12.9 days, and in-hospital mortality 35.2%. Bundle compliance increased from zero to 51.2% at the end of the study period. During the emergency department stay, patients with the bundle completed received more CVP/Scvo₂ monitoring (100.0 vs. 64.8%, p < .01), more antibiotics (100.0 vs. 89.7%, p = .04), and more corticosteroid (29.9 vs. 16.2%, p = .01) compared with patients with the bundle not completed. In a multivariate regression analysis including the five quality indicators, completion of early goal-directed therapy was significantly associated with decreased mortality (odds ratio, 0.36; 95% confidence interval, 0.17–0.79; p = .01). In-hospital mortality was less in patients with the bundle completed compared with patients with the bundle not completed (20.8 vs. 39.5%, p < .01). Conclusions: Implementation of a severe sepsis bundle using a quality improvement feedback to modify physician behavior in the emergency department setting was feasible and was associated with decreased in-hospital mortality.

Few studies have explored the relative burden and trends in pulmonary (PTB) vs. extra-pulmonary (EPTB) tuberculosis in the United States using a nationally representative sample. This study examined trends in hospitalization rates, length-of-stay (LOS), in-hospital mortality and inflation-adjusted charges, for PTB vs. EPTB using the Nationwide/National Inpatient Sample (NIS) from 1998 to 2014. Descriptive and multivariable analyses (linear, negative binomial and logistic) were utilized adjusting for demographics, co-morbidity and hospital characteristics. During the study period there were a survey-adjusted, estimated 258,631 PTB (75.5%), 76,476 EPTB (22.3%) and 7552 concurrent PTB and EPTB (2.2%) discharges. Whites accounted for 27.6% of PTB, 21.9% of EPTB and 17.6% of concurrent discharges; and self-pay or no insurance accounted for 22.2%, 18.4%, and 25.9%, respectively. EPTB was more common among blacks (22.5%), and combined TB more common among Hispanics (24.8%). Mean LOS was 11.4 days, 13.2 days, and 19.5 days; with mean nominal charges of $48,031, $62,255, and $89,364 for PTB, EPTB and combined TB respectively. Inpatient mortality for all three groups was approximately 5.7%. Miliary TB and TB of meninges and central nervous system were positively associated with mortality (odds ratios of 2.44 and 2.11, respectively), as was alcohol abuse (OR 1.21). Trend analyses showed decreased hospitalizations for all TB types, no change in LOS trends, decreased mortality for PTB and ETB and increased charges for PTB and ETB from 1998 to 2014. Increased utilization, higher charges and higher risk of mortality (to some extent) among the EPTB cases warrant improved methods for screening, diagnosis and treatment. Though rates of TB hospitalization are declining, EPTB is becoming relatively more common and is more costly compared to pulmonary TB. Screening methods that focus on identification of ETB contrary to current practice guidelines are needed to aid ETB case finding.

Objectives: The primary objective of this study was to identify which patient demographic, patient health, and hospital characteristics were associated with in-hospital mortality. A secondary objective was to determine the relative influence of these characteristics on mortality. Design and Setting: Public-use data for 2005–2010 were used in this retrospective, cross-sectional analysis of discharges from nonfederal, general acute hospitals in California. A staged logistic regression approach was used to examine the relative influence of variables associated with in-hospital mortality. Patients: A total of 1,213,219 patient discharges for adults (aged ≥18 yrs) having International Classification of Diseases-9 diagnosis and procedure codes indicating severe sepsis. Intervention: None. Measurements and Main Results: Patient demographics (age, gender, race, ethnicity, and payer category), patient health status (acute transfer, Charlson-Deyo comorbidity index, and organ failures), and hospital characteristics (ownership type, teaching status, bed size, annual patient days, acute discharges, emergency department visits, inpatient surgeries, severe sepsis as a percentage of all discharges, and year) were obtained from the California Office of Statewide Health Planning and Development. Overall, in-hospital mortality was 17.8%. There was a steady annual increase in the number of sepsis discharges, but a decrease in mortality throughout the study period. Mortality increased with age and was associated with white race, and Medicaid (Medi-Cal) and private insurance. Patient health status additionally explained inpatient mortality. Hospital volume measures were statistically significant in regression analysis, whereas static structural measures were not. There were modest associations between measures of annual treatment volume and likelihood of inpatient mortality, notably decreasing likelihood with more acute discharges and with greater severe sepsis volume. Conclusions: Although patient demographics and health status are the most important predictors of in-hospital mortality of patients with severe sepsis, hospital characteristics do play a substantial role. Findings regarding hospital volume can be used to improve processes and improve patient outcomes.

A novel coronavirus disease (COVID-19) was reported in Wuhan, China late December 2019. The disease has as of the end of March 2020, affected over 35 countries (with over 570,000 cases and 26,000 deaths) worldwide. This includes the U.S., where cases are increasing by the thousands every day (100,000 cases with 1500 deaths as of April 2020). We set out to investigate new or increased stressful life events (SLEs) as a result of this pandemic in the U.S. In this exploratory qualitative study, we examined new or heightened SLEs during an active phase of this outbreak. We used a list of SLEs acquired from the first phase of our study, whereby we conducted open-ended surveys and performed an in-depth focus group. We applied Lazarus and Folkman’s transactional model of stress and coping to understand diverse focus-group participants’ appraisal of events. We coded survey data and applied sentiment analysis. Participants varied in perceived threat and challenge appraisals of COVID-19, indicating both calm and fear. From 267 coded and sentiment analyzed events from survey text, 95% were predominantly negative; 112 (42%) very negative and 142 (53%) moderately negative. Social capital was unanimously emphasized upon as monumental for example: family, friends or technology mediated. We additionally identified seven major themes of SLEs due to the pandemic. Our sample profile is not inclusive of all subsets of the population. Participants mostly shared similar frustrations and a variety of SLEs such as fear of the unknown and concern for loved ones as a result of COVID-19.