Agree Dale. Regarding diagnosis, management, and prognosis the arrest patients are a much different cohort than the sepsis group at large and may benefit from a focused study. Ron Elkin
-------- Original message --------From: "Brochis, Dale." <[email protected]> Date: 6/1/17 11:59 (GMT-08:00) To: "Barnes-Daly, Mary Ann, MS, RN, CCRN, DC" <[email protected]>, Ron Elkin <[email protected]>, "Townsend, Sean, M.D." <[email protected]> Cc: [email protected] Subject: RE: [Sepsis Groups] [**External**] Sepsis Alert The interesting point I pulled from this thread is “The study showed worse physiologic derangements and ED survival in arrest patients that were bacteremia, but survivals were not different at 28 days or beyond. I don't see a comparison of outcomes for bacteremia patients who received antibiotics in ED versus those that did not.” How does that translate to treatment? We can exclude patients in arrest so our data is clean. Because if they come in “dead” of course they will have worsened physiological derangements and survival. OR we can include patients in arrest because aggressive TX will make a difference in those not past the point of no return. “but survivals were not different at 28 days or beyond.” Is anyone interested in capturing data on bacteremia post arrest survivor rates based on time of antibiotic administration? From: Sepsisgroups [mailto:[email protected]] On Behalf Of Barnes-Daly, Mary Ann, MS, RN, CCRN, DC Sent: Tuesday, May 30, 2017 3:58 PM To: Ron Elkin; Townsend, Sean, M.D. Cc: [email protected] Subject: Re: [Sepsis Groups] [**External**] Sepsis Alert Great points Ron; I agree with your conclusion Thanks, MARY ANN BARNES-DALY MS RN CCRN DC | Clinical Performance Improvement Consultant Quality & Clinical Effectiveness Team | Office of Patient Experience Sutter Health -2200 River Plaza Drive, Sacramento, CA 95833 Mobile 916.200.5604| [email protected] “Do the best you can until you know better. Then when you know better, do better” Maya Angelou From: Sepsisgroups [mailto:[email protected]] On Behalf Of Ron Elkin Sent: Friday, May 19, 2017 9:32 AM To: Townsend, Sean, M.D. <[email protected]> Cc: [email protected] Subject: Re: [Sepsis Groups] [**External**] Sepsis Alert The study showed worse physiologic derangements and ED survival in arrest patients that were bacteremic, but survivals were not different at 28 days or beyond. I don't see a comparison of outcomes for bacteremic patients who received antibiotics in ED versus those that did not. The criteria for a diagnosis of severe sepsis or septic shock have included suspicion of infection (susceptible to the biases of the observer), SIRS (not sensitive or specific but quite likely in arrest both with or without sepsis), and evidence of acute organ dysfunction related to infection (but common in arrest with or without sepsis). For the individual patient, a significant challenge would be to distinguish between arrest only, arrest with severe sepsis/septic shock, and arrest with coincidental bacteremia insufficient to cause severe sepsis/septic shock. Organ failure, lactate, and procalcitonin, the latter two sometimes elevated in severe physiologic stress of any kind, will not provide this distinction for the individual patient. Therefore,one can make a good case for excluding these patients from analysis in the larger group of patients with severe sepsis/septic shock without arrest, or at least restricting the analysis to arrest patients. Thanks for the discussion. Ron Elkin San Francisco On Fri, May 19, 2017 at 7:19 AM, Townsend, Sean, M.D. <[email protected]> wrote: The interesting thing is that the original proposal was to delete these patients from your data, but based on Ron’s sleuthing, they may actually be a real part of the data. As a practical matter, it’s one of the last things docs will be thinking of in this situation. Arguing for antibiotics in these cases at a minimum is not a bad idea. Sounds like all providers will be affected equally with this problem, so I’m not worried from a data perspective, but interesting effort to provide education around antibiotics in post-arrest situations. From: Cynthia Wells [mailto:[email protected]] Sent: Friday, May 19, 2017 7:04 AM To: Ron Elkin <[email protected]>; Townsend, Sean, M.D. <[email protected]> Cc: [email protected] Subject: RE: [Sepsis Groups] [**External**] Sepsis Alert Hello, I definitely agree.. In order to meet the sepsis bundle we would still need the other two criteria- suspicion of infection/SIRS, hence we should start abx earlier to if nothing else prevent progression if arrest not related to bacteremia. I am concerned about the fluids because most of these lactates are sky high they are automatically pulled into shock elements. Cindy Cynthia Wells Steward Health Care Director of Clinical Performance Analytics (508) 404-8647 From: Sepsisgroups [mailto:[email protected]] On Behalf Of Ron Elkin Sent: Thursday, May 18, 2017 10:43 PM To: Townsend, Sean, M.D. <[email protected]> Cc: [email protected] Subject: Re: [Sepsis Groups] [**External**] Sepsis Alert Attached is a study showing a 38% incidence of bacteremia in ED patients presenting with out of hospital cardiac arrest. It is often unclear if the bacteremia was a contributing cause, or a result of the arrest, but the study suggests we should have a low threshold for instituting immediate empirical antimicrobial therapy in these patients. Such patients will certainly complicate diagnosis, treatment, and outcomes if included in analysis of severe sepsis or septic shock unassociated with arrest. Ron Elkin MD San Francisco On Wed, May 17, 2017 at 10:56 AM, Townsend, Sean, M.D. <[email protected]> wrote: I would agree this is a confounder. You could delete from your local focus study, but they will still hit the metric for purposes of SEP-1. I'm not sure how often you see this to justify a change to SEP-1, but if common I'd take a look. On May 17, 2017, at 10:52 AM, Mary Draper <[email protected]> wrote: Hi Dr. Townsend, I have been looking through the Severe Sepsis guidelines with regards to patient who present in cardiac arrest to the ED. I have not found any information specific to this issue. Most of them have an elevated lactate. It is difficult to determine what was the cause of the arrest. We are proposing to our Sepsis committee that we delete these patients from the focus study. What are your thoughts on this subject? Thanks Mary Draper RN BSN Coordinator Quality Improvement Peer Review Support CV/CT Quality Management JMH Office (925) 674-2045 Cell (925) 451-8792 Fax (925) 674-2373 [email protected] "O, let us always have a mountain within our soul, with a peak so high that we never quite reach the top... For then we will always strive for greater things and will not be content with merely climbing hills." Ardath Rodale -----Original Message----- From: Sepsisgroups [mailto:[email protected]] On Behalf Of Gwen S. Schneider Sent: Saturday, May 13, 2017 10:20 AM To: Townsend, Sean, M.D. <[email protected]>; Parker, Erin <[email protected]> Cc: [email protected] Subject: Re: [Sepsis Groups] [**External**] Sepsis Alert Hello, I am interested in the responses you might receive from your question. We use EPIC, and we have for LA a value of >2.0 a call from lab as a critical. I am wondering if other hospitals are doing the same. And what does MS have to say about it? Sierra Schneider Salem Oregon ________________________________________ From: Sepsisgroups [[email protected]] On Behalf Of Townsend, Sean, M.D. [[email protected]] Sent: Thursday, May 11, 2017 9:36 PM To: Parker, Erin Cc: [email protected] Subject: Re: [Sepsis Groups] [**External**] Sepsis Alert Erin, I'm sorry you received an inflammatory and obtuse response to your question. Such posts have earned the name "troll" or having been "trolled" for for a reason. Maybe to get a real answer to your question, you could share with us which EHR you use? Sean On May 5, 2017, at 7:05 AM, Parker, Erin <[email protected]<mailto:[email protected]>> wrote: WARNING: This email originated outside of the Sutter Health email system! DO NOT CLICK links if the sender is unknown and never provide your User ID or Password. Would any one like to share EHR sepsis alert criteria, and also be willing to share how it is working? 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