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Does Sepsis Treatment Differ Between Primary and Overflow Intensive Care ORIGINAL RESEARCH Does Sepsis Treatment Differ Between Primary and Overflow Intensive Care Units? Kittane Vishnupriya, MBBS,* Olufunmilayo Falade, MD, Addisu Workneh, MD, MSc, Satish Chandolu, MBBS, Regina Landis, BA, Kaweesa Elizabeth, Reethi Iyengar, PhD, Scott Wright, MD, Jonathan Sevransky, MD, MHS Department of Medicine, Johns Hopkins University School of Medicine and Johns Hopkins Bayview Medical Center, Baltimore, Maryland. BACKGROUND: Sepsis is a major cause of death in health evaluation (APACHE II) scores were similar. Patients hospitalized patients. Early goal-directed therapy is the received similar processes-of-care in the primary ICU and standard of care. When primary intensive care units (ICUs) overflow ICU with the exception of deep vein thrombosis are full, sepsis patients are cared for in overflow ICUs. (DVT) and gastrointestinal (GI) prophylaxis within 24 hours of admission, which were better adhered to in the primary OBJECTIVE: To determine if process-of-care measures in ICU (74% vs 49%, P ¼ 0.004, and 68% vs 44%, P ¼ 0.012, the care of sepsis patients differed between primary and respectively). There were no significant differences in overflow ICUs at our institution. hospital and ICU length of stay between the 2 units (9.68 DESIGN: We conducted a retrospective study of all adult days vs 9.73 days, P ¼ 0.98, and 4.78 days vs 4.92 days, patients admitted with sepsis between July 2009 and P ¼ 0.97, respectively). February 2010 to either the primary ICU or the overflow ICU. CONCLUSIONS: Patients with sepsis admitted to the MEASUREMENTS: Baseline patient characteristics and primary ICU and overflow ICU at our institution were multiple process-of-care measures, including diagnostic managed similarly. Overflowing sepsis patients to non- and therapeutic interventions. primary intensive care units may not affect guideline- RESULTS: There were 141 patients admitted with sepsis to concordant care delivery or length of stay. Journal of our hospital; 100 were cared for in the primary ICU and 41 Hospital Medicine 2012;7:600–605. VC 2012 Society of in the overflow ICU. Baseline acute physiology and chronic Hospital Medicine Sepsis is a major cause of death in hospitalized At our hospital, we have an active bed management patients.1–3 It is recommended that patients with sep- system led by the hospitalist division.11 This system sis be treated with early appropriate antibiotics, as includes protocols to place sepsis patients in the over- well as early goal-directed therapy including fluid and flow ICU if the primary ICU is full. We hypothesized vasopressor support according to evidence-based that process-of-care interventions would be more guidelines.4–6 Following such evidence-based protocols strictly adhered to when sepsis patients were in the and process-of-care interventions has been shown to primary ICU rather than in the overflow unit at our be associated with better patient outcomes, including institution. decreased mortality.7,8 Most patients with severe sepsis are cared for in in- METHODS tensive care units (ICUs). At times, there are no beds Design available in the primary ICU and patients presenting This was a retrospective cohort study of all patients to the hospital with sepsis are cared for in other units. with sepsis admitted to either the primary medical in- Patients admitted to a non-preferred clinical inpatient tensive care unit (MICU) or the overflow cardiac in- setting are sometimes referred to as ‘‘overflow.’’9 tensive care unit (CICU) at our hospital between July ICUs can differ significantly in staffing patterns, equip- 2009 and February 2010. We reviewed the admission ment, and training.10 It is not known if overflow database starting with the month of February 2010 sepsis patients receive similar care when admitted to and proceeded backwards, month by month, until we non-primary ICUs. reached the target number of patients. Setting The study was conducted at our 320-bed, university- *Address for correspondence and reprint requests: Kittane affiliated academic medical center in Baltimore, MD. Vishnupriya, MBBS, Johns Hopkins Bayview Medical Center, 5200 Eastern Ave, Baltimore, MD 21224; Telephone: 410-550-5018; The MICU and the CICU are closed units that are Fax: 410-550-2972; E-mail: [email protected] located adjacent to each other and have 12 beds each. Additional Supporting Information may be found in the online version of They are staffed by separate pools of attending physi- this article. cians trained in pulmonary/critical care medicine and Received: December 7, 2011; Revised: March 9, 2012 and May 16, cardiovascular diseases, respectively, and no attending 2012; Accepted: May 26, 2012 2012 Society of Hospital Medicine DOI 10.1002/jhm.1955 physician attends in both units. During the study pe- Published online in Wiley Online Library (Wileyonlinelibrary.com). riod, there were 10 unique MICU and 14 unique 600 An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 7 | No 8 | October 2012 Sepsis Outcomes Across Settings | Vishnupriya et al CICU attending physicians; while most attending nation of processes, we used a goal of having at least physicians covered the unit for 14 days, none of the 31 patients in each ICU. physicians were on service more than 2 of the 2-week The study was approved by the Johns Hopkins Insti- blocks (28 days). Each unit is additionally staffed by tutional Review Board. The need for informed consent fellows of the respective specialties, and internal medi- was waived given the retrospective nature of the cine residents and interns belonging to the same resi- study. dency program (who rotate through both ICUs). Resi- dents and fellows are generally assigned to these ICUs Data Extraction Process and Procedures for 4 continuous weeks. The assignment of specific The clinical data was extracted from the EMR and attendings, fellows, and residents to either ICU is per- patient charts using a standardized data extraction formed by individual division administrators on a instrument, modified from a case report form (CRF) rotational basis based on residency, fellowship, and used and validated in previous studies.15,16 The fol- faculty service requirements. The teams in each ICU lowing procedures were used for the data extraction: function independently of each other. Clinical care of 1. The data extractors included 4 physicians and 1 patients requiring the assistance of the other specialty research assistant and were trained and tested by a sin- (pulmonary medicine or cardiology) have guidance gle expert in data review and extraction. conferred via an official consultation. Orders on 2. Lab data was transcribed directly from the EMR. Calcu- patients in both ICUs are written by the residents lation of acute physiology and chronic health evalua- using the same computerized order entry system tion (APACHE II) scores were done using the website (CPOE) under the supervision of their attending physi- http://www.sfar.org/scores2/apache22.html (Societ e cians. The nursing staff is exclusive to each ICU. The Franc¸aise d’Anesthesie et de Reanimation). Sepsis- respiratory therapists spend time in both units. The related organ failure assessment (SOFA) scores were nursing and respiratory therapy staff in both ICUs are calculated using usual criteria.17 similarly trained and certified, and have the same 3. Delivery of specific treatments and interventions, patient-to-nursing ratios. including their timing, was extracted from the EMR. Subjects 4. The attending physicians’ notes were used as the final source to assign diagnoses such as presence of acute All patients admitted with a possible diagnosis of sep- lung injury, site of infection, and record interventions. sis to either the MICU or CICU were identified by querying the hospital electronic triage database called ‘‘etriage.’’ This Web-based application is used to Data Analysis admit patients to all the Medicine services at our hos- Analyses focused primarily on assessing whether pital. We employed a wide case-finding net using key- patients were treated differently between the MICU words that included pneumonia, sepsis, hypotension, and CICU. The primary exposure variables were the high lactate, hypoxia, UTI (urinary tract infection)/ process-of-care measures. We specifically used mea- urosepsis, SIRS (systemic inflammatory response syn- surement of central venous saturation, checking of drome), hypothermia, and respiratory failure. A total lactate level, and administration of antibiotics within of 197 adult patients were identified. The charts and 60 minutes in patients with severe sepsis as our ‘‘pri- the electronic medical record (EMR) of these patients mary’’ process-of-care measures.13 Continuous varia- were then reviewed to determine the presence of a bles were reported as mean 6 standard deviation, and sepsis diagnosis using standard consensus criteria.12 Student’s t tests were used to compare the 2 groups. Severe sepsis was defined by sepsis associated with Categorical data were expressed as frequency distribu- organ dysfunction, hypoperfusion, or hypotension tions, and chi-square tests were used to identify differ- using criteria described by Bone et al.12 ences between the 2 groups. All tests were 2-tailed Fifty-six did not meet the criteria for sepsis and with statistical significance set at 0.05. Statistical anal- were excluded from the analysis. A total of 141 ysis was performed using SPSS version 19.0. (IBM, patients were included in the study. This being a pilot Armonk, NY). study, we did not have any preliminary data regarding To overcome data constraints, we created a dichoto- adherence to sepsis guidelines in overflow ICUs to cal- mous variable for each of the 3 primary processes-of- culate appropriate sample size. However, in 2 recent care (indicating receipt of process or not) and then studies of dedicated ICUs (Ferrer et al13 and Castella- combined them into 1 dichotomous variable indicat- nos-Ortega et al14), the averaged adherence to a single ing whether or not the patients with severe sepsis measure like checking of lactate level was 27% pre- received all 3 primary processes-of-care.
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