The pregnancy-related mortality rate in the US exceeds that of other developed nations and is marked by significant disparities in outcome by race. This article reviews the evidence supporting the implementation of a variety of best practices designed to reduce maternal mortality. Evidence from maternal mortality review committees suggests that delays in diagnosis, delays in initiation of treatment and use of ineffective treatments contribute to preventable cases of maternal death. We review several protocols for maternal warning signs that have been used successfully to facilitate early identification and intervention. Care bundles, a collection of best practices, have been developed and implemented to address several maternal emergencies. We review the evidence that supports reduction in adverse outcomes with consistent implementation of obstetric hemorrhage and severe hypertension bundles in a collaborative, team-based setting. The article concludes with suggestions for the future.
Acute ischemic stroke affects over 800,000 US adults annually, with hundreds of thousands more experiencing a transient ischemic attack. Emergent evaluation, prompt acute treatment, and identification of stroke or TIA (transient ischemic attack) etiology for specific secondary prevention are critical for decreasing further morbidity and mortality of cerebrovascular disease. The Biomarkers of Acute Stroke Etiology (BASE) study is a multicenter observational study to identify serum markers defining the etiology of acute ischemic stroke. Observational trial of patients presenting to the hospital within 24 h of stroke onset. Blood samples are collected at arrival, 24, and 48 h later, and RNA gene expression is utilized to identify stroke etiology marker candidates. The BASE study began January 2014. At the time of writing, there are 22 recruiting sites. Enrollment is ongoing, expected to hit 1000 patients by March 2017. The BASE study could potentially aid in focusing the initial diagnostic evaluation to determine stroke etiology, with more rapidly initiated targeted evaluations and secondary prevention strategies.Clinical Trial Registration Clinicaltrials.gov NCT02014896 https://clinicaltrials.gov/ct2/show/NCT02014896?term=biomarkers+of+acute+stroke+etiology&rank=1
Methods: An electronic screening system for severe sepsis was created in our EHR and implemented in our ED. A best practice advisory (BPA) notifies physicians and nurses of possible severe sepsis and prompts utilization of an order set when three criteria are met. These include: 2 or more modified SIRS criteria positive (Temp>38 C, HR>90, RR>20, SBP<90 or MAP<65, and WBC>12), evidence of end-organ dysfunction (hypotension or organ dysfunction lab values consistent with CMS measure definition) and suspected infection (either temperature > 38 C, antibiotics ordered for the indication of suspected infection, or documented physician suspicion of infection). We performed a retrospective manual chart review of all adult patient encounters with a triggered severe sepsis BPA over a 3-month period to determine whether the patient had potential or suspected severe sepsis at the time the BPA fired. A second reviewer reviewed the cases to determine agreement with a third used as a tiebreaker if disagreement. In addition, we reviewed patients over a 7-week period who received ICD-10 codes for severe sepsis or septic shock to determine if any cases were missed in the ED by our screening criteria.Results: 301 ED patient encounters (2.01% of all adult ED patient encounters) triggered the severe sepsis BPA alert in the 3-month study period. 295 of the 301 encounters were determined via chart review to have suspected severe sepsis or septic shock at the time that the alert fired. The remaining 6 encounters were determined not to have suspected severe sepsis or septic shock at the time of BPA alert and included: alcohol withdrawal, salicylate toxicity, transfusion reaction, GI bleed, and prophylactic antibiotics ordered without appropriately indicating intent. The observed kappa for interrater reliability was 0.854. The positive predictive value of our BPA alert for suspected severe sepsis is 98% (295/301). Over a 7-week period, 86 patients ultimately received ICD-10 codes for severe sepsis or septic shock. 71 met criteria for severe sepsis during their ED evaluation with 70 caught by our automated screening criteria, resulting in a sensitivity of 98.59% (CI 92.4-99.96%). The single case not caught by our BPA logic was due to antibiotics not administered in the ED.Conclusions: The development of an automated severe sepsis screen in the ED at our institution was found to have very high positive predictive value as well as high sensitivity for patients ultimately diagnosed with severe sepsis or septic shock.
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