Rationale: The 2016 definitions of sepsis included the quick Sepsisrelated Organ Failure Assessment (qSOFA) score to identify highrisk patients outside the intensive care unit (ICU).Objectives: We sought to compare qSOFA with other commonly used early warning scores. . Using the highest non-ICU score of patients, >2 SIRS had a sensitivity of 91% and specificity of 13% for the composite outcome compared with 54% and 67% for qSOFA >2, 59% and 70% for MEWS >5, and 67% and 66% for NEWS >8, respectively. Most patients met >2 SIRS criteria 17 hours before the combined outcome compared with 5 hours for >2 and 17 hours for >1 qSOFA criteria.Conclusions: Commonly used early warning scores are more accurate than the qSOFA score for predicting death and ICU transfer in non-ICU patients. These results suggest that the qSOFA score should not replace general early warning scores when risk-stratifying patients with suspected infection.

An electronically generated eCART score was more accurate than commonly used paper based observation tools for predicting the composite outcome of in-hospital cardiac arrest, ICU transfer and death within 24h of observation. The outcomes of this analysis lend weight for a move towards an algorithm based electronic risk identification tool for deteriorating patients to ensure earlier detection and prevent adverse events in the hospital.

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ObjectiveSeveral large studies have shown that improving the patient experience is associated with higher reported patient satisfaction, increased adherence to treatment and clinical outcomes. Whether physician attire can affect the patient experience—and how this influences satisfaction—is unknown. Therefore, we performed a national, cross-sectional study to examine patient perceptions, expectations and preferences regarding physicians dress.Setting10 academic hospitals in the USA.ParticipantsConvenience sample of 4062 patients recruited from 1 June 2015 to 31 October 2016.Primary and secondary outcomes measuresWe conducted a questionnaire-based study of patients across 10 academic hospitals in the USA. The questionnaire included photographs of a male and female physician dressed in seven different forms of attire. Patients were asked to rate the provider pictured in various clinical settings. Preference for attire was calculated as the composite of responses across five domains (knowledgeable, trustworthy, caring, approachable and comfortable) via a standardised instrument. Secondary outcome measures included variation in preferences by respondent characteristics (eg, gender), context of care (eg, inpatient vs outpatient) and geographical region.ResultsOf 4062 patient responses, 53% indicated that physician attire was important to them during care. Over one-third agreed that it influenced their satisfaction with care. Compared with all other forms of attire, formal attire with a white coat was most highly rated (p=0.001 vs scrubs with white coat; p<0.001 all other comparisons). Important differences in preferences for attire by clinical context and respondent characteristics were noted. For example, respondents≥65 years preferred formal attire with white coats (p<0.001) while scrubs were most preferred for surgeons.ConclusionsPatients have important expectations and perceptions for physician dress that vary by context and region. Nuanced policies addressing physician dress code to improve patient satisfaction appear important.

BackgroundWhile midline vascular catheters are gaining popularity in clinical practice, patterns of use and outcomes related to these devices are not well known.MethodsTrained abstractors collected data from medical records of hospitalised patients who received midline catheters in 12 hospitals. Device characteristics, patterns of use and outcomes were assessed at device removal or at 30 days. Rates of major (upper-extremity deep vein thrombosis [DVT], bloodstream infection [BSI] and catheter occlusion) and minor complications were assessed. χ2 tests were used to examine differences in rates of complication by number of lumens, reasons for catheter removal l, and hospital-level differences in rates of midline use.ResultsComplete data on 1161 midlines representing 5%–72% of all midlines placed in participating hospitals between 1 January 2017 and 1 March 2018 were available. Most (70.8%) midlines were placed in general ward settings for difficult intravenous access (61.4%). The median dwell time of midlines across hospitals was 6 days; almost half (49%) were removed within 5 days of insertion. A major or minor complication occurred in 10.3% of midlines, with minor complications such as dislodgement, leaking and infiltration accounting for 71% of all adverse events. While rates of major complications including occlusion, upper-extremity DVT and BSI were low (2.2%, 1.4% and 0.3%, respectively), they were just as likely to lead to midline removal as minor complications (53.8% vs 52.5%, p=0.90). Across hospitals, absolute volume of midlines placed varied from 100 to 1837 devices, with corresponding utilisation rates of 0.97%–12.92% (p<0.001).ConclusionMidline use and outcomes vary widely across hospitals. Although rates of major complications are low, device removal as a result of adverse events is common.

Early warning scores are predictive of severe adverse events in postoperative patients. eCART is significantly more accurate in this patient population than both NEWS and MEWS.

OBJECTIVE Studies in sepsis are limited by heterogeneity regarding what constitutes suspicion of infection. We sought to compare potential suspicion criteria using antibiotic and culture order combinations in terms of patient characteristics and outcomes. We further sought to determine the impact of differing criteria on the accuracy of sepsis screening tools and early warning scores. DESIGN Observational cohort study SETTING Academic center from November 2008 until January 2016 PATIENTS Hospitalized patients outside the intensive care unit (ICU) INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS Six criteria were investigated: 1) any culture; 2) blood culture; 3) any culture plus intravenous (IV) antibiotics; 4) blood culture plus IV antibiotics; 5) any culture plus IV antibiotics for at least four of seven days; and 6) blood culture plus IV antibiotics for at least four of seven days. Accuracy of the quick Sepsis-related Organ Failure Assessment (qSOFA) score, SOFA score, systemic inflammatory response system (SIRS) criteria, the National and Modified Early Earning Score (NEWS and MEWS), and the electronic Cardiac Arrest Risk Triage (eCART) score were calculated for predicting ICU transfer or death within 48 hours of meeting suspicion criteria. A total of 53,849 patients met at least one infection criteria. Mortality increased from 3% for group 1 to 9% for group 6 and percentage meeting Angus sepsis criteria increased from 20% to 40%. Across all criteria, score discrimination was lowest for SIRS (median AUC 0.60) and SOFA score (median AUC 0.62), intermediate for qSOFA (median AUC 0.65) and MEWS (median AUC 0.67), and highest for NEWS (median AUC 0.71) and eCART (median AUC 0.73). CONCLUSIONS The choice of criteria to define a potentially infected population significantly impacts on prevalence of mortality but has little impact on accuracy. SIRS was the least predictive and eCART the most predictive regardless of how infection was defined.

In a multihospital quality improvement project, implementation of MAGIC improved PICC appropriateness and reduced complications to a modest extent. Given the size and resources required for this study, future work should consider cost-to-benefit ratio of similar approaches.