Challenging the One-hour Sepsis Bundle

Kalantari, Annahieta; Rezaie, Salim R.

doi:10.5811/westjem.2018.11.39290

Cited by 29 publications

(23 citation statements)

References 44 publications

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“…This occurs despite patient satisfaction correlating poorly with quality of care 93–97. Similarly, the guidelines and care metrics nominally designed to improve patient care (eg, door-to-doc/needle/antibiotics time) are rigorously enforced despite lack of evidence of patient benefit 98–99. Such metrics and guidelines, particularly prominent in EM as the initial provider of care, deprive physicians of autonomy and the ability to practice the art of medicine, leading to job dissatisfaction and burnout 82, 100…”

Section: Discussionmentioning

confidence: 99%

Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I

Stehman

Testo

Gershaw

et al. 2019

WestJEM

274

214

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Each year more than 400 physicians take their lives, likely related to increasing depression and burnout. Burnout-a psychological syndrome featuring emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment-is a disturbingly and increasingly prevalent phenomenon in healthcare, and emergency medicine (EM) in particular. As self-care based solutions have proven unsuccessful, more system-based causes, beyond the control of the individual physicians, have been identified. Such system-based causes include limitations of the electronic health record, long work hours and substantial educational debt, all in a culture of "no mistakes allowed." Blame and isolation in the face of medical errors and poor outcomes may lead to physician emotional injury, the so-called "second victim" syndrome, which is both a contributor to and consequence of burnout. In addition, emergency physicians (EP) are also particularly affected by the intensity of clinical practice, the higher risk of litigation, and the chronic fatigue of circadian rhythm disruption. Burnout has widespread consequences, including poor quality of care, increased medical errors, patient and provider dissatisfaction, and attrition from medical practice, exacerbating the shortage and maldistribution of EPs. Burned-out physicians are unlikely to seek professional treatment and may attempt to deal with substance abuse, depression and suicidal thoughts alone. This paper reviews the scope of burnout, contributors, and consequences both for medicine in general and for EM in particular. [

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Section: Discussionmentioning

confidence: 99%

Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I

Stehman

Testo

Gershaw

et al. 2019

WestJEM

274

214

View full text Add to dashboard Cite

show abstract

“…Phenotypically, we do not know which patient with infection will develop a dysregulated host response and will succumb to sepsis and/or shock 6–8 . The existing bundle lacks high quality evidence to support its recommendations and a blanket implementation for all patients with ‘suspected’ sepsis could be harmful 7 . Indeed, a significant reduction of sepsis and septic shock in Australia and New Zealand was observed in a bundle-free region 8 .…”

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confidence: 99%

Sepsis Care Pathway 2019

Labib

2020

Qatar Medical Journal

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Editorial Background: Sepsis, a medical emergency and life-threatening disorder, results from abnormal host response to infection that leads to acute organ dysfunction1. Sepsis is a major killer across all ages and countries and remains the most common cause of admission and death in the Intensive Care Unit (ICU)2. The true incidence remains elusive and estimates of the global burden of sepsis remain a wild guess. One study suggested over 19 million cases and 5 million sepsis-related deaths annually3. Addressing the challenge, the World Health Assembly of the World Health Organisation (WHO) passed a resolution on better prevention, diagnosis, and management of sepsis4. Current state of sepsis guidelines: Despite thousands of articles and hundreds of trials, sepsis remains a major killer. The cornerstones of sepsis care remain early recognition, adoption of a systematic evidence-based bundle of care, and timely escalation to higher level of care. The bundle approach has been advocated since 2004 but underwent major modifications in subsequent years with more emphasis on the time-critical nature of sepsis and need to restore physiological variables within one hour of recognition. A shift from a three and six-hour bundle to one-hour bundle has been recommended5. This single hour approach has been faced with an outcry and been challenged6–8. One size never fits all: Over several decades, the individual components of the sepsis bundle have not changed. Encountering a patient with suspected sepsis, one should measure lactate, obtain blood cultures, swiftly administer broad spectrum antimicrobials and fluids, and infuse vasopressors. A critical question arises: should we do this for all patients? Sepsis is not septic shock and guidelines did not make distinctive recommendations for each. Septic patients will present differently with some having more subtle signs and symptoms. Phenotypically, we do not know which patient with infection will develop a dysregulated host response and will succumb to sepsis and/or shock6–8. The existing bundle lacks high quality evidence to support its recommendations and a blanket implementation for all patients with ‘suspected’ sepsis could be harmful7. Indeed, a significant reduction of sepsis and septic shock in Australia and New Zealand was observed in a bundle-free region8. Emergency Department (ED) challenges: Upon arrival in the ED, patients will be triaged. This is ‘time zero’5. Those with hypotension and hypoperfusion will be easily recognised and at most need to receive emergent care. Sepsis, per se, may not manifest clear cut signs and expertise to identify it is required. Those with non-specific symptoms may trigger an early warning scoring system and receive unnecessary antimicrobials and a large volume of intravenous (IV) fluids. Both therapies are not without significant side effects. Putting pressure on ED physicians to implement the 60-minute bundle without individualisation of care puts our patients at risk6–8. Diagnostic challenges: Given the heterogenous nature and divers...

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“…The EQ-5D is a common PBM recommended by the UK National Institute for Health and Care Excellence for estimation of health state utilities. It measures quality of life in five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression [ 21 ]. This study used the EQ-5D-3L instrument, and index values were derived from the UK value set [ 22 ].…”

Section: Methodsmentioning

confidence: 99%

Application of a Mapping Function to Estimate Utilities for Ragweed Allergy Immunotherapy Trials

Dick

Briggs

Brandi

2020

PharmacoEconomics Open

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Background Ragweed pollen sensitivity is a common cause of allergic rhinitis (AR) worldwide. AR symptoms include itchy and runny eyes, sneezing, blocked nose, impaired sleep and social and emotional problems, which can have a significant impact on quality of life. Objective The objective of this analysis was to estimate utilities for two pooled standardised quality (SQ) ragweed sublingual immunotherapy (SLIT) tablet trials by applying a previously developed mapping algorithm. This study validated the algorithm and extended its application to ragweed seasonal allergy trials. The mapping algorithm relates disease-specific quality-of-life scores to preference-based utilities that may be used to calculate quality-adjusted life-years (QALYs) in cost-effectiveness studies. Methods A mapping algorithm based on a grass pollen allergy immunotherapy trial, GT-08 (EudraCT no. 2004-000083-27) was applied to pooled data from two ragweed pollen immunotherapy trials, P05233 (EudraCT 2008-003863-38) and P05234 (EudraCT 2008-003864-20) to generate EuroQoL 5-Dimensions, 3-Levels (EQ-5D-3L) utilities from Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) data. Results The mean utility difference between the SQ ragweed SLIT tablet and placebo was 0.025 [95% confidence interval (CI) 0.011-0.038]. The SQ ragweed SLIT tablet showed an incremental quality-adjusted life-days (QALDs) benefit of 1.900 (95% CI 0.835-2.916) over 75 days. Conclusions Application of a previously developed mapping function allowed for the calculation of QALDs associated with the SQ ragweed SLIT tablet. The results showed a QALD benefit of the SQ ragweed SLIT tablet in P05233 and P05234 trials in the treatment of ragweed pollen-induced AR.

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Challenging the One-hour Sepsis Bundle

Cited by 29 publications

References 44 publications

Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I

Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I

Sepsis Care Pathway 2019

Application of a Mapping Function to Estimate Utilities for Ragweed Allergy Immunotherapy Trials

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