Triage and flow management in sepsis

Abstract

BackgroundSepsis is a major public health problem, with a growing incidence and mortality rates still close to 30% in severe cases. The speed and adequacy of the treatment administered in the first hours of sepsis, particularly access to intensive care, are important to reduce mortality. This study compared the triage strategies and intensive care rationing between septic patients and patients with other indications of intensive care. This study included all patients with signs for intensive care, enrolled in the intensive care management system of a Brazilian tertiary public emergency hospital, from January 1, 2010, to December 31, 2016. The intensivist periodically evaluated the requests, prioritizing them according to a semi-quantitative scale. Demographic data, Charlson Comorbidity Index (CCI), Sequential Organ Failure Assessment (SOFA), and quick SOFA (qSOFA), as well as surgical interventions, were used as possible confounding factors in the construction of incremental logistic regression models for prioritization and admission to intensive care outcomes.ResultsThe study analyzed 9195 ICU requests; septic patients accounted for 1076 cases (11.7%), 293 (27.2%) of which were regarded as priority 1. Priority 1 septic patients were more frequently hospitalized in the ICU than nonseptic patients (52.2% vs. 34.9%, p < 0.01). Septic patients waited longer for the vacancy, with a median delay time of 43.9 h (interquartile range 18.2–108.0), whereas nonseptic patients waited 32.5 h (interquartile range 11.5–75.8)—p < 0.01. Overall mortality was significantly higher in the septic group than in the group of patients with other indications for intensive care (72.3% vs. 39.8%, p < 0.01). This trend became more evident after the multivariate analysis, and the mortality odds ratio was almost three times higher in septic patients (2.7, 2.3–3.1).ConclusionSeptic patients had a lower priority for ICU admission and longer waiting times for an ICU vacancy than patients with other critical conditions. Overall, this implied a 2.7-fold increased risk of mortality in septic patients.

An analysis of the concept of patient flow management

“…Decision‐making is limited by number of beds, physical space, staffing, and equipment 18,28 . Therefore, patient flow management is a process of matching supply and demand, 13,18 including rationing, prioritization, and concern with efficiency 19,32,34 …”

“…Patient flow management also influences left without being seen rates, 16,20,22 patient satisfaction, and patient safety 13,16 . Small changes in ED wait times impact patient outcomes, 14 and prolonged waits for transfers to the ICU are associated with higher patient mortality 24,34 …”

Decreasing Boarders in the Emergency Department By Reducing Clerical Work in the Discharge Process of In-Hospital Patients – An Interrupted Time-Series Analysis

“…Our hospital implemented an in-house developed electronic health record (EHR) which is continuously actualized and grants us the opportunity to customize processes. We use business process management (BPM) tools to implement any change in the EHR and succeed in other areas of study as sepse [5]. We recently reviewed the discharge process using a through output method.…”

Impacto da informatização do processo de alta hospitalar em um hospital público terciário

“…Dentre as múltiplas causas, três principais situações guardam maior relação com este risco: erros de prescrição médica, tromboembolismo venoso desencadeado pela imobilização ao leito e a ocorrência de infecções hospitalares. Enquanto os erros de prescrição sejam os mais relacionados à internação tanto precoce como tardia, o tromboembolismo e a infecção hospitalar são grandes causas de complicações mais tardias (3)(4)(5) .…”

“…Outra estratégia adotada na U.E-HCFMRP/USP para auxiliar nos fluxos internos e melhorar sua capacidade operacional foi organizar a priorização de pacientes para Unidade de Terapia Intensiva, com a criação de um sistema de informação para a organização da fila de espera por leitos, e o objetivo inicial foi avaliar sua utilização sob a perspectiva da mortalidade e permanência hospitalar (5) .…”