Surviving Sepsis Campaign: Association Between Performance Metrics and Outcomes in
a 7.5-Year Study. Levy MM, Rhodes A, Phillips GS, Townsend SR, Schorr CA, Beale R, Osborn T, Lemeshow S, Chiche JD, Artigas A, Dellinger RP. Crit Care Med. 2015 Jan;43(1):3-12.
The 2002 Surviving Sepsis Campaign established guidelines for the identification and treatment of severe sepsis and septic shock. Since that time multiple assessments of the effectiveness of this treatment bundle have been made with some showing trend to improvement in mortality and others showing no difference. For example the recent ProCESS study which compared early goal-directed therapy to “usual” care showed no difference in outcomes, nor did the first review of the surviving sepsis campaign hospitals. This study is a retrospective review of the same hospitals at 7.5 years including a total of nearly 30,000 patients in which they compared mortality as a function of duration of compliance to the guideline bundle as well as fidelity of compliance to the guidelines.
This study indicates that mortality decreases directly as a function of how long a hospital has participated in the SCC collaborative (7% decline in the risk of mortality for every additional quarter a site participates in the SSC) as well as how compliant a hospital is to the guidelines (for every 10% increase in compliance at a given site, the risk of hospital mortality decreases 3% to 5%). This seems to indicate as per the authors claim that performance metrics combined with guideline directed care improves quality of care and outcomes over time.
Failure of anticoagulant thromboprophylaxis: risk factors in medical-surgical critically ill patients*. Lim W, Meade M, Lauzier F, Zarychanski R, Mehta S, Lamontagne F, Dodek P, McIntyre L, Hall R, Heels-Ansdell D, Fowler R, Pai M, Guyatt G, Crowther MA, Warkentin TE, Devereaux PJ, Walter SD, Muscedere J, Herridge M, Turgeon AF, Geerts W, Finfer S, Jacka M, Berwanger O, Ostermann M, Qushmaq I, Friedrich JO, Cook DJ; PROphylaxis for ThromboEmbolism in Critical Care Trial Investigators. Crit Care Med. 2015 Feb;43(2):401-10.
This is a subset analysis of the Protect trial which used multivariate regression analysis to evaluate potential reasons for chemical thromboprophylaxis failure in 3746 critically ill patients. In this study 289 patients (7.7%) developed VTE and were deemed to have failed standard thromboprophylaxis. The results were: Predictors of thromboprophylaxis failure as measured by development of venous thromboembolism included a personal or family history of venous thromboembolism (hazard ratio, 1.64) and body mass index (hazard ratio, 1.18 per 10-point increase). Increasing body mass index was also a predictor for developing proximal leg deep vein thrombosis (hazard ratio, 1.25), which occurred in 182 patients (4.9%). Pulmonary embolism occurred in 47 patients (1.3%) and was associated with body mass index (hazard ratio, 1.37) and vasopressor use (hazard ratio, 1.84). Low molecular weight heparin was more protective of PE (hazard ratio 0.51) although it showed no significant decrease in VTE.
The authors conclude that knowledge of the risk factors for thromboprophylaxis failure should hasten diagnosis and help to reduce VTE-associated mortality. Individualization of thromboprophylaxis may be helpful in this patient population including monitoring of factor X levels, dosing changes, use of intravenous heparin rather than relying on SQ absorption, or other modifications of the usual prophylaxis regimen.
Cervical spine clearance in obtunded patients after blunt traumatic injury: a systematic review. Badhiwala JH, Lai CK, Alhazzani W, Farrokhyar F, Nassiri F, Meade M, Mansouri A, Sne N, Aref M, Murty N, Witiw C, Singh S, Yarascavitch B, Reddy K, Almenawer SA. Ann Intern Med. 2015 Mar 17;162(6):429-37.
This is the first of two reviews of the literature in regard to and recommendations for management of cervical spine immobilization in obtunded trauma patients with a normal CT scan of the cervical spine. In this study, the authors included 125 of the 2112 initial studies identified, using strict defined criteria and conforming to the MOOSE (Meta-analysis Of Observational Studies in Epidemiology) guidelines and the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) Statement. They then reviewed the studies for the primary outcome of clinically significant cervical spine injury missed by CT scan but revealed by subsequent confirmatory testing, defining clinically significant as one resulting in mechanical instability or requiring intervention or change in management. Three groups of studies were identified by the type of post normal CT management they utilized: those that routinely performed MRI, those that utilized dynamic radiography, and those that used serial examination with no routine further imaging unless clinically indicated. For each group mechanical cervical spine instability, need for operative stabilization, and collar use after negative CT results and additional findings on the confirmatory test were evaluated.
For studies utilizing routine MRI (20 studies, 2099 patients) the incidences of cervical spine instability, surgical intervention, and prolonged collar use after routine MRI ranged from 0% to 1.5%, from 0% to 7.3%, and from 0% to 29.5%, respectively and interestingly the use of prolonged collar immobilization was extremely variable with some institutions using them routinely in situations of any soft tissue signal changes.
For studies that used clinical examination and selective confirmatory testing (5 studies, 728 patients) no patient went on to have the diagnosis of unstable cervical spine injury, and none required operation or cervical collar replacement.
In studies (3 studies, 800 patients), dynamic images were obtained after normal CT scans. Incidences of unstable cervical spine injury and operative intervention ranged from 0% to 0.2%, and incidence of prolonged collar use after dynamic radiography was 0%.
The authors conclude that a high quality review of the available data indicates that removal of the cervical collar in obtunded trauma patients is “probably a safe and efficient practice” as evidence indicates no added benefits from prolonged collar use or further imaging. This practice may reduce the reported 26.2% increased incidence of ICU complications such as pressure ulcers, delirium, and VAP as well as a reduction in costs and resource utilization.
Cervical spine collar clearance in the obtunded adult blunt trauma patient: A systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. Patel MB, Humble SS, Cullinane DC, Day MA, Jawa RS, Devin CJ, Delozier MS, Smith LM, Smith MA, Capella JM, Long AM, Cheng JS, Leath TC, Falck-Ytter Y, Haut ER, Como JJ. J Trauma Acute Care Surg. 2015 Feb;78(2):430-41.
This is an EAST guideline presented at the 2015 EAST Meeting in Orlando, FL. Giving recommendations for management of cervical spine immobilization in obtunded trauma patients with a normal CT scan of the cervical spine.
The authors performed a review of 52 studies, of which 40 were rejected for design or technology (CT scan slice >3mm thickness) limitations and they defined a limit of 3/1000 rate of missed unstable C-spine injury (0.3%) as the upper limit for acceptable by consensus. Results: Of five articles with a total follow-up of 1,017 included subjects, none reported new neurologic change (paraplegia or quadriplegia) after cervical collar removal. Of 11 studies with a total of 1,718 subjects, no study reported an unstable C-spine fracture; one of the studies did not clearly report this outcome. There is a 9% incidence of stable injuries (161 of 1,718 in 11 studies) after coupling a negative high-quality C-spine CT result with 1.5-T MRI, upright x-ray series, flexion-extension CT, and/or clinical follow-up. Thus, the negative predictive value for C-spine CT was 100% for an unstable C-spine injury and 91% for any stable injury of the C-spine with a worst case scenario of missed stable C-spine injury of 9%.
Consistent with the meta-analysis above this Guideline of the Eastern Association of the Surgery of Trauma makes a conditional recommendation that cervical immobilization in trauma patients with normal, high-quality CT scans be discontinued without routine confirmatory testing. This study utilized the GRADE methodology basing their recommendation on admittedly poor data. The authors state that “we cannot continue indiscriminate two-stage sequential screening for C-spine injuries if the injury rate is near 0% for the first test and the second adjunctive test results in false positives and inconsistent treatment plans.”