Search

Objective: To evaluate a standardized hospital order set for the management of septic shock in the emergency department., Design: Before-after study design with prospective consecutive data collection., Setting: Emergency department of a 1,200-bed academic medical center., Patients: A total of 120 patients with septic shock., Interventions: Implementation of a standardized hospital order set for the management of septic shock., Measurements and Main Results: A total of 120 consecutive patients with septic shock were identified. Sixty patients (50.0%) were managed before the implementation of the standardized order set, constituting the before group, and 60 (50.0%) were evaluated after the implementation of the standardized order set, making up the after group. Demographic variables and severity of illness measured by the Acute Physiology and Chronic Health Evaluation II were similar for both groups. Patients in the after group received statistically more intravenous fluids while in the emergency department (2825 +/- 1624 mL vs. 3789 +/- 1730 mL, p = .002), were more likely to receive intravenous fluids of >20 mL/kg body weight before vasopressor administration (58.3% vs. 88.3%, p < .001), and were more likely to be treated with an appropriate initial antimicrobial regimen (71.7% vs. 86.7%, p = .043) compared with patients in the before group. Patients in the after group were less likely to require vasopressor administration at the time of transfer to the intensive care unit (100.0% vs. 71.7%, p < .001), had a shorter hospital length of stay (12.1 +/- 9.2 days vs. 8.9 +/- 7.2 days, p = .038), and a lower risk for 28-day mortality (48.3% vs. 30.0%, p = .040)., Conclusions: Our study found that the implementation of a standardized order set for the management of septic shock in the emergency department was associated with statistically more rigorous fluid resuscitation of patients, greater administration of appropriate initial antibiotic treatment, and a lower 28-day mortality. These data suggest that the use of standardized order sets for the management of septic shock should be routinely employed.

Objective: To determine the occurrence and type of medical errors in an intensive care setting using a voluntary reporting method., Design: Prospective, single-center, observational study., Setting: The medical intensive care unit (19 beds) at an urban teaching hospital., Patients: Adult patients requiring at least 48 hrs of intensive care., Interventions: Prospective reporting of medical errors., Measurements and Main Results: During a 6-month period, 232 medical events were reported involving 147 patients. A total of 2598 patient days were surveyed yielding 89.3 medical events reported per 1000 intensive care unit days. The source of the reports included nurses, who reported most of the medical events (59.1%), followed by physicians-in-training (27.2%) and intensive care unit attending physicians (2.6%). One hundred thirty (56.2%) medical events occurred within the intensive care unit and were judged to involve patient careproviders who were working directly in the intensive care unit area. One hundred and two (43.8%) medical events were commissions or omissions that occurred outside of the intensive care unit during patient transports or in the emergency department and hospital floors. Twenty-three (9.9%) medical events leading to a medical error resulted in the need for additional life-sustaining treatment, and seven (3.0%) medical errors may have contributed to patient deaths., Conclusion: Medical errors appear to be common among patients requiring intensive care. Medical events resulting in an error can result in the need for additional life-sustaining treatments and, in some circumstances, can contribute to patient death. Patient healthcare providers appear to be in a unique position to identify medical errors. Institutions should develop formalized methods for the reporting and analysis of medical errors to improve patient care.

Objective: The purpose of this study was to determine the impact of scheduled changes of antibiotic classes, used for the empirical treatment of suspected or documented Gram-negative bacterial infections, on the occurrence of inadequate antimicrobial treatment of nosocomial infections., Design: Prospective observational study., Setting: Medical (19-bed) and surgical (18-bed) intensive care units in an urban teaching hospital., Patients: A total of 3,668 patients requiring intensive care unit admission were prospectively evaluated during three consecutive time periods., Interventions: During each time period, one antibiotic class was selected for the empirical treatment of Gram-negative bacterial infections as follows: time period 1 (baseline period) (1,323 patients), ceftazidime; time period 2 (1,243 patients), ciprofloxacin; and time period 3 (1,102 patients), cefepime., Measurements and Main Results: The overall administration of inadequate antimicrobial treatment for nosocomial infections decreased during the course of the study (6.1%, 4.7%, and 4.5%; p = .15). This was primarily because of a statistically significant decrease in the administration of inadequate antibiotic treatment for Gram-negative bacterial infections (4.4%, 2.1%, and 1.6%; p < .001). There were no statistically significant differences in the overall hospital mortality rate among the three time periods (15.6%, 16.4%, and 16.2%; p = .828) despite a significant increase in severity of illness as measured with Acute Physiology and Chronic Health Evaluation (APACHE) II scores (15.3 +/- 7.6, 15.7 +/- 8.0, and 20.7 +/- 8.6; p < .001). The hospital mortality rate decreased significantly during time period 3 (20.6%) compared with time period 1 (28.4%; p < .001) and time period 2 (29.5%; p < .001) for patients with an APACHE II score > or = 15., Conclusions: These data suggest that scheduled changes of antibiotic classes for the empirical treatment of Gram-negative bacterial infections can reduce the occurrence of inadequate antibiotic treatment for nosocomial infections. Reducing inadequate antibiotic administration may improve the outcomes of critically ill patients with APACHE II scores > or = 15.