Showing papers by "Tamas Szakmany published in 2018"
TL;DR: There is wide variability in the sepsis rate and outcomes in ICU patients around the globe, and independent risk factors for in-hospital death included older age, higher simplified acute physiology II score, comorbid cancer, chronic heart failure, cirrhosis, use of mechanical ventilation or renal replacement therapy, and infection with Acinetobacter spp.
Abstract: Background There is a need to better define the epidemiology of sepsis in intensive care units (ICUs) around the globe. Methods The Intensive Care over Nations (ICON) audit prospectively collected data on all adult (>16 years) patients admitted to the ICU between May 8 and May 18, 2012, except those admitted for less than 24 hours for routine postoperative surveillance. Data were collected daily for a maximum of 28 days in the ICU, and patients were followed up for outcome data until death, hospital discharge, or for 60 days. Participation was entirely voluntary. Results The audit included 10069 patients from Europe (54.1%), Asia (19.2%), America (17.1%), and other continents (9.6%). Sepsis, defined as infection with associated organ failure, was identified during the ICU stay in 2973 (29.5%) patients, including in 1808 (18.0%) already at ICU admission. Occurrence rates of sepsis varied from 13.6% to 39.3% in the different regions. Overall ICU and hospital mortality rates were 25.8% and 35.3%, respectively, in patients with sepsis, but it varied from 11.9% and 19.3% (Oceania) to 39.5% and 47.2% (Africa), respectively. After adjustment for possible confounders in a multilevel analysis, independent risk factors for in-hospital death included older age, higher simplified acute physiology II score, comorbid cancer, chronic heart failure (New York Heart Association Classification III/IV), cirrhosis, use of mechanical ventilation or renal replacement therapy, and infection with Acinetobacter spp. Conclusions Sepsis remains a major health problem in ICU patients worldwide and is associated with high mortality rates. However, there is wide variability in the sepsis rate and outcomes in ICU patients around the globe.
235 citations
TL;DR: Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine.
Abstract: Background The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Methods Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. Results We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality [odds ratio (OR) 0.49 (0.32–0.77); P Conclusions Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine.
85 citations
TL;DR: The Sequential Organ Failure Assessment score appeared to be the best tool for identifying patients with high risk of death and sepsis‐induced organ dysfunction.
Abstract: Our aim was to prospectively determine the predictive capabilities of SEPSIS-1 and SEPSIS-3 definitions in the emergency departments and general wards. Patients with National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled over a 24-h period in 13 Welsh hospitals. The primary outcome measure was mortality within 30 days. Out of the 5422 patients screened, 431 fulfilled inclusion criteria and 380 (88%) were recruited. Using the SEPSIS-1 definition, 212 patients had sepsis. When using the SEPSIS-3 definitions with Sequential Organ Failure Assessment (SOFA) score ≥ 2, there were 272 septic patients, whereas with quickSOFA score ≥ 2, 50 patients were identified. For the prediction of primary outcome, SEPSIS-1 criteria had a sensitivity (95%CI) of 65% (54-75%) and specificity of 47% (41-53%); SEPSIS-3 criteria had a sensitivity of 86% (76-92%) and specificity of 32% (27-38%). SEPSIS-3 and SEPSIS-1 definitions were associated with a hazard ratio (95%CI) 2.7 (1.5-5.6) and 1.6 (1.3-2.5), respectively. Scoring system discrimination evaluated by receiver operating characteristic curves was highest for Sequential Organ Failure Assessment score (0.69 (95%CI 0.63-0.76)), followed by NEWS (0.58 (0.51-0.66)) (p < 0.001). Systemic inflammatory response syndrome criteria (0.55 (0.49-0.61)) and quickSOFA score (0.56 (0.49-0.64)) could not predict outcome. The SEPSIS-3 definition identified patients with the highest risk. Sequential Organ Failure Assessment score and NEWS were better predictors of poor outcome. The Sequential Organ Failure Assessment score appeared to be the best tool for identifying patients with high risk of death and sepsis-induced organ dysfunction.
44 citations
TL;DR: This study demonstrates the ease and feasibility of collecting detailed descriptive data on central line insertion and its immediate complications in the UK over two weeks.
Abstract: BackgroundCentral venous catheters are inserted ubiquitously in critical care and have roles in drug administration, fluid management and renal replacement therapy. They are also associated with nu...
22 citations
TL;DR: It was found that older age was associated with death with OR of 1.03, and SOFA score 2 or above was independently associated with increased risk of death at 90 days, and the sequalae of infection-related organ dysfunction cannot be reliably captured based on routine clinical and physiological parameters alone.
22 citations
TL;DR: The aim of the study was to establish the fraction of deaths directly related to the sepsis episode on the general wards and emergency departments in 2016 and 2017 and to know what proportion of deaths are potentially preventable or modifiable after a sepsi episode.
Abstract: Sepsis mortality is reported to be high worldwide, however recently the attributable fraction of mortality due to sepsis (AFsepsis) has been questioned. If improvements in treatment options are to be evaluated, it is important to know what proportion of deaths are potentially preventable or modifiable after a sepsis episode. The aim of the study was to establish the fraction of deaths directly related to the sepsis episode on the general wards and emergency departments. 839 patients were recruited over the two 24-h periods in 2016 and 2017. 521 patients fulfilled SEPSIS-3 criteria. 166 patients (32.4%) with sepsis and 56 patients (17.6%) without sepsis died within 90 days. Out of the 166 sepsis deaths 12 (7.2%) could have been directly related to sepsis, 28 (16.9%) possibly related and 96 (57.8%) were not related to sepsis. Overall AFsepsis was 24.1%. Upon analysis of the 40 deaths likely to be attributable to sepsis, we found that 31 patients (77.5%) had the Clinical Frailty Score ≥ 6, 28 (70%) had existing DNA-CPR order and 17 had limitations of care orders (42.5%).
11 citations
TL;DR: The aim was to explore adherence to local guidelines and establish an understanding as to why, in clinical practice, prescribing patterns may differ, based on the antibiotic prescribing patterns across hospitals in Wales from the Defining Sepsis on the Wards Study.
Abstract: Sir, Sepsis is frequent, potentially fatal condition characterised by organ dysfunction as a result of a dysregulated host response to infection [1]. We estimated that the combined point-prevalence of sepsis is around 5.5% amongst hospital in-patients in Wales [2, 3]. It has been argued that rapid administration of an appropriately chosen antibiotic is the cornerstone of the effective treatment of sepsis [4]. Recently, a standardised sepsis screening tool and the Sepsis 6 treatment protocol has been rolled out across Wales [5]. However, the antibiotic prescribing element has been traditionally based on local guidance and antimicrobial resistance patterns [6]. Evidence suggests that incorrect antibiotic prescribing may lead to an increased emergence of antibiotic resistant organisms [7]. Therefore, it is crucial that local guidance is followed. Our aim was to explore adherence to local guidelines and establish an understanding as to why, in clinical practice, prescribing patterns may differ. We obtained data based on the antibiotic prescribing patterns across hospitals in Wales from the Defining Sepsis on the Wards Study which has been described previously in detail (ISCRTN: 86502304) [3]. Briefly, it was a point-prevalence study in every Welsh hospital over a 24-hour period on the 19/10/2016. Patients with National Early Warning Score of 3 or above with clinical suspicion of infection were recruited following informed consent. Various demographic, care process and outcome data were collected, including antibiotic prescribing and administration. We contacted the critical care outreach or acute intervention teams in the hospitals where this service is provided, to identify barriers to successfully implement early and appropriate antibiotic therapy as part of the Sepsis 6 initiative. Data were analysed using Microsoft Excel. Within the study period there were similar numbers of patients with sepsis in each hospital (Table 1). Antibiotic treatment within one hour was administered at a variable rate, from 27% to 64%. In 35% of all cases of sepsis, the cause was unknown and within this sub-group the percentage of antibiotics prescribed was slightly higher, varying from 20% to 90%. In accordance to local guidelines, antibiotic prescribing for patients with sepsis of unknown origin was correct in 22% of cases (Table 2). Out of the patients who did receive antibiotics, the majority of them received either an incorrect antibiotic regime (59%) or a partially correct antibiotic regime (19%). There was significant inter-hospital variability in the correct prescription of antimicrobials. In many cases, partially correct antibiotic regimes were administered, as only one of the two suggested antibiotics were prescribed (Table 2). Four key barriers to effectively implementing the antibiotic therapy in the Sepsis 6 initiative were identified: 1. Lack of education — understanding when to trigger the pathway. 2. Complexity of guidelines. 3. Lack of a leadership role — giving IV antibiotics requires communication. between different healthcare professionals. 4. Practical issues — sourcing equipment or acute bed shortages.
2 citations