We hear the overhead announcements all the time in the hospital … Code Blue … Code Red … and more recently, Code Trauma … Code STEMI … Code Stroke … and Code Sepsis. From the standpoint of risk and safety, these latter four are the “Codes” that practitioners and nurses must master in order to deliver the best possible care in the safest manner, thereby reducing risk to patients and clinicians alike. Previous blogs featured two time-sensitive emergencies: Code Stroke and Code Sepsis. Today I will highlight a third time-sensitive “code” — Code STEMI (ST-elevation MI.)
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Surgical Site infections (SSIs) occur in 2% to 5% of surgery patients. This category of infection comprises approximately 22% of all healthcare-associated infections and has a 3% mortality. Patients with SSIs require significant care and average 7 to 10 days of increased length of hospital stay. The cost of providing care for a single SSI ranges from $3,000 to $29,000. The total cost of care for SSIs is estimated at $10 billion dollars per year. There are of course additional expenditures for outpatient care, readmissions, and care of long-term disabilities.
Catheter-associated urinary tract infections are the fourth most common HAI. They comprise over 12% of all acquired infections in acute care hospitals. 93,300 of these UTIs are estimated to be acquired in hospitals each year, with an estimated death toll of 13,000 patients.
If you ask leadership at many hospital organizations to name their highest current quality priority, many will respond that it is sepsis. In recent years, medical researchers have identified that key interventions dramatically alter the course of sepsis. Key factors such as early identification, early administration of antibiotics, and appropriate fluid loading significantly reduce morbidity and mortality. Hospitals and organizations that have followed the evidence have consistently demonstrated significant improvements in patient outcomes.
The CDC defines a Central Line-Associated Bloodstream Infection as: “A laboratory-confirmed bloodstream infection (LCBI) where central line (CL) or umbilical catheter (UC) was in place for more than 2 calendar days on the date of event, with day of device placement being Day 1 and the line was in place on the date of event or the day before.” In other words, the patient must have had the device in place for at least 2 days and the diagnosis must be made while the device is still indwelling or was indwelling on the day before.
The Centers for Disease Control and Prevention defines healthcare-associated infections (HAIs) as: “Infections that patients acquire during the course of receiving healthcare treatment for other conditions.”
Healthcare-associated infections are very common, and the cost associated with them is enormous. It is estimated that 1 out of every 25 hospitalized patients is treated for an HAI, with costs ranging between $28 billion and $33 billion per year.
In general, practitioners don’t appreciate anything that “pops up” or gets in the way of their typical workflow. This aspect of some EMRs can cause dissatisfaction, even anger. A good example is warnings related to medication prescribing. In some programs, drug interactions of any severity and their complications litter the screen with overwhelming frequency. This simply becomes white noise and is soon ignored, sometimes to the peril of the patient as well as the practitioner.
In emergency medicine and presumably in urgent and primary care, one of the common failure-to-diagnose drivers is the failure to recognize or act upon abnormal vital signs. In one analysis of 90,000 patients that we published in Annals of Emergency Medicine, 16% of patients presented to the emergency department with an abnormal vital sign, and 10% of that group went home without a single repeat of the abnormal vital sign. That analysis came from over 200 emergency departments across the U.S., representing over 7 million patient visits annually. From a quick calculation, you can see there are a lot of patients with abnormal vital signs being discharged from EDs across the U.S., and there are undoubtedly failure-to-diagnose adverse events and significant morbidity in that patient group.
Any discussion of communication in healthcare must include the process of transferring patients and their vital medical information from one provider to another and/or from one healthcare setting to another. Such transfers are known as healthcare handoffs; examples include when a patient is transferred from an ambulance to an ED or when a surgical patient is moved from the recovery room to a surgical floor.
There are four time-sensitive emergencies that that every practitioner of acute care medicine should master to deliver the best possible care in the safest manner: Code Trauma, Code STEMI, Code Stroke, and today's topic – Code Sepsis. Depending on the specialty, practitioners are involved in sepsis care at one or more stages of sepsis. In the office, urgent care or ED, the first two stages are paramount – early recognition and aggressive resuscitation. Hospitalists and admitting practitioners continue the initial management through recovery.