The retrospective design of the study limited its ability to determine causal relationship. Extensive education may have contributed to the change (Hawthorne effect). Management in the ICU and ED, not the hospital wards, was the primary reason for mortality difference.
Bottom line: A standardized order set for bacteremic sepsis was associated with increased compliance with evidence-based treatment and improved outcomes. Hospitalists should promptly treat bacteremic sepsis with appropriate fluid resuscitation and antibiotics.
Citation: Thiel SW, Asghar MF, Micek ST, Reichley RM, Doherty JA, Kollef MH. Hospital-wide impact of a standardized order set for the management of bacteremic severe sepsis. Crit Care Med. 2009;37(3):819-824.
Admission Day of the Week Predicts Mortality in Patients with Acute Pulmonary Embolus
Clinical question: Do weekend pulmonary embolus (PE) admissions have worse outcomes than weekday admissions?
Background: Studies of patients with acute cardiovascular diagnoses (e.g., stroke, cardiac arrest) have shown higher short-term mortality and longer length of stay (LOS) for weekend versus weekday admissions. PE diagnosis is complex, requiring timely testing and experienced staff who are sometimes unavailable on weekends. Optimal anticoagulation therapy also depends on provider skill.
Study design: Retrospective observational study.
Setting: 186 private Pennsylvania hospitals, January 2000 through November 2002.
Synopsis: Using the Pennsylvania Health Care Cost Containment Council database, the authors reviewed 15,531 records of patients with a primary or secondary PE diagnosis code. The primary outcome was all-cause mortality over 30 days; LOS was the secondary outcome.
Weekend admissions in the highest severity of illness risk class had higher 30-day mortality than weekday admissions. Weekend admissions were significantly more likely than weekday admissions to be clinically unstable and to have abnormal lab parameters. Adjusted for severity of illness risk class, overall mortality was 1.4% higher for weekend versus weekday admissions. All excess mortality came from the sickest group of patients. LOS did not differ.
Less-experienced caregivers or delayed diagnostic testing may play a role in poor outcomes. Patients admitted on weekends might receive delayed care from the first onset of symptoms. This is important because timely therapy has been shown to influence outcomes in acute PE. Reasons for these observed differences should be explored further to help provide more consistent PE management, regardless of admission day.
Bottom line: The sickest patients with PE admitted on weekends experienced small but significantly greater 30-day mortality compared with those admitted on weekdays.
Citation: Aujesky D, Jimenez D, Mor M, Geng M, Fine M, Ibrahim S. Weekend versus weekday admission and mortality after acute pulmonary embolism. Circulation. 2009;119:962-968. TH