Objective:To determine the location of acquisition, timing, and outcomes associated with severe sepsis in community and teaching hospital critical care units. Design:Prospective, observational study. Setting:Twelve Canadian community and teaching hospital critical care units. Patients:All patients admitted between March 17, 2003, and November 30, 2004 to the study critical care units with at least a 24-hr length of stay or severe sepsis identified during the first 24 hrs. Interventions:Daily monitoring for severe sepsis. Measurements and Main Results:We recorded data describing characteristics of patients, infections, systemic responses, and organ dysfunction. Severe sepsis occurred in 1238 patients (overall rate, 19.0%; range, 8.2%–35.3%). Hospital mortality was 38.1% (95% confidence interval [CI]: 35.4–40.8). Median intensive care unit length of stay was 10.3 days (interquartile range: 5.5, 17.9). Variables associated with mortality in multivariable analysis included age (odds ratio [OR] by decade 1.50; 95% CI: 1.36–1.65), acquisition location of severe sepsis (with community as the reference—hospital [OR: 1.69; CI: 1.16–2.46], early intensive care unit [OR: 2.15; CI: 1.42–3.25], late intensive care unit [OR: 2.65; CI: 1.82–3.87]), late intensive care unit (OR: 2.65; CI: 1.82–3.87), any comorbidity (OR: 1.42; CI: 1.04–1.93), chronic renal failure (OR: 2.03; CI: 1.10–3.76), oliguria (OR: 1.34; CI: 1.02–1.76), thrombocytopenia (OR: 2.12; CI: 1.43–3.13), metabolic acidosis (OR: 1.54; CI: 1.13–2.10), Multiple Organ Dysfunction Score (OR: 1.15; CI: 1.09–1.21) and Acute Physiology and Chronic Health Evaluation II predicted risk (OR: 3.75; CI: 2.08–6.76). Conclusion:These data confirm that sepsis is common and has high mortality in general intensive care unit populations. Our results can inform healthcare system planning and clinical study designs. Modifiable variables associated with worse outcomes, such as nosocomial infection (hospital acquisition), and metabolic acidosis indicate potential targets for quality improvement initiatives that could decrease mortality and morbidity.

SOCIETY OF CRITICAL CARE MEDICINE 34TH CRITICAL CARE CONGRESS PHOENIX, ARIZONA, USA JANUARY 15-19, 2005: Poster Presentation: Clinical Science: Sepsis/Inflammation/Infection/Antimicrobial Agents (Adult) III

Background: The provision of nutritional support for patients in intensive care,units (ICUs) varies widely both within and between institutions. We tested the hypothesis that evidence-based algorithms to improve nutritional support in the ICU would improve patient outcomes.Methods: A cluster-randomized controlled trial was performed in the ICUs of,1 1 community and 3 teaching hospitals between. October 1997 and September 1998. Hospital ICUs were stratified by hospital type and randomized to the intervention or control arm. Patients at least 16 years of age with an expected ICU stay of at least 48 hours were enrolled in the study (n = 499). Evidence-based recommendations were introduced in the 7 intervention hospitals by means of in-service education sessions, reminders (local dietitian, posters) and academic detailing that stressed early institution of nutritional support, preferably enteral.Results: Two hospitals crossed over and were excluded from the primary analysis. Compared with the patients in the control hospitals (n = 214), the patients in the intervention hospitals (n = 248) received significantly more days of enteral nutrition (6.7 v. 5.4 per 10 patient-days; p = 0.042), had a significantly shorter mean stay in hospital (25 v. 35 days; p = 0.003) and showed a trend toward reduced mortality (27% v. 37%; p = 0.058). The mean stay in the ICU did not differ between the control and intervention groups (10.9 v. 11.8 days; p = 0.7).Interpretation: Implementation of evidence-based recommendations improved the provision of nutritional support and was associated with improved clinical outcomes.

SOCIETY OF CRITICAL CARE MEDICINE 34TH CRITICAL CARE CONGRESS PHOENIX, ARIZONA, USA JANUARY 15-19, 2005: Poster Presentation: Clinical Science: Sepsis/Inflammation/Infection/Antimicrobial Agents (Adult) I

OBJECTIVES:To examine interobserver reliability of the Acute Physiologic and Chronic Health Evaluation (APACHE) II score and identify major causes of variability in data collection. DESIGN:Descriptive, comparative analysis. SETTING:Nine intensive care units in two teaching and six community hospitals SUBJECTS:A random sample of 342 patient records selected from a network database. INTERVENTION:None. MEASUREMENTS AND MAIN RESULTS:Data were reabstracted and compared with the original records. Individual physiologic points derived from the APACHE II scoring system (instead of the actual physiologic values) were compared using the kappa statistic. Paired measurements of the continuous variables were compared using the interclass correlation coefficient and Bland-Altman plots. Excellent agreement was found in most demographic, admission, and discharge data. The system failure requiring intensive care unit admission was consistently identified by both data collectors in 88% of cases, but only 66% agreed on the exact admitting diagnosis. For APACHE II score components, the kappa statistic ranged from 0.315 for the Glasgow Coma Scale point to 0.976 for the age point. Significant disagreement regarding the probability of death derived from the APACHE II model was evident in some patient records. Overall agreement among groups of patients regarding the APACHE II score was good, however, with no significant difference in the mean score (20.2 vs. 20.1; p = .758). The predicted mortality from the reabstracted data was 30%, similar to the 27% predicted mortality from the original data (p = .380). CONCLUSION:Reliability of data collection varied widely in different components of the APACHE II probability-of-death model. Significant discrepancies in some components suggested a lack of explicit definitions and timing for consistent data collection between institutions or between data collectors. Nonetheless, variability resulting from data collection appears to be randomly distributed, so that comparisons of group means are valid.