The sepsis alert developed at Barnes-Jewish Hospital was shown to increase early therapeutic and diagnostic interventions among nonintensive care unit patients at risk for sepsis.

IntroductionThe assessment of volume responsiveness and the decision to administer a fluid bolus is a common dilemma facing physicians caring for critically ill patients. Static markers of cardiac preload are poor predictors of volume responsiveness, and dynamic markers are often limited by the presence of spontaneous respirations or cardiac arrhythmias. Passive leg raising (PLR) represents an endogenous volume challenge that can be used to predict fluid responsiveness.MethodsMedical intensive care unit (ICU) patients requiring volume expansion were eligible for enrollment. Non-invasive measurements of stroke volume (SV) were obtained before and during PLR using a transthoracic Doppler ultrasound device prior to volume expansion. Measurements were then repeated following volume challenge to classify patients as either volume responders or non-responders based on their hemodynamic response to volume expansion. The change in SV from baseline during PLR was then compared with the change in SV with volume expansion to determine the ability of PLR in conjunction with SV measurement to predict volume responsiveness.ResultsA total of 102 fluid challenges in 89 patients were evaluated. In 47 of the 102 fluid challenges (46.1%), SV increased by ≥15% after volume infusion (responders). A SV increase induced by PLR of ≥15% predicted volume responsiveness with a sensitivity of 81%, specificity of 93%, positive predictive value of 91% and negative predictive value of 85%.ConclusionsNon-invasive SV measurement and PLR can predict fluid responsiveness in a broad population of medical ICU patients. Less than 50% of ICU patients given fluid boluses were volume responsive.

BACKGROUND:Hospitalized patients who develop severe sepsis have significant morbidity and mortality. Early goal‐directed therapy has been shown to decrease mortality in severe sepsis and septic shock, though a delay in recognizing impending sepsis often precludes this intervention.OBJECTIVE:To identify early predictors of septic shock among hospitalized non‐intensive care unit (ICU) medical patients.DESIGN:Retrospective cohort analysis.SETTING:A 1200‐bed academic medical center.PATIENTS:Derivation cohort consisted of 13,785 patients hospitalized during 2005. The validation cohorts consisted of 13,737 patients during 2006 and 13,937 patients from 2007.INTERVENTION:Development and prospective validation of a prediction model using Recursive Partitioning And Regression Tree (RPART) analysis.METHODS:RPART analysis of routine laboratory and hemodynamic variables from the derivation cohort to identify predictors prior to the occurrence of shock. Two models were generated, 1 including arterial blood gas (ABG) data and 1 without.RESULTS:When applied to the 2006 cohort, 347 (54.7%) and 121 (19.1%) of the 635 patients developing septic shock were correctly identified by the 2 models, respectively. For the 2007 patients, the 2 models correctly identified 367 (55.0%) and 102 (15.3%) of the 667 patients developing septic shock, respectively.CONCLUSIONS:Readily available data can be employed to predict non‐ICU patients who develop septic shock several hours prior to ICU admission. Journal of Hospital Medicine 2010;5:19–25. © 2010 Society of Hospital Medicine.

The implementation of a hospital-wide standardized order set for the management of bacteremic severe sepsis was associated with greater fluid administration, improved antibiotic therapy, decreased incidence of organ failure, and improved survival.