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BACKGROUND:Variation in the use of ICUs for low-risk conditions contributes to health system inefficiency. We sought to examine the relationship between ICU use for patients with pulmonary embolism (PE) and cost, mortality, readmission, and procedure use. METHODS:We performed a retrospective cohort study including 61,249 adults with PE discharged from 263 hospitals in three states between 2007 and 2010. We generated hospital-specific ICU admission rate quartiles and used a series of multilevel models to evaluate relationships between admission rates and risk-adjusted in-hospital mortality, readmission, and costs and between ICU admission rates and several critical care procedures. RESULTS:Hospital quartiles varied in unadjusted ICU admission rates for PE (range, ≤ 15% to > 31%). Among all patients, there was a small trend toward increased use of arterial catheterization (0.6%-1.1%,P< .01) in hospital quartiles with higher levels of ICU admission. However, use of invasive mechanical ventilation (14.4%-7.9%,P< .01), noninvasive ventilation (6.6%-3.0%,P< .01), central venous catheterization (14.6%-11.3%,P< .02), and thrombolytics (11.0%-4.7%,P< .01) in patients in the ICU declined across hospital quartiles. There was no relationship between ICU admission rate and risk-adjusted hospital mortality, costs, or readmission. CONCLUSIONS:Hospitals vary widely in ICU admission rates for acute PE without a detectable impact on mortality, cost, or readmission. Patients admitted to ICUs in higher-using hospitals received many critical care procedures less often, suggesting that these patients may have had weaker indications for ICU admission. Hospitals with greater ICU admission may be appropriate targets for improving efficiency in ICU admissions.

Sepsis most often presents to the ED, and delayed detection is harmful. WBC count is often used to detect sepsis, but changes in WBC count size also correspond to sepsis. We sought to determine if volume increases of circulating immune cells add value to the WBC count for early sepsis detection in the ED.A blinded, prospective cohort study was conducted in two different ED populations within a large academic hospital.Neutrophil and monocyte volume parameters were measured in conjunction with routine CBC testing on a UniCel DxH 800 analyzer at the time of ED admission and were evaluated for the detection of sepsis. There were 1,320 subjects in the ED consecutively enrolled and categorized as control subjects (n = 879) and those with systemic inflammatory response syndrome (SIRS) (n = 203), infection (n = 140), or sepsis (n = 98). Compared with other parameters, monocyte distribution width (MDW) best discriminated sepsis from all other conditions (area under the curve [AUC], 0.79; 95% CI, 0.73-0.84; sensitivity, 0.77; specificity, 0.73; MDW threshold, 20.50), sepsis from SIRS (AUC, 0.74; 95% CI, 0.67-0.84), and severe sepsis from noninfected patients in the ED (AUC, 0.88; 95% CI, 0.75-0.99; negative predictive value, 99%). The added value of MDW to WBC count was statistically significant (AUC, 0.89 for MDW + WBC vs 0.81 for WBC alone; P .01); a decision curve analysis also showed improved performance compared with WBC count alone.The incorporation of MDW with WBC count is shown in this prospective cohort study to improve detection of sepsis compared with WBC count alone at the time of admission in the ED.ClinicalTrials.gov; No.: NCT02232750; URL: www.clinicaltrials.gov.

Background Sepsis is a major public health problem. Social factors may affect health behaviors, economic resources, and immune response, leading to hospitalization for infection. This study examines the association between marital status and sepsis incidence and outcomes in a population-based cohort. Methods We analyzed 1,113,581 hospitalizations in New Jersey in 2006. We estimated risk-adjusted incidence rate ratios (IRRs) for sepsis among divorced, widowed, legally separated, single, and married subjects using population data from the American Community Survey. We used multivariable logistic regression to estimate marital status-specific hospital mortality. Results We identified 37,524 hospitalizations for sepsis, of which 40% were among married (14,924), 7% were among divorced (2,548), 26% were among widowed (9,934), 2% (763) were among legally separated, and 26% (9355) were among single subjects. The incidence of hospitalization for sepsis was 5.8 per 1,000 population. The age, sex, and race-adjusted IRR for hospitalization with sepsis was greatest for single (IRR = 3.47; 95% CI, 3.1, 3.9), widowed (IRR = 1.38; 95% CI, 1.2, 1.6), and legally separated (IRR = 1.46; 95% CI, 1.2, 1.8) subjects compared with married (referent). We observed that single men and women and divorced men had greater odds of in-hospital mortality compared with married men; widowed and legally separated men and all ever-married women had no excess mortality during hospitalization for sepsis. Conclusions Hospitalization for sepsis is more common among single, widowed, and legally separated individuals, independent of other demographic factors. Among patients hospitalized for sepsis, single and divorced men and single women experience greater hospital mortality, highlighting the need to characterize the potentially modifiable mechanisms linking marital status to its greater burden of critical illness.

Study objectives: To determine if minute ventilation ( e ) measured as a trend following the final weaning trial prior to extubation may identify patients ready for extubation and be useful as a predictive measure of extubation outcome. Design: Prospective observational study. Setting: Community hospital medical/surgical ICU. Patients: Sixty-nine patients receiving mechanical ventilation enrolled in an ICU weaning protocol who underwent planned extubation during 6 months of prospective evaluation. The failed extubation group included patients reintubated within 7 days. Patients were excluded if they received ventilation by noninvasive mask, bilevel positive airway pressure, tracheostomy, or were self-extubated. Interventions: Patients tolerating a spontaneous breathing trial (SBT) and ready for planned extubation were placed back on their pre-SBT ventilator settings for up to 25 min, during which respiratory parameters were recorded. Respiratory parameters (respiratory rate, tidal volume, e , rapid shallow breathing index [ f /V t ]) were obtained at three time points: baseline (pre-SBT), posttrial (immediate conclusion of SBT), and recovery (return to baseline). Patients were assumed to recover when e decreased to 110% of the predetermined baseline. Measurements and results: Fifty-nine patients were successfully extubated, and 10 patients required reintubation after 2.5 ± 2.6 days (mean ± SD). Both groups were similar in age, comorbid status, primary diagnosis, APACHE (acute physiology and chronic health evaluation) II score, mode of weaning, and SBT length (p > 0.1). Respiratory parameters measured were similar at all three time points studied (p > 0.1). e recovery time of successful extubations was significantly shorter than failed extubations (3.6 ± 2.7 min vs 9.6 ± 5.8 min, p e recovery time was an independent predictor of extubation outcome (p e recovery time (0.85 ± 0.07) was larger than that for baseline e , posttrial e , posttrial f /V t , or Pa co 2 . Conclusions: e recovery time is an easy-to-measure parameter that may assist in determining respiratory reserve. Preliminary data demonstrates that it may be a useful adjunct in the decision to discontinue mechanical ventilation.