The computer knows all in modern medicine. The electronic health record is the new Big Brother, all-seeing, never un-seeing. And it sees “sepsis” – a lot.
This is a report on the downstream effects of an electronic sepsis alert system at an academic medical center. Their sepsis alert system was based loosely on the systemic inflammatory response syndrome for the initial warning to nursing staff, followed by additional alerts triggered by hypotension or elevated lactate. These alerts prompted use of sepsis order sets or triggering of internal “sepsis alert” protocols. Their outcomes of interest in their analysis were length-of-stay and in-hospital mortality.
At first glance, the alert appears to be a success – length of stay dropped from 10.1 days to 8.6, and in-hospital mortality from 8.5% to 7.0%. It would have been quite simple to stop there and trumpet these results as favoring the alerts, but the additional analyses performed by these authors demonstrate otherwise. In the case of both length-of-stay and mortality, both of those measures were trending downward independently regardless of the intervention, and in their adjusted analyses, none of the improvements could be conclusively tied to the sepsis alerts – and some relating to diagnoses of less-severe cases of sepsis probably prompted by the alert itself.
What is not debatable, however, is the burden on clinicians and staff. During their ~2.5 year study period, the sepsis alerts were triggered 97,216 times – 14,207 of which in the 2,144 subsequently receiving a final diagnosis of sepsis. The SIRS-based alerts comprised most (83,385) of these alerts, but only captured 73% of those with an ultimate diagnosis of sepsis, while having only a 13% true positive rate. The authors’ conclusion gets it right:
Our results suggest that more sophisticated approaches to early identification of sepsis patients are needed to consistently improve patient outcomes.
NuVasive, a company based in San Diego, California, is now making available its LessRay radiation dose-reduction system. It consists of a computer cart that connects to an operating room’s fluoroscopy system. The fluoroscope can be set to a lower level of X-ray exposure, and the LessRay, using its proprietary software algorithms, then corrects the image to achieve a quality that would have been produced using a standard exposure. The system is expected to be used particularly during minimally invasive spinal surgical procedures, but should also be applicable in other applications when repeat exposures are required (ERCPs, central lines, etc).
The firm believes that it is the clinicians that will benefit the most from its technology, as people working around fluoroscopes can be irradiated on a nearly daily basis repeatedly, being exposed to levels far beyond that of the general population. According to NuVasive, in a recent study, the exposure was reduced by “between 62 percent and 84 percent …in the LessRay group compared to the conventional fluoroscopy group.”
Here are a few other advances that come with the LessRay, according to the announcement:
C-arm tracking: Simplifies localization and target anatomy quickly, accurately and without the unnecessary fluoroscopy time and scouting images.
Image stitching: Minimizes surgical workflow interruption by quickly stitching together fluoroscopic images of any spine segment.
Angle finder: Minimizes O.R. steps required to obtain crisp endplate shots with fewer fluoroscopic images than traditional C-arm scouting.
Alternate view: Improves visualization by making metal instruments invisible or semi-transparent by fading out their obstruction.
Medtronic won FDA approval and is releasing in the U.S. its Intellis spinal cord neurostimulation platform, which includes the world’s smallest fully implantable spinal cord neurostimulator. The system delivers both high-dose and low-dose therapy, depending on the patient’s needs, and tracks patient activity to help physicians improve how the therapy targets individual’s pain. It is made to wirelessly, and securely, interface with a Samsung Galaxy Tab S2 tablet which is used by the physician to adjust settings and set parameters that best address the patient’s needs. The same tablet can be used to upgrade the neurostimulator implant with new versions of its firmware.
One thing in particular that Medtronic touts is its Overdrive technology, which makes it a reality to recharge the implant from null to full in about an hour. Moreover, the Samsung tablet provides estimates of how long the device will last on a charge based on selected parameters combined with data gathered previously on the patient’s activity levels and pain reduction requirements.
The implant is also safe to wear while inside an MRI machine, given certain conditions and as long as precautions are taken. Even full body scans are possible, so having the device does not limit the patient’s future diagnostic options.
The company hopes that neurostimulation will have an impact on the opioid epidemic that the United States, as well as many other countries, is currently dealing with.