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Home hospital programs continue to grow across the United States. There are limited studies around the process of patient selection and successful acquisition from the emergency department. The article describes how an interdisciplinary team used quality improvement methodology to significantly increase the number of admissions directly from the emergency department to the Advanced Care at Home program.

Abstract Background Early diagnosis, prognostication, and treatment initiation are the cornerstones of sepsis management. There remains an immense interest in exploring the diagnostic and prognostic roles of neutrophil-lymphocyte ratio (NLR) in the sepsis population. Methods We performed a retrospective multi-center observational study including patients admitted to different Mayo Clinic sites with a diagnosis of sepsis between October 2018 and August 2022. Patients were excluded if they were aged < 18 years, lacked research authorization, or had missing Neutrophil or Lymphocyte count at admission. Data were collected from an existing sepsis database and Mayo Data Explorer (MDE). Categorical variables were summarized as percentages and continuous variables were summarized as medians. Chi-square test for significance, independent sample t-test, and multivariate Cox Proportional Hazard models were performed on IBM SPSS Statistics v28.0. Results Our study cohort consisted of 13968 patients, of which the majority were males (55.9%), Caucasian (91.6%), and non-Hispanic or Latino (94.3%). The median age of the cohort was 71 (60, 80) years, and the median BMI was 27.7 (23.4, 33.3) kg/m2. Among all sepsis patients, 6.0% had a positive blood culture and the most common organisms were E. coli (26.5%), Klebsiella sp. (15.6%), Streptococcus sp. (12.8%) and Staphylococcus aureus (9.9%). 13131 patients (94.1%) survived the hospital stay and 837 (5.9%) did not. There was no difference in mortality based on blood culture positivity status (6.0% vs 6.6%, p=0.41). However, the median NLR was higher among patients with a positive blood culture (16.4 vs. 12.1, p< 0.001) and among non-survivors (14.3 vs 12.2, p< 0.001). NLR did not significantly vary based on the type of organism growing in the blood culture. A multivariate model revealed NLR as an independent predictor of mortality (HR 1.003, 95% CI: 1.000-1.006, p=0.029) after adjusting for comorbidities, baseline clinical and laboratory variables. (Tables 1 & 2) Conclusion Our retrospective multicentric study showed that the Neutrophil-Lymphocyte ratio at admission was higher among bacteremic sepsis patients and non-survivors. Further prospective studies are needed to explore its diagnostic and prognostic utility. Disclosures All Authors: No reported disclosures

IMPORTANCE: Aggressive fluid resuscitation remains a cornerstone of the Surviving Sepsis Campaign (SSC) guidelines, but there is growing controversy regarding the recommended 30 mL/kg IV fluid dosage. It is contended that, in selected patients, this volume confers an increased risk of volume overload without either concomitant benefit or strong evidence in support of the recommended IV fluid dosage. OBJECTIVES: Assessment of practice patterns and their impact on patient outcomes following the surviving sepsis guidelines for fluid resuscitation. DESIGN: Large, multisite retrospective cohort study. SETTING AND PARTICIPANTS: The retrospective study included all adult patients who presented to the emergency department at one of 19 different Mayo Clinic sites throughout the Midwest, Southeast, and Southwest from August 2018 to November 2020 with suspected sepsis. MAIN OUTCOMES AND MEASURES: Eight-thousand four-hundred fourteen patients suspected to have sepsis were assessed regarding fluid resuscitation and outcomes among patients receiving 30 mL/kg IV fluid dosing compared with patients who did not. Patient demographics and clinical information were collected via electronic health records. Patients were divided into two cohorts: those who received 0–29.9 mL/kg of IV fluid and those who received 30.0+ mL/kg of IV fluid. Statistical analyses were performed to evaluate the impact of fluid dose on in-hospital death, 30-day mortality, ICU admission after diagnosis, dialysis initiation after diagnosis, ventilator use, vasopressor use, as well as ICU and hospital length of stay. RESULTS: We observed lower in-hospital mortality and 30-day mortality risk in the 30+ mL/kg dosing group. Increased fluid dosage did, however, carry a much greater chance of ICU admission. Most patients (72% after propensity score weighting) in our population received less than 30 mL/kg fluid (based on ideal body weight). CONCLUSIONS AND RELEVANCE: IV fluid dosing for sepsis resuscitation greater than 30 mL/kg was associated with decreased risk of in-hospital mortality, 30-day mortality, and reduced risk of requiring mechanical ventilation. Our data does ultimately seem to support the SSC recommendation.

ABSTRACT The coronavirus disease 2019 (COVID-19) pandemic has required swift implementation of innovative practices in health care across the globe. We describe a nurse practitioner (NP) and physician assistant (PA)–led initiative to implement telemonitoring (TM) of noncritical patients with COVID-19 by critical care NPs and PAs (C19TM) for early detection of decompensation and early transfer to the intensive care unit (ICU). Every hospitalized patient with suspected or confirmed COVID-19 received an initial telemedicine consult with a critical care NP or PA. Patients were subsequently monitored via electronic health record once every 12-hour shift for the following indicators: oxygen modality and flow, increase in oxygen requirements, sustained tachypnea, and hemodynamic instability. If signs of decompensation were noted, the NP/PA would remotely reassess the patient, provide recommendations to the hospital internal medicine team, and transfer the patient to the ICU. The primary goal was to avoid cardiopulmonary deterioration requiring aerosol-generating procedures outside of the ICU. Over 65 days, 113 patients (86 suspected and 27 confirmed) were enrolled in C19TM. As a result, there were 13 transfers to the ICU, none of which required an aerosol-generating procedure outside of the ICU.