Hi, everyone, and thank you for coming today. So again, I have no conflict of interest to disclose for today's presentation. And as we might have mentioned earlier, we've been asked to do this using the flipped classroom, which requires an active role for the participants. So we will have some questions throughout the presentation and one activity that requires you to do some group work, but we'll see. So we were able to find two studies that were published last year by nursing authors. And we chose those studies, again, as Elena mentioned, because of the methodological strength. And both of those studies were actually looking at the epidemiology and the outcomes of sepsis. It's important to share the learning outcome, because the way flipped classroom works is that you set your learning outcomes, your activities, and then you add your content. So we have three learning outcomes. The major learning outcomes are two and three. So basically, we need to be able to analyze the methodological strengths and weaknesses in those studies. And we also wanted to be able to develop implications for the presented evidence. So this is the first study that was published by a group of researchers from Harvard University. And the group was led by a nurse, who's Mohammad Rawajdeh. He has a joint appointment at the Harvard University as well as University of Technology in Jordan. This was published in Critical Care Medicine in 2021. And the aim of this study was to investigate the epidemiology and the outcomes of sepsis patients admitted with opioid abuse. And I find this is an interesting kind of topic. I wasn't really familiar with this area. But it's interesting, the combination of opioid abuse and sepsis. This was a retrospective cohort study. And they collected data from 373 hospitals in the US. And the data were collected between 2009 and 2015. So those are the databases that they collected the data from. So they included Cerner, Health Facts, Institute of Health Metrics, as well as HCA Healthcare. So let's talk about measurements. So the primary independent variables in this study, so it was sepsis against outcomes, right? So sepsis is one of the primary independent variables in this study. And they define sepsis by two criteria. The first criteria, as you see here, is the indicators of infection. And this was indicated by an order for blood culture in addition to a commencement of antibiotics for four or more days or within one day of death. So that was the first criteria, so blood culture or antibiotic. The second criteria, which was a concurrent organ dysfunction, and this was indicated by the initiation of vasopressors or mechanical ventilation or the increase in lactate or the increase in bilirubin, creatinine, or decrease in platelets. So they had strict criteria for the definition of sepsis. The second independent variable in this study was opioid. And remember, this was a retrospective study. So they collected the data from the data sets. They didn't really recruit patients. So they extracted the opioid-related diagnoses from the Medicare records using the ICD-9 codes. But they defined opioid abuse as drug poisoning related to opioid or opium or heroin, opioid analgesics or opioid adverse effects, or opioid abuse or dependence. So the first question is about methodology. And this speaks to our second learning outcome. So what is the major methodological strength in this study? Is it A, it addressed a significant problem? B, it was endorsed by the CDC? C, it was a population-based study? And D, it utilized a cohort design? So let's see who would vote for A. All right. Who would vote for B? OK, how about C? C, maybe? Then D? OK, so it's actually C. It was a population-based study. And that's the reason why we've chosen this study. And you'll see in the results, they recruited more than 6 million patients, or they collected data from more than 6 million patients. And this is a very robust evidence and research. But A has nothing to do with the design, right? So it's the questions about the design, right? Two, that has nothing to do with the design. D has something to do with the design, but cohort isn't really experimental, right? It's only observational. So the answer is C. Now, let's go to the finding. And this is a very busy slide. And to be honest with you, it can be a bit confusing, because we will talk about sepsis or sepsis death in patients admitted for opioid abuse, and opioid death in patients admitted for sepsis abuse. It might be a bit, sorry, for sepsis diagnosis. So it might be a bit confusing to look at the results. But let's try to go through them or walk through them. So as you see here, there was more than six, the data was collected from more than 6 million and 700,000 patients. It's a lot of data here. And as you see here also, there were more than 375,000 patients admitted with sepsis-related diagnoses. Whereas there was more than 130,000 patients admitted with opioid-related diagnoses. On the other hand, there was 8,764 patients admitted with both sepsis and opioid diagnoses. So it was 0.1% of the entire sample. Interestingly, in the middle here, we have the hospital mortality rate for patients who were admitted with sepsis and opioid diagnoses versus patients who were admitted with sepsis without opioid. So interestingly, the mortality rate was 10% for those who were admitted with sepsis and opioid compared to 16% for those who were admitted with sepsis but with no opioid abuse. So that's interesting. You would probably expect the other way, but I think the patient population in the... Looks like the opioid abusers are younger. That's why they had a lower percentage of mortality. This is the percentage of opioid death in patients who were admitted because of sepsis. And it was 51%, that's a lot of patients. So almost half of those who are admitted because of sepsis and they're opioid abusers, they die because of opioid. Those are the percentages of sepsis death in patients who were admitted because of opioid abuse. And the results here were dependent on age. So in the younger patient population, it was 5.7% in those who are less than 50 years of age compared to 1% in those who are 50 or more. Interestingly enough also, from 2009 to 2015, the percentage of sepsis hospitalizations that were opioid related increased by 77%. So that's a lot, that's a lot. That's actually increased the burden on healthcare systems and of course not so good for the patient outcomes. So as you see here, there was a 77% increase from 2009 to 2015. So we talked about this already. What's interesting about this graph is the bottom line here, which represents the fraction of patients who received perbinorphine, which is a medication used to treat opioid abuse or opioid disorders. So despite the increase in the opioid abuse and opioid related admission, as you see here, the percentage of those patients who received perbinorphine wasn't really great. So that was interesting to see. Now, this is the time for our activity. It's not a question. So this is something that we've never tried. And to be honest with you, I was talking to Lynn before the presentation. We're not sure if it's gonna work, but we will have to try or otherwise we will not know. So what we will need to do, next slide will include the QR code. You can pull your phone, scan the QR code, and you will be taken to a website called Padlet. It would be ideal if you can collaborate with the people that you're sitting next to, maybe pairs, and then ask your colleague and try to think about the implications for this study on your practice. So this is the QR code. I can't show the Padlet website on the screen here, but you will find inside the Padlet, you will find boxes, and you can add sections. So you can add your name or your nickname on top, and then you can add the answer at the bottom. And I'm happy to come down and take a look. But you can scan the QR code, and probably we'll spend maybe five minutes on this. So maybe, Jose, if you can set up the timer for five minutes, it would be great. So basically, implications, one or two, let's just make it quick. And hopefully, so you can always add sections. So I added two sections or three sections. You can add sections. There is a plus sign on your right side. You can click on the three dots to edit the name of the section or the name for the answers. So, I can see Teresa, Jen, Lindsey, they've started to post. That's great. But it would be ideal to have a column for each one of you guys. So, the top would be your name, the bottom would be your answer, and then you can add column on the right. So, there is an option that you can, if you scroll to the left, you will find an option called add section. I can see Elisa did that. That's amazing. Excellent. Elisa, at the bottom of your name, there's a plus sign. If you click there, you can add a box where you can add your answer. So, basically, one or two implications for Rebecca as well. I can see this in real time. It would be really nice to have it on the big screen, but we can't exit the PowerPoint. Implications for your practice based on these findings. So, there was an increase in the percentage of patients who are dying because of opioid and sepsis. Remember, small patients or a small fraction of patients received peripnorphine. Those are the findings. So, what kind of implications do you think you can have for your practice? I can see Brian, AC. Excellent. So, for those of you guys who added their name, there is a plus sign under your name. You can add that to add your answer. Again, one or two implications. It would be ideal to discuss these implications with the person that sits next to you. You don't have to, but that would be ideal. Okay, I have a very interesting answer here. Opioid patients have nine lives. Very interesting. Very good implication. And you can see the answers, by the way. You can see the answers in your mobile phone as well. One minute? Okay, so we have one minute left. And if you can just post a quick answer, it would be appreciated. I can give you a hint. So, for example, for those patients who are admitted with sepsis and opioid abuse and did not receive enough peripnorphine, does that make you think about any implication about the treatment of opioid and sepsis? Okay. Yeah, that's the hypothesis. That's the hypothesis. Yeah, I should have added this in the background, but thanks for asking. This is hard, sort of hard to figure out. Yeah, maybe. Older patients with opioid use and sepsis are at higher risk of death. Yeah, but how does that translate into the practice? What should we do based on this kind of finding? Time's up? All right. Time is up, and let's see. So, we have Megan. She posted more than a couple of answers. All right. That was excellent, Megan. That was excellent. So, she had some questions, but better awareness for inappropriate opioid use and community education on reversal agents to prevent aspiration and sepsis. Yeah? Interesting. I think I've seen in Copenhagen, in Denmark, in Europe, they have, interestingly enough, they have rooms for drug addicts where they can use sterile needles. I think that would be something. Really? Okay, I didn't know that. Interesting. But that would be some of the things that we might think. If they're going to use drugs anyways, then… And by the way, the studies showed that… You might be surprised to hear this. I was surprised when I heard it. But studies showed that providing sterile needles does not increase the rate of drug abusers. It just decreases the rate of infectious diseases. All right. Thank you, guys. Thank you very much.

epidemiology

sepsis

opioid abuse

mortality rate

harm reduction strategies