Improving Outcomes in Severe Sepsis and Septic Shock: Results of a Prospective Multicenter Collaborative (original) (raw)
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The GENESIS Project (GENeralized Early Sepsis Intervention Strategies)
Journal of Intensive Care Medicine, 2012
Background: Improved outcomes for severe sepsis and septic shock have been consistently observed with implementation of early best practice intervention strategies or the 6-hour resuscitation bundle (RB) in single-center studies. This multicenter study examines the in-hospital mortality effect of GENeralized Early Sepsis Intervention Strategies (GENESIS) when utilized in community and tertiary care settings. Methods: This study was comprised of 2 strategies to assess treatment. The first was a prospective before-and-after observational comparison of historical controls to patients receiving the RB after implementation of GENESIS in 4 community and 4 tertiary hospitals. The second was a concurrent examination comparing patients not achieving all components of the RB to those achieving all components of the RB in 1 community and 2 tertiary care hospitals after implementation of GENESIS. These 4 subgroups merged to comprise a control (historical controls treated before GENESIS and RB n...
Early Goal-Directed Therapy: Improving Mortality and Morbidity of Sepsis in the Emergency Department
The Joint Commission Journal on Quality and Patient Safety, 2009
C arolinas Medical Center (CMC), located in Charlotte, North Carolina, is the flagship hospital of Carolinas HealthCare System (CHS), the third-largest health care system in the United States. With more than 800 beds, this public, not-for-profit, tertiary and Level 1 trauma center supports various residency programs, as well as numerous large multispecialty private medical groups. CMC is the only indigent-care hospital in Charlotte, providing care for more than 1 million patients annually. The emergency department (ED) evaluates more than 100,000 patients each year. The high acuity of illness of those presenting in the ED results in an annual admission rate of approximately 14% of all visits. Of these admissions, approximately 1% are due to septicemia, the incidence of which, following national estimates, is projected to increase by 1.5% each year. 1 The implementation of early goal-directed therapy (EGDT) on November 15, 2005, for the treatment of severe sepsis/septic shock in the ED was a priority to potentially reduce morbidity and mortality in our patients with sepsis. Before we implemented the EGDT protocol, our in-hospital mortality rate for those patients presenting in the ED was approximately 27%, in contrast with the 30% mortality rate reported in national studies. 1,2 Because approximately 50% of our hospital sepsis cases originated in the ED, a significant number of lives could be saved by initiating an effective intervention. Methods CODE SEPSIS TASK FORCE Following Institutional Review Board approval, CMC's ED physicians began identifying and tracking patients who presented with symptoms of severe sepsis or septic shock in August 2004. A code sepsis task force composed of ED, ICU, internal medicine, and infectious disease physicians; ED and ICU nurses; and a pharmacist was formed to address the following objectives: 1. Critically evaluate the evidence supporting EGDT 2. If evidence supports this therapy, develop an acceptable Article-at-a-Glance Background: The growing number of patients with severe sepsis or septic shock and the resulting mortality rate (30%) require changes in the current protocols used to treat these conditions. Through adaptation of early goal-directed therapy (EGDT), Carolinas Medical Center developed a process improvement strategy for decreasing mortality associated with severe sepsis and septic shock. Before implementing the EDGT protocol, the ED did not follow a written management protocol for septic patients. Methods: Following establishment of an interdisciplinary team, several process improvement activities were conducted, including the development of a standardized algorithm and treatment protocol, a physician order sheet, a nursing flow sheet, and a code sepsis response team. Results: A total of 381 patients were enrolled: 79 in the pre-intervention phase and 302 in the postintervention phase. Mortality rates decreased from 27% pre-intervention to 19% postintervention (-8% absolute mortality; 95% confidence interval [C.I.], 7-9; p = .2138). There were significant differences between the pre-and postintervention groups for endotracheal intubation (17%, p = .0012), crystalloid infusion (1.4 L, p < .0001), vasopressor administration (33%, p < .0001), and packed red blood cells (34%, p < .0001). Both groups were generally similar in their demographics, comorbidities, and vital signs. Discussion: As a result of this process improvement initiative, patients who might have received delayed and/or inadequate treatment for severe sepsis or septic shock are now receiving effective, life-saving treatment. Because of the emphasis on training, consistency in applying the protocol, relatively few changes in current ED practice, and low direct expenditures for equipment, the protocol can be easily integrated into existing ED environments to allow hospitals to quickly implement this successful, best-practice program.
Critical Care Medicine, 2007
P atients suffering from severe sepsis or septic shock have a mortality rate of 20 -54% (1-3). Among the 751,000 annual cases of severe sepsis in the United States, approximately 458,200 cases (or 61%) are first encountered in the emergency department (ED) (1, 4). Early appropriate antibiotics (5-7), early goal-directed therapy Objective: The purpose of this study was to examine the outcome implications of implementing a severe sepsis bundle in an emergency department as a quality indicator set with feedback to modify physician behavior related to the early management of severe sepsis and septic shock.
Academic Emergency Medicine, 2007
The research in the management of severe sepsis and septic shock has resulted in a number of therapeutic strategies with significant survival benefits. These results also emphasize the primary importance of early hemodynamic resuscitation, or early goal-directed therapy (EGDT), and place the emergency physician in the center of the multidisciplinary team caring for patients with this disease. However, in a busy emergency department, the translation of research into clinical practice is far from ideal. While the benefits are significant, the successful implementation of EGDT is filled with challenges and obstacles. In this article, we will discuss the steps taken at our institution to create, implement, measure, and improve on a six-hour severe sepsis and septic shock treatment bundle incorporating EGDT in the emergency department setting, resulting in significant mortality benefit.
The Ochsner journal, 2013
Sepsis, an inflammatory response to an infection that may lead to severe organ dysfunction and death, is the leading cause of death in medical intensive care units. The Society of Critical Care Medicine has issued guidelines and promoted protocols to improve the management of patients with severe sepsis and septic shock. Generally, the medical community has been slow to adopt these guidelines because of the system challenges associated with protocol implementation. We describe an interdisciplinary team approach to the development and implementation of management protocols for treating patients with severe sepsis and septic shock. To determine the effectiveness of the bundled emergency department and critical care order sets developed by the Sepsis Steering Committee, we performed a case review of 1,105 sequential patients admitted to a large academic tertiary referral hospital with a diagnosis of severe sepsis or septic shock between July 2008 and January 2012. Implementation of the...
The Joint Commission Journal on Quality and Patient Safety, 2015
Background-Sepsis is a leading cause of death, but evidence suggests that early recognition and prompt intervention can save lives. In 2005 Houston Methodist Hospital prioritized sepsis detection and management in its ICU. In late 2007, because of marginal effects on sepsis death rates, the focus shifted to designing a program that would be readily used by nurses and ensure early recognition of patients showing signs suspicious for sepsis, as well as the institution of prompt, evidence-based interventions to diagnose and treat it. Methods-The intervention had four components: organizational commitment and data-based leadership; development and integration of an early sepsis screening tool into the electronic health record; creation of screening and response protocols; and education and training of nurses. Twicedaily screening of patients on targeted units was conducted by bedside nurses; nurse practitioners initiated definitive treatment as indicated. Evaluation focused on extent of implementation, trends in inpatient mortality, and, for Medicare beneficiaries, a before-after (2008-2011) comparison of outcomes and costs. A federal grant in 2012 enabled expansion of the program. Results-By year 3 (2011) 33% of inpatients were screened (56,190 screens in 9,718 unique patients), up from 10% in year 1 (2009). Inpatient sepsis-associated death rates decreased from 29.7% in the preimplementation period (2006-2008) to 21.1% after implementation (2009-2014). Death rates and hospital costs for Medicare beneficiaries decreased from preimplementation levels without a compensatory increase in discharges to postacute care. Conclusion-This program has been associated with lower inpatient death rates and costs. Further testing of the robustness and exportability of the program is under way. * Sepsis International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code (0.38.0-038.9; 995.91; 995.92; or 758.52) in any diagnosis field of Uniform Billing Form 04, first six months of 2008 (preimplementation; baseline period) and first six months of 2011 (postimplementation; comparison period). Data are drawn from hospital claims databases. † Discharge destination was unknown for three survivors in 2008.
Critical Care Medicine, 2019
Objectives: Assess patient outcomes in patients with suspected infection and the cost-effectiveness of implementing a quality improvement program. Design, Setting, and Participants: We conducted an observational single-center study of 13,877 adults with suspected infection between March 1, 2014, and July 31, 2017. The 18-month period before and after the effective date for mandated reporting of the sepsis bundle was examined. The Sequential Organ Failure Assessment score and culture and antibiotic orders were used to identify patients meeting Sepsis-3 criteria from the electronic health record. Interventions: The following interventions were performed as follows: 1) multidisciplinary sepsis committee with sepsis coordinator and data abstractor; 2) education campaign; 3) electronic health record tools; and 4) a Modified Early Warning System. Main Outcomes and Measures: Primary health outcomes were in-hospital death and length of stay. The incremental cost-effectiveness ratio was calc...