Decreasing Mortality in Severe Sepsis and Septic Shock Patients by Implementing a Sepsis Bundle in a Hospital Setting (original) (raw)
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Six-hour sepsis bundle decreases mortality: Truth or illusion – A prospective observational study
Indian Journal of Critical Care Medicine
IntroductIon Sepsis is a systemic, deleterious host response to infection leading to severe sepsis and septic shock. Severe sepsis and septic shock are major health-care problems, affecting millions of people around the world each year, killing one in four (and often more), and increasing in incidence. [1-5] According to the World Health Organization estimates, sepsis accounts for 60%-80% of lost lives per year in childhood. [6] Similar to polytrauma, acute myocardial infarction or stroke, the speed and appropriateness of therapy administered in the initial hours after severe sepsis develops are likely to influence outcome. The recommendations of surviving sepsis campaign (SSC) guidelines are intended to provide guidance for the clinician caring for a patient with severe sepsis or septic shock. The outcome improvement can be made through education and process change by SSC guidelines for those caring for severe sepsis patients in the intensive care unit (ICU) and non-ICU settings across the spectrum of acute care. [7] In 2004, the SSC endorsed the early goal-directed therapy for the management of severe sepsis and septic shock. It was aimed at obtaining a 25% reduction in mortality over the following 5 years in patients with septic shock worldwide. [8,9] These guidelines have been summarized by the SSC in sepsis bundles, which represent key elements of care regarding the diagnosis and treatment of patients with septic shock. [10] The Institute for the SSC provides in 2004 two bundles for septic shock patients: The 6-h resuscitation bundle and the 24-h management bundle (http://www.ihi.org/IHI/Topics/ CriticalCare/Sepsis). Many studies showed that implementation of 6-h resuscitation and 24-h management sepsis bundles decreased crude in-hospital or day 28 mortality, reduced the length of stay (in hospital/ICU), reduced the cost of care and Aim: The aim of the study is to evaluate whether 6-h sepsis bundle component compliance (complete vs. incomplete) decreases mortality in pediatric patients with severe sepsis and septic shock. Methodology: The study was conducted at a tertiary care hospital. Patients aged 1 month-13 years admitted to pediatric intensive care unit with severe sepsis, or septic shock were prospectively enrolled. The clinical data and blood investigations required for sepsis bundle were recorded. Predicted mortality was calculated at admission by the online pediatric index of mortality-2 (PIM-2) score calculator. Patients who fulfilled all the components of 6-h sepsis bundle were taken as compliant while failure to fulfill even a single component rendered them noncompliant. The outcome was recorded as died or discharged. Results: Of 116 patients, 90 (77.59%) had 100% sepsis bundle component compliance and were taken into the compliant group while the rest 26 (22.41%) were noncompliant. Forty out of 90 patients (44.4%) died in compliant group in comparison to 5 out of 26 (19.3%) in noncompliant group, P = 0.020. The pre-and post-interventional lactates were significantly higher in compliant group as compared to the noncompliant group, P < 0.0001 and 0.019, respectively. Rising lactate level parallels increasing predicted mortality by PIM-2 score in compliant group, but this association failed to reach significance in noncompliant group which can be attributed to less number of subjects available in this group. Conclusion: Irrespective of sepsis bundle compliance (complete/incomplete), outcome depends on the severity of illness reflected by high lactate and predicted mortality.
CHEST Journal, 2012
ABSTRACT SESSION TYPE: Sepsis/ShockPRESENTED ON: Sunday, October 21, 2012 at 10:30 AM - 11:45 AMPURPOSE: Effect of improved compliance to 6-hour sepsis resuscitation bundle and mortality reduction in severe sepsis and septic shock patients.METHODS: Quasi-experimental prospective study conducted at 10- bedded combined medical and surgical ICU. The historical group included all consecutive patients with severe sepsis and septic shock admitted from January 2008 to March 2009. Intervention included evidence based written sepsis pathway, antibiotic recommendations and educational program. Post-intervention group included all consecutive patients admitted from July 2009 to June 2011. The primary outcome measures were the overall compliance to seven 6-hour sepsis resuscitation bundle elements and 30-day hospital mortalityRESULTS: There were 99 patients in historical group and 199 in post-intervention group. The baseline patients' characteristics were similar. Overall compliance to all seven sepsis resuscitation bundle elements in historical group was 5.1% (95% CI, 2.1% - 11.3%) which improved after intervention to 23.6% (95% CI, 17.9% - 30.1 %); p < 0.001. Also, overall compliance was related to improved survival [OR 5.8 (95% CI, 2.2 - 15.1; p < 0.001)]. 30-day hospital mortality reduced from 31.3% to 21.1%; p = 0.05.CONCLUSIONS: Our intervention significantly improved compliance to 6-hour sepsis resuscitation bundle and reduction in 30-day hospital mortality.CLINICAL IMPLICATIONS: All efforts should be made to comply and improve 6-hour sepsis resuscitation bundle in patients with severe sepsis and septic shock to decrease the mortality.DISCLOSURE: The following authors have nothing to disclose: Javed Memon, Rifat Rehmani, Abdulsalam Alaithan, Ayman Al-Gammal, Talib Lone, Khaled Ghorab, Abdulsaboor BasiratNo Product/Research Disclosure InformationKing Abdulaziz National Guard Hospital, Al Ahsa, Saudi Arabia.
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.
Critical Care, 2010
Introduction To evaluate the impact of compliance with a core version of the Surviving Sepsis Campaign 6-hour bundle on 28 days mortality. Methods Cohort, multi-centre, prospective study on community-acquired sepsis (CAS). Results Seventeen intensive care units (ICU) entered the study. Over a one year period, 4,142 patients were enrolled in the study. Of the 897 (24%) admitted with CAS, 778 (87%) had severe sepsis or septic shock on ICU admission. In the first six hours of hospital admission: (1) 62% had serum lactate measured; (2) 69% fluids administered; (3) 77% specimens collected for microbiology before antibiotic administration; (4) 48% blood cultures obtained; (5) 52% antibiotics administered within the first hour of the diagnosis; (6) vasopressors were given in 78%; (7) 56% had central venous measurement (CVP) measurement; (8) 17% had a central venous oxygen saturation (ScvO2) measurement; (9) dobutamine was administered in 52%. Compliance with all actions 1 to 6 (core bundle) was associated with an odds ratio (OR) of 0.44 [95% confidence interval (CI) = 0.24-0.80] in severe sepsis and 0.49 (95% CI = 0.25-0.95) in septic shock, for 28 days mortality. This corresponded to a number needed to treat of 6 patients to save one life. Conclusions Compliance with this core bundle was associated with a significant reduction in the 28 days mortality. Urgent action should be taken in order to ensure that early sepsis diagnosis is followed by full completion of this "core bundle" followed by activation of expertise help in severe sepsis.
2008
Objective: Despite the existence of evidence-based guidelines for the management of patients with severe sepsis and septic shock, there is much variation among individual treatments. Methods: A before-after study with prospective data collection was performed at the emergency department and intensive care unit of a 485-bed, private, tertiary, general hospital. A total of 160 patients were enrolled (94 in a "pre-protocol phase" and 66 in a "post-protocol phase"). A resuscitation bundle for the first six hours and a management bundle for 24 hours were used. Additional quality indicators were also proposed and evaluated. The outcomes analyzed included hospital mortality, hospital and intensive care unit length of stay, compliance with bundles and performance related to quality indicators. results: From the "pre-protocol" to "post-protocol" phase, the diagnosis moved from the intensive care unit (52.0 to 18.2%) to the emergency department (26.6 to 40.9%) and to the wards (17.0 to 36.4%). Number of blood cultures prior to antibiotics, administration of activated drotrecogin alfa, use of corticosteroids and compliance with six-hour and 24-hour sepsis bundles were significantly higher after protocol implementation. Patients in the "post-protocol" group had a statistically lower risk of in-hospital mortality (56.4 versus 36.4%, p = 0.01). The greatest decrease in mortality rate occurred among the most critically ill patients (67.7 to 40.7%, p = 0.004). conclusions: Adopting an institutional protocol focused on behavioral changes and using quality improvement tools led to reduced hospital mortality and generated changes in healthcare team practice. This result adds to the growing evidence that optimized process-of-care by implementing managed protocols for sepsis patients can reduce mortality. Therefore, similar strategies should be routinely employed.