Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality*

Nguyen, H. Bryant; Corbett, Stephen W.; Steele, R.; Banta, Jim E.; Clark, Robin; Hayes, Sean R.; Edwards, Jeremy; Cho, Thomas W.; Wittlake, William A.

doi:10.1097/01.ccm.0000259463.33848.3d

Cited by 492 publications

(358 citation statements)

References 32 publications

Supporting

Mentioning

317

Contrasting

Unclassified

Order By: Relevance

“…[4][5][6] Following such evidence-based protocols and process-of-care interventions has been shown to be associated with better patient outcomes, including decreased mortality. 7,8 Most patients with severe sepsis are cared for in intensive care units (ICUs). At times, there are no beds available in the primary ICU and patients presenting to the hospital with sepsis are cared for in other units.…”

Section: Discussionmentioning

confidence: 99%

Does sepsis treatment differ between primary and overflow intensive care units?

Vishnupriya

Falade

Workneh

et al. 2012

Journal of Hospital Medicine

View full text Add to dashboard Cite

BACKGROUND:Sepsis is a major cause of death in hospitalized patients. Early goal‐directed therapy is the standard of care. When primary intensive care units (ICUs) are full, sepsis patients are cared for in overflow ICUs.OBJECTIVE:To determine if process‐of‐care measures in the care of sepsis patients differed between primary and overflow ICUs at our institution.DESIGN:We conducted a retrospective study of all adult patients admitted with sepsis between July 2009 and February 2010 to either the primary ICU or the overflow ICU.MEASUREMENTS:Baseline patient characteristics and multiple process‐of‐care measures, including diagnostic and therapeutic interventions.RESULTS:There were 141 patients admitted with sepsis to our hospital; 100 were cared for in the primary ICU and 41 in the overflow ICU. Baseline acute physiology and chronic health evaluation (APACHE II) scores were similar. Patients received similar processes‐of‐care in the primary ICU and overflow ICU with the exception of deep vein thrombosis (DVT) and gastrointestinal (GI) prophylaxis within 24 hours of admission, which were better adhered to in the primary ICU (74% vs 49%, P = 0.004, and 68% vs 44%, P = 0.012, respectively). There were no significant differences in hospital and ICU length of stay between the 2 units (9.68 days vs 9.73 days, P = 0.98, and 4.78 days vs 4.92 days, P = 0.97, respectively).CONCLUSIONS:Patients with sepsis admitted to the primary ICU and overflow ICU at our institution were managed similarly. Overflowing sepsis patients to non‐primary intensive care units may not affect guideline‐concordant care delivery or length of stay. Journal of Hospital Medicine 2012; © 2012 Society of Hospital Medicine

show abstract

Section: Discussionmentioning

confidence: 99%

Does sepsis treatment differ between primary and overflow intensive care units?

Vishnupriya

Falade

Workneh

et al. 2012

Journal of Hospital Medicine

View full text Add to dashboard Cite

show abstract

“…A partir de entonces, se han corroborado los beneficios de esta estrategia de reanimación en múltiples estudios (9,10,(14)(15)(16)(17). A pesar de los hallazgos y de ser una estrategia recomendada en las guías internacionales y por importantes sociedades e instituciones, es preocupante ver la poca observancia a las guías detectada en diferentes sitios del mundo.…”

Section: Discussionunclassified

“…La escasa observancia de dichas recomendaciones demuestra la dificultad de trasladar los conocimientos a la práctica (7,10).…”

Section: Discussionunclassified

“…Estudios similares al nuestro, desarrollados en otros países, muestran que a la fecha pocas instituciones en el mundo han adoptado un protocolo formal para el tratamiento temprano dirigido por objetivos en el manejo de la sepsis grave y el choque séptico (6,7) y, aun en instituciones con protocolos establecidos, la observancia de las guías varía entre el 50 y el 60 % (7,10). Un estudio reciente demostró que el conjunto de medidas de reanimación no se implementó en 42 % de los pacientes elegibles y que, en aquellos en quienes se inició el protocolo, este se desarrolló de manera incompleta en 43 % de los casos (18).…”

Section: Discussionunclassified

See 1 more Smart Citation

Adherencia a las guías internacionales de manejo temprano en sepsis grave y choque séptico

et al. 2012

View full text Add to dashboard Cite

e Isadora Ortiz: participaron en el diseño del estudio, la recolección de datos, el análisis de la información y la escritura del manuscrito. Fabian Jaimes participó en el diseño del estudio, el análisis de la información y la revisión del manuscrito. Introducción. La observancia completa del tratamiento temprano dirigido por objetivos, disminuye significativamente la mortalidad a 28 días, mientras que la observancia parcial no tiene ningún beneficio. Objetivos. Determinar la observancia de las guías internacionales en sepsis grave y choque séptico, mediante el conjunto de medidas (bundle) de reanimación de las primeras seis horas en pacientes mayores de 16 años de edad, en un centro de referencia de alta complejidad. Materiales y métodos. Se presenta un estudio de cohorte, prospectivo y descriptivo, llevado a cabo durante un período de seis meses, en pacientes con sepsis grave o choque séptico admitidos a los servicios de urgencias, unidades de cuidados intensivos y cuidados especiales. Se midió la observancia del conjunto de medidas mediante ocho intervenciones: 1) medición del lactato sérico, 2) inicio temprano de antibióticos, 3) toma de hemocultivos, 4) infusión de líquidos intravenosos, 5) uso de medicamentos vasopresores, 6) inserción de catéter venoso central, 7) presión venosa central mayor de 8 mm Hg, y 8) saturación venosa central de oxígeno mayor de 70 %.Resultados. Se tamizaron 723 pacientes; 16 % (n=116) cumplieron los criterios de inclusión, 92,2 % (n=107) cumplieron los criterios para sepsis grave y 37,9 % (n=44) para choque séptico. El 62,9 % (n=73) fue subdiagnosticado. La observancia completa de las 8 intervenciones del conjunto de medidas fue de 0 %; de 6 a 7, 19 % (n=22); de 3 a 5, 67,2 % (n=78), y de 0 a 2, 98,3 % (n=114). Conclusión. La completa observancia de las guías internacionales de manejo en sepsis grave y choque séptico en las primeras seis horas es nula y solo se cumple de manera parcial. Adherence to international guidelines on early management in severe sepsis and septic shock Introduction. Complete adherence to early goal-directed therapy has shown a significant reduction in 28-day mortality rate, whereas partial adherence has not shown beneficial effect. Objectives. The effect of adherence to 6 hour sepsis bundle treatment was evaluated on patients with severe sepsis and septic shock. Materials and methods. A prospective cohort study was conducted during a six-month period. The patients were limited to those 16 years or older and included admissions to intensive care units, special care units or emergency departments with severe sepsis or septic shock. The adherence to the 6-hour sepsis bundle was evaluated through 8 interventions as follows: (1) serum lactate measure,( 2) early antibiotic administration, (3) blood culture samples, (4) infusion of intravenous fluids, (5) vasopressor use, (6) central venous catheter, (7) central venous pressure >8 mm Hg, and (8) central venous oxygen saturation >70%. Results. Seven hundred and twenty three patients were screened; 16% (n=116) me...

show abstract

“…That discovery ushered in an exciting era of early identification, resuscitation and monitoring of patients with sepsis. Since 2003, EGDT has been recommended in international sepsis guidelines [2][3][4], and implementation in routine care has been associated with benefits [5]. Likewise, many observers suggested that prompt recognition and treatment of sepsis may partly explain declining mortality from sepsis [6,7].…”

mentioning

confidence: 99%

Early goal-directed therapy: from discovery through enthusiasm to equipoise?

2015

View full text Add to dashboard Cite

The original Rivers trial [1] of early goal-directed therapy (EGDT) discovered that a process of EGDT that guided fluids, vasopressors, inotropic agents and transfusions in the first 6 h of sepsis dramatically reduced mortality (relative risk reduction, RRR of 42 %) compared to usual care in an emergency department (ED) setting. That discovery ushered in an exciting era of early identification, resuscitation and monitoring of patients with sepsis. Since 2003, EGDT has been recommended in international sepsis guidelines [2][3][4], and implementation in routine care has been associated with benefits [5]. Likewise, many observers suggested that prompt recognition and treatment of sepsis may partly explain declining mortality from sepsis [6,7].Some have suggested that EGDT as described in Rivers' trial may not apply to the intensive care setting, because it was a single-centre trial conducted in the emergency department, the control mortality rate was higher than expected, and baseline central venous oxygen saturation (ScvO 2 ) was remarkably low (about 50 %)-an observation thought to be rare in septic ICU patients. Accordingly, many argued that there was clinical equipoise about the role of EGDT in ICU patients with sepsis, and several subsequent multicentre RCTs [8-10] did not find survival benefits from EGDT (mortality was actually slightly higher in EGDT than the usual care group in ProMISe).In this issue of Intensive Care Medicine, Peake and colleagues [11] report a systematic review with metaanalysis of five RCTs [1,[8][9][10][11][12] showing no difference in mortality between ED-initiated EGDT versus usual care groups. However, the ED-initiated EGDT group had significantly more use of vasopressors and duration of stay in the ICU. Peake and colleagues [11] also reviewed six RCTs of non-ED-initiated EGDT, again finding no difference in mortality between EGDT versus usual care. The systematic review adheres to current standards for the conduct and reporting of a systematic review [13,14], including a pre-experimentally published protocol, a comprehensive search strategy, adequate conventional cumulative meta-analyses, relevant sensitivity and subgroup analyses, and adequate assessment of risk of bias. Conventional cumulative meta-analyses are at risk of producing random errors because of sparse data and repetitive testing of accumulating data [15][16][17]. The risk of random errors can be assessed by trial sequential analysis (TSA), where trial sequential monitoring boundaries are applied to the conventional meta-analysis. The underlying assumption of TSA is that significance testing and calculation of the 95 % confidence interval are performed each time a new trial result is published or available. TSA depends on the accrued information

show abstract

Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality*

Abstract: Implementation of a severe sepsis bundle using a quality improvement feedback to modify physician behavior in the emergency department setting was feasible and was associated with decreased in-hospital mortality.

Cited by 492 publications

References 32 publications

Does sepsis treatment differ between primary and overflow intensive care units?

Does sepsis treatment differ between primary and overflow intensive care units?

Adherencia a las guías internacionales de manejo temprano en sepsis grave y choque séptico

Early goal-directed therapy: from discovery through enthusiasm to equipoise?

Contact Info

Product

Resources

About