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      The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis

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          Abstract

          Objective

          The Surviving Sepsis Campaign (SSC or “the Campaign”) developed guidelines for management of severe sepsis and septic shock. A performance improvement initiative targeted changing clinical behavior (process improvement) via bundles based on key SSC guideline recommendations on process improvement and patient outcomes.

          Design and setting

          A multifaceted intervention to facilitate compliance with selected guideline recommendations in the ICU, ED, and wards of individual hospitals and regional hospital networks was implemented voluntarily in the US, Europe, and South America. Elements of the guidelines were “bundled” into two sets of targets to be completed within 6 h and within 24 h. An analysis was conducted on data submitted from January 2005 through March 2008.

          Main results

          Data from 15,022 subjects at 165 sites were analyzed to determine the compliance with bundle targets and association with hospital mortality. Compliance with the entire resuscitation bundle increased linearly from 10.9% in the first site quarter to 31.3% by the end of 2 years ( P < 0.0001). Compliance with the entire management bundle started at 18.4% in the first quarter and increased to 36.1% by the end of 2 years ( P = 0.008). Compliance with all bundle elements increased significantly, except for inspiratory plateau pressure, which was high at baseline. Unadjusted hospital mortality decreased from 37 to 30.8% over 2 years ( P = 0.001). The adjusted odds ratio for mortality improved the longer a site was in the Campaign, resulting in an adjusted absolute drop of 0.8% per quarter and 5.4% over 2 years (95% CI, 2.5–8.4%).

          Conclusions

          The Campaign was associated with sustained, continuous quality improvement in sepsis care. Although not necessarily cause and effect, a reduction in reported hospital mortality rates was associated with participation. The implications of this study may serve as an impetus for similar improvement efforts.

          Electronic supplementary material

          The online version of this article (doi:10.1007/s00134-009-1738-3) contains supplementary material, which is available to authorized users.

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          Most cited references15

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          Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain.

          Concern exists that current guidelines for care of patients with severe sepsis and septic shock are followed variably, possibly due to a lack of adequate education. To determine whether a national educational program based on the Surviving Sepsis Campaign guidelines affected processes of care and hospital mortality for severe sepsis. Before and after design in 59 medical-surgical intensive care units (ICUs) located throughout Spain. All ICU patients were screened daily and enrolled if they fulfilled severe sepsis or septic shock criteria. A total of 854 patients were enrolled in the preintervention period (November-December 2005), 1465 patients during the postintervention period (March-June 2006), and 247 patients during the long-term follow-up period 1 year later (November-December 2006) in a subset of 23 ICUs. The educational program consisted of training physicians and nursing staff from the emergency department, wards, and ICU in the definition, recognition, and treatment of severe sepsis and septic shock as outlined in the guidelines. Treatment was organized in 2 bundles: a resuscitation bundle (6 tasks to begin immediately and be accomplished within 6 hours) and a management bundle (4 tasks to be completed within 24 hours). Hospital mortality, differences in adherence to the bundles' process-of-care variables, ICU mortality, 28-day mortality, hospital length of stay, and ICU length of stay. Patients included before and after the intervention were similar in terms of age, sex, and Acute Physiology and Chronic Health Evaluation II score. At baseline, only 3 process-of-care measurements (blood cultures before antibiotics, early administration of broad-spectrum antibiotics, and mechanical ventilation with adequate inspiratory plateau pressure) we had compliance rates higher than 50%. Patients in the postintervention cohort had a lower risk of hospital mortality (44.0% vs 39.7%; P = .04). The compliance with process-of-care variables also improved after the intervention in the sepsis resuscitation bundle (5.3% [95% confidence interval [CI], 4%-7%] vs 10.0% [95% CI, 8%-12%]; P < .001) and in the sepsis management bundle (10.9% [95% CI, 9%-13%] vs 15.7% [95% CI, 14%-18%]; P = .001). Hospital length of stay and ICU length of stay did not change after the intervention. During long-term follow-up, compliance with the sepsis resuscitation bundle returned to baseline but compliance with the sepsis management bundle and mortality remained stable with respect to the postintervention period. A national educational effort to promote bundles of care for severe sepsis and septic shock was associated with improved guideline compliance and lower hospital mortality. However, compliance rates were still low, and the improvement in the resuscitation bundle lapsed by 1 year.
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            Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality.

            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. Two-year prospective observational cohort. Academic tertiary care facility. Patients were 330 patients presenting to the emergency department who met criteria for severe sepsis or septic shock. Five quality indicators comprised the bundle for severe sepsis management in the emergency department: a) initiate central venous pressure (CVP)/central venous oxygen saturation (Scvo2) monitoring within 2 hrs; b) give broad-spectrum antibiotics within 4 hrs; c) complete early goal-directed therapy at 6 hrs; d) give corticosteroid if the patient is on vasopressor or if adrenal insufficiency is suspected; and e) monitor for lactate clearance. Patients had a mean age of 63.8 +/- 18.5 yrs, Acute Physiology and Chronic Health Evaluation II score 29.6 +/- 10.6, emergency department length of stay 8.5 +/- 4.4 hrs, hospital length of stay 11.3 +/- 12.9 days, and in-hospital mortality 35.2%. Bundle compliance increased from zero to 51.2% at the end of the study period. During the emergency department stay, patients with the bundle completed received more CVP/Scvo2 monitoring (100.0 vs. 64.8%, p < .01), more antibiotics (100.0 vs. 89.7%, p = .04), and more corticosteroid (29.9 vs. 16.2%, p = .01) compared with patients with the bundle not completed. In a multivariate regression analysis including the five quality indicators, completion of early goal-directed therapy was significantly associated with decreased mortality (odds ratio, 0.36; 95% confidence interval, 0.17-0.79; p = .01). In-hospital mortality was less in patients with the bundle completed compared with patients with the bundle not completed (20.8 vs. 39.5%, p < .01). 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.
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              Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia.

              A "bundle" of ventilator care processes (peptic ulcer disease prophylaxis, deep vein thrombosis prophylaxis, elevation of the head of the bed, and a sedation vacation), which may also reduce ventilator-associated pneumonia (VAP) rates, can serve as a focus for improvement strategies in intensive care units (ICUs). Between July 2002 and January 2004, teams of critical care clinicians from 61 health care organizations participated in a collaborative on improving care in the ICU. ICU team members posted data monthly on a Web-based extranet and submitted narrative descriptions describing the changes tested and the strategies implemented. For the 35 units that consistently collected data on ventilator bundle element adherence and VAP rates, an average 44.5% reduction of VAP was observed. The goal-oriented nature of the bundle appears to demand development of the teamwork necessary to improve reliability. The observations seem sufficiently robust to support implementing the ventilator bundles to provide a focus for additional change in ICUs.
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                Author and article information

                Contributors
                Mitchell_Levy@brown.edu
                Journal
                Intensive Care Med
                Intensive Care Medicine
                Springer-Verlag (Berlin/Heidelberg )
                0342-4642
                1432-1238
                13 January 2010
                13 January 2010
                February 2010
                : 36
                : 2
                : 222-231
                Affiliations
                [1 ]Division of Pulmonary, Sleep and Critical Care Medicine, Brown University School of Medicine, Rhode Island Hospital, 593 Eddy St., Providence, RI 02903 USA
                [2 ]Department of Medicine, University of Medicine and Dentistry of New Jersey, Cooper University Hospital, Camden, NJ USA
                [3 ]Division of Pulmonary, Allergy, and Critical Care Medicine, University of Massachusetts Medical School, Worcester, MA USA
                [4 ]The Institute for Healthcare Improvement, Cambridge, MA USA
                [5 ]ZD Associates LLC, Perkasie, PA USA
                [6 ]Department of Surgery, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, ON Canada
                [7 ]University Department of Anaesthesia and Intensive Care Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
                [8 ]Critical Care Centre, Sabadell Hospital, CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Barcelona, Spain
                [9 ]Mid Essex Hospital Services NHS Trust, London, UK
                [10 ]Guy’s and St. Thomas’ NHS Foundation Trust, St. Thomas’ Hospital, London, UK
                [11 ]Department of Medicine, Stony Brook University, Stony Brook, NY USA
                [12 ]Vivantes-Klinikum Neukoelln, Berlin, Germany
                [13 ]Clinic for Anesthesiology and Intensive Care, Jena, Germany
                [14 ]Hospital Israelita Albert Einstein, Sao Paolo, Brazil
                [16 ]Consultants in Critical Care, Inc., Glenbrook, NV USA
                [15 ]Department of Medicine, Harvard Medical School and General Medicine Division, Massachusetts General Hospital, Boston, MA USA
                [17 ]CRISMA Laboratory, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA
                Article
                1738
                10.1007/s00134-009-1738-3
                2826633
                20069275
                b25984f5-d6cf-48d9-9677-92f23795a037
                © Copyright jointly hold by Springer and ESICM 2010
                History
                : 26 May 2009
                : 27 November 2009
                Categories
                Original
                Custom metadata
                © Copyright jointly hold by Springer and ESICM 2010

                Emergency medicine & Trauma
                performance measures,knowledge transfer,sepsis bundles,septic shock,performance improvement,quality improvement,surviving sepsis campaign,severe sepsis

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