Christa Schorr

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

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. Design and Setting: A multifaceted intervention to facilitate compliance with selected guideline recommendations in the intensive care unit, emergency department, and wards of individual hospitals and regional hospital networks was implemented voluntarily in the United States, Europe, and South America. Elements of the guidelines were “bundled” into two sets of targets to be completed within 6 hrs and within 24 hrs. An analysis was conducted on data submitted from January 2005 through March 2008. Subjects: A total of 15,022 subjects. Measurements and 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 yrs (p < .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 yrs (p = .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 yrs (p = .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 yrs (95% confidence interval, 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.

Empiric Antibiotic Treatment Reduces Mortality in Severe Sepsis and Septic Shock From the First Hour: Results From a Guideline-Based Performance Improvement Program*

Objectives:Compelling evidence has shown that aggressive resuscitation bundles, adequate source control, appropriate antibiotic therapy, and organ support are cornerstone for the success in the treatment of patients with sepsis. Delay in the initiation of appropriate antibiotic therapy has been recognized as a risk factor for mortality. To perform a retrospective analysis on the Surviving Sepsis Campaign database to evaluate the relationship between timing of antibiotic administration and mortality. Design:Retrospective analysis of a large dataset collected prospectively for the Surviving Sepsis Campaign. Setting:One hundred sixty-five ICUs in Europe, the United States, and South America. Patients:A total of 28,150 patients with severe sepsis and septic shock, from January 2005 through February 2010, were evaluated. Interventions:Antibiotic administration and hospital mortality. Measurements and Main Results:A total of 17,990 patients received antibiotics after sepsis identification and were included in the analysis. In-hospital mortality was 29.7% for the cohort as a whole. There was a statically significant increase in the probability of death associated with the number of hours of delay for first antibiotic administration. Hospital mortality adjusted for severity (sepsis severity score), ICU admission source (emergency department, ward, vs ICU), and geographic region increased steadily after 1 hour of time to antibiotic administration. Results were similar in patients with severe sepsis and septic shock, regardless of the number of organ failure. Conclusions:The results of the analysis of this large population of patients with severe sepsis and septic shock demonstrate that delay in first antibiotic administration was associated with increased in-hospital mortality. In addition, there was a linear increase in the risk of mortality for each hour delay in antibiotic administration. These results underscore the importance of early identification and treatment of septic patients in the hospital setting.

Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study.

Purpose:To determine the association between compliance with the Surviving Sepsis Campaign (SSC) performance bundles and mortality. Design:Compliance with the SSC performance bundles, which are based on the 2004 SSC guidelines, was measured in 29,470 subjects entered into the SSC database from January 1, 2005, through June 30, 2012. Compliance was defined as evidence that all bundle elements were achieved. Setting:Two hundred eighteen community, academic, and tertiary care hospitals in the United States, South America, and Europe. Patients:Patients from the emergency department, medical and surgical wards, and ICU who met diagnosis criteria for severe sepsis and septic shock. Methods:A multifaceted, collaborative change intervention aimed at facilitating adoption of the SSC resuscitation and management bundles was introduced. Compliance with the SSC bundles and associated mortality rate was the primary outcome variable. Results:Overall lower mortality was observed in high (29.0%) versus low (38.6%) resuscitation bundle compliance sites (p < 0.001) and between high (33.4%) and low (32.3%) management bundle compliance sites (p = 0.039). Hospital mortality rates dropped 0.7% per site for every three months (quarter) of participation (p < 0.001). Hospital and intensive care unit length of stay decreased 4% (95% CI: 1% - 7%; p = 0.012) for every 10% increase in site compliance with the resuscitation bundle. Conclusions:This analysis demonstrates that increased compliance with sepsis performance bundles was associated with a 25% relative risk reduction in mortality rate. Every 10% increase in compliance and additional quarter of participation in the SSC initiative was associated with a significant decrease in the odds ratio for hospital mortality. These results demonstrate that performance metrics can drive change in clinical behavior, improve quality of care, and may decrease mortality in patients with severe sepsis and septic shock.

Lactate measurements in sepsis-induced tissue hypoperfusion: results from the Surviving Sepsis Campaign database.

Objective:The Surviving Sepsis Campaign guidelines recommend obtaining a serum lactate measurement within 6 hours of presentation for all patients with suspected severe sepsis or septic shock. A lactate greater than 4 mmol/L qualifies for administration of early quantitative resuscitation therapy. We evaluated lactate elevation (with special attention to values > 4 mmol/L) and presence or absence of hypotension as a marker of clinical outcome. Design and Setting:The Surviving Sepsis Campaign developed a database to assess the overall effect of the sepsis bundles as a performance improvement tool for clinical practice and patient outcome. This analysis focuses on one element of the Surviving Sepsis Campaign’s resuscitation bundle, measuring serum lactate in adult severe sepsis or septic shock patients and its interaction with hypotension. This analysis was conducted on data submitted from January 2005 through March 2010. Subjects:Data from 28,150 subjects at 218 sites were analyzed. Interventions:None. Measurements and Main Results:Unadjusted analysis of the 28,150 observations from the Surviving Sepsis Campaign database demonstrated a significant mortality increase with the presence of hypotension in conjunction with serum lactate elevation greater than 2 mmol/L. On multivariable analysis, only lactate values greater than 4 mmol/L, in conjunction with hypotension, significantly increased mortality when compared with the referent group of lactate values less than 2 mmol/L and not hypotensive. Mortality was 44.5% in patients with combined lactate greater than 4 mmol/L and hypotension when compared with 29% mortality in patients not meeting either criteria. Conclusions:Serum lactate was commonly measured within 6 hours of presentation in the management of severe sepsis or septic shock in this subset analysis of the Surviving Sepsis Campaign database in accordance with the Surviving Sepsis Campaign guidelines. Our results demonstrate that elevated lactate levels are highly associated with in-hospital mortality. However, only patients who presented with lactate values greater than 4 mmol/L, with and without hypotension, are significantly associated with in-hospital mortality and is associated with a significantly higher risk than intermediate levels (2–3 and 3–4 mmol/L). This supports the use of the cutoff of greater than 4 mmol/L as a qualifier for future clinical trials in severe sepsis or septic shock in patient populations who use quantitative resuscitation and the Surviving Sepsis Campaign bundles as standard of care.

Reducing mortality in severe sepsis: the Surviving Sepsis Campaign.

This article traces the history and evolution of the Surviving Sepsis Campaign as a public health initiative through its several stages of development. The literature that has characterized clinical experiences with interventions related to the campaign is reviewed and conclusions discussed.

Prevention of central venous catheter-related bloodstream infections: is it time to add simulation training to the prevention bundle?☆☆☆

STUDY OBJECTIVE To study the impact of adding simulation-based education to the pre-intervention mandatory hospital efforts aimed at decreasing central venous catheter-related blood stream infections (CRBSI) in intensive care units (ICU). DESIGN Pre- and post-intervention retrospective observational investigation. SETTING 24-bed ICU and a 562-bed university-affiliated, urban teaching hospital. PATIENTS ICU patients July 2004-June 2008 were studied for the development of central venous catheter related blood stream infections (CRBSI). MEASUREMENTS ICU patients from July 2004-June 2008 were studied for the development of central venous catheter-related blood stream infections (CRBSI). PRE-INTERVENTION: mandatory staff and physician education began in 2004 to reduce CRBSI. The CRBSI-prevention program included online and didactic courses, and a pre- and post-test. Elements in the pre-intervention efforts included hand hygiene, full barrier precautions, use of Chlorhexidine skin preparation, and mask, gown, gloves, and hat protection for operators. A catheter-insertion cart containing all supplies and checklist were was a mandatory element of this program; a nurse was empowered to stop the procedure for non-performance of checklist items. INTERVENTION As of July 1, 2006, a mandatory simulation-based program for all intern, resident, and fellow physicians was added to teach central venous catheter (CVC) insertion. MEASUREMENTS Data collected pre- and post-intervention were CRBSI incidence, number of ICU catheter days, mortality, laboratory pathogen results, and costs. MAIN RESULTS The pre-intervention CRBSI incidence of 6.47/1,000 catheter days was reduced significantly to 2.44/1,000 catheter days post-intervention (58%; P < 0.05), resulting in a

Severe sepsis and septic shock: Management and performance improvement

539,902 savings (USD; 47%), and was attributed to shorter ICU and hospital lengths of stay. CONCLUSIONS Following simulation-based CVC program implementation, CRBSI incidence and costs were significantly reduced for two years post-intervention.

Sepsis severity score: an internationally derived scoring system from the surviving sepsis campaign database*.

Morbidity and mortality from sepsis remains unacceptably high. Large variability in clinical practice, plus the increasing awareness that certain processes of care associated with improved critical care outcomes, has led to the development of clinical practice guidelines in a variety of areas related to infection and sepsis. The Surviving Sepsis Guidelines for Management of Severe Sepsis and Septic Shock were first published in 2004, revised in 2008, and recently revised again and published in 2013. The first part of this manuscript is a summary of the 2013 guidelines with some editorial comment. The second part of the manuscript characterizes hospital based sepsis performance improvement programs and highlights the sepsis bundles from the Surviving Sepsis Campaign as a key component of such a program.

Transfusion of packed red blood cells is not associated with improved central venous oxygen saturation or organ function in patients with septic shock.

Objective:As the Surviving Sepsis Campaign was assessing patient-level data over multiple countries, we sought to evaluate the use of a pragmatic and parsimonious severity-of-illness scoring system for patients with sepsis in an attempt to provide appropriate comparisons with practical application. Design:Prospective, observational evaluation. Patients:Data from 23,438 patients with suspected or confirmed sepsis from 218 hospitals in 18 countries were evaluated. Setting:This analysis was conducted on prospective data submitted to a database from January 2005 through March 2010. Interventions:None. Measurements and Main Results:Maximum likelihood logistic regression was used to estimate model coefficients, and these were then used to develop a Sepsis Severity Score. The probability of hospital mortality was estimated using the Sepsis Severity Score as the sole variable in a logistic regression model. Univariable logistic regression determined which variables were included in the multivariable predictor model. The scale of continuous variables was assessed using fractional polynomials. Two-way interactions between variables were considered for model inclusion if the interaction p value is less than 0.05. The prediction model was developed based on randomly selecting 90% of available patients and was validated on the remaining 10%, as well as by using a bootstrapping technique. The p values for the Hosmer-Lemeshow goodnessof-fit statistic in the developmental and validation datasets were considerably greater than 0.05, suggesting good calibration. Development and validation areas under the receiver operator curve curves were 0.736 and 0.748, respectively. Observed and estimated probabilities of hospital mortality for the total population were both 0.334. The validation and the developmental datasets were gradually compared over deciles of predicted mortality and found to be very similar. Conclusion:The Sepsis Severity Score accurately estimated the probability of hospital mortality in severe sepsis and septic shock patients. It performed well with respect to calibration and discrimination, which remained consistent over deciles. It functioned well over international geographic regions. This robust, population-specific evaluation of international severe sepsis patients provides an effective and accurate mortality estimate allowing for appropriate quality comparisons with practical clinical and research application.

Knowledge translation and the multifaceted intervention in the intensive care unit.

BACKGROUND The exact role of packed red blood cell (PRBC) transfusion in the setting of early resuscitation in septic shock is unknown. STUDY OBJECTIVE To evaluate whether PRBC transfusion is associated with improved central venous oxygen saturation (ScvO(2)) or organ function in patients with severe sepsis and septic shock receiving early goal-directed therapy (EGDT). METHODS Retrospective cohort study (n=93) of patients presenting with severe sepsis or septic shock treated with EGDT. RESULTS Thirty-four of 93 patients received at least one PRBC transfusion. The ScvO(2) goal>70% was achieved in 71.9% of the PRBC group and 66.1% of the no-PRBC group (p=0.30). There was no difference in the change in Sequential Organ Failure Assessment (SOFA) score within the first 24 h in the PRBC group vs. the no-PRBC group (8.6-8.3 vs. 5.8-5.6, p=0.85), time to achievement of central venous pressure>8 mm Hg (732 min vs. 465 min, p=0.14), or the use of norepinephrine to maintain mean arterial pressure>65 mm Hg (81.3% vs. 83.8%, p=0.77). CONCLUSIONS In this study, the transfusion of PRBC was not associated with improved cellular oxygenation, as demonstrated by a lack of improved achievement of ScvO(2)>70%. Also, the transfusion of PRBC was not associated with improved organ function or improved achievement of the other goals of EGDT. Further studies are needed to determine the impact of transfusion of PRBC within the context of early resuscitation of patients with septic shock.