Multicenter implementation of a severe sepsis and septic shock treatment bundle

Abstract

Rationale: Severe sepsis and septic shock are leading causes of intensive care unit (ICU) admission, morbidity, and mortality. The effect of compliance with sepsis management guidelines on outcomes is unclear.

Objectives: To assess the effect on mortality of compliance with a severe sepsis and septic shock management bundle.

Methods: Observational study of a severe sepsis and septic shock bundle as part of a quality improvement project in 18 ICUs in 11 hospitals in Utah and Idaho.

Measurements and main results: Among 4,329 adult subjects with severe sepsis or septic shock admitted to study ICUs from the emergency department between January 2004 and December 2010, hospital mortality was 12.1%, declining from 21.2% in 2004 to 8.7% in 2010. All-or-none total bundle compliance increased from 4.9-73.4% simultaneously. Mortality declined from 21.7% in 2004 to 9.7% in 2010 among subjects noncompliant with one or more bundle element. Regression models adjusting for age, severity of illness, and comorbidities identified an association between mortality and compliance with each of inotropes and red cell transfusions, glucocorticoids, and lung-protective ventilation. Compliance with early resuscitation elements during the first 3 hours after emergency department admission caused ineligibility, through lower subsequent severity of illness, for these later bundle elements.

Conclusions: Total severe sepsis and septic shock bundle compliances increased substantially and were associated with a marked reduction in hospital mortality after adjustment for age, severity of illness, and comorbidities in a multicenter ICU cohort. Early resuscitation bundle element compliance predicted ineligibility for subsequent bundle elements.

Figure 1.

Flow diagram of subjects by study period.

Figure 2.

P-chart of total bundle compliance and mortality, 2004–2010. (A) Among all subjects, mortality (circles) decreased while all-or-none total bundle compliance (squares) increased over time. The 95% statistical process control limits are represented by dashed lines. (B) Among only subjects with septic shock, mortality (circles) also decreased while all-or-none total bundle compliance (squares) increased over time. The 95% statistical process control limits are represented by dashed lines.