Effect of performance improvement programs on compliance with sepsis bundles and mortality: a systematic review and meta-analysis of observational studies

Abstract

Background: Several reports suggest that implementation of the Surviving Sepsis Campaign (SSC) guidelines is associated with mortality reduction in sepsis. However, adherence to the guideline-based resuscitation and management sepsis bundles is still poor.

Objective: To perform a systematic review of studies evaluating the impact of performance improvement programs on compliance with Surviving Sepsis Campaign (SSC) guideline-based bundles and/or mortality.

Data sources: Medline (PubMed), Scopus and Intercollegiate Studies Institute Web of Knowledge databases from 2004 (first publication of the SSC guidelines) to October 2014.

Study selection: Studies on adult patients with sepsis, severe sepsis or septic shock that evaluated changes in compliance to individual/combined bundle targets and/or mortality following the implementation of performance improvement programs. Interventions may consist of educational programs, process changes or both.

Data extraction: Data from the included studies were extracted independently by two authors. Unadjusted binary data were collected in order to calculate odds ratios (OR) for compliance to individual/combined bundle targets. Adjusted (if available) or unadjusted data of mortality were collected. Random-effects models were used for the data synthesis.

Results: Fifty observational studies were selected. Despite high inconsistency across studies, performance improvement programs were associated with increased compliance with the complete 6-hour bundle (OR = 4.12 [95% confidence interval 2.95-5.76], I(2) = 87.72%, k = 25, N = 50,081) and the complete 24-hour bundle (OR = 2.57 [1.74-3.77], I(2) = 85.22%, k = 11, N = 45,846) and with a reduction in mortality (OR = 0.66 [0.61-0.72], I(2) = 87.93%, k = 48, N = 434,447). Funnel plots showed asymmetry.

Conclusions: Performance improvement programs are associated with increased adherence to resuscitation and management sepsis bundles and with reduced mortality in patients with sepsis, severe sepsis or septic shock.

Fig 1. Flow-chart showing the study selection process.

Fig 2. Forest plot showing individual and overall ES of studies that evaluated changes in compliance with the complete 6-hour bundle following the implementation of the performance improvement program (k = 25).

The size of the boxes is inversely proportional to the size of the result study variance, so that more precise studies have larger boxes. The ES is expressed as odds ratio (OR) and the correspondent 95% confidence interval (CI). An OR above 1.00 (right side of the plot) indicates an association between the intervention and increased compliance. ES = effect size; CI = confidence interval; Sig. = p value.

Fig 3. Forest plots showing individual and overall ES of studies that evaluated changes in compliance with individual 6-hour bundle targets following the implementation of the performance improvement program. (A) Measure lactate (k = 31); (B) Blood cultures (k = 28); (C) Antibiotics (k = 35); (D) Fluid resuscitation (k = 24).

The size of the boxes is inversely proportional to the size of the result study variance, so that more precise studies have larger boxes. The ES is expressed as odds ratio (OR) and the correspondent 95% confidence interval (CI). An OR above 1.00 (right side of the plot) indicates an association between the intervention and increased compliance. ES = effect size; CI = confidence interval; Sig. = p value.

Fig 4. Forest plots showing individual and overall ES of studies that evaluated changes in compliance with individual 6-hour bundle targets following the implementation of the performance improvement program. (A) Measure central venous pressure (k = 8); (B) Central venous pressure above 8 mmHg (k = 16); (C) Measure SvO₂ (k = 8); (D) SvO₂ above 70% (k = 15); (E) Mean arterial pressure above 65 mmHg (k = 9); (F) Use of vasopressors (k = 9).

The size of the boxes is inversely proportional to the size of the result study variance, so that more precise studies have larger boxes. The ES is expressed as odds ratio (OR) and the correspondent 95% confidence interval (CI). An OR above 1.00 (right side of the plot) indicates an association between the intervention and increased compliance. ES = effect size; CI = confidence interval; Sig. = p value.

Fig 5. Forest plot showing individual and overall ES of studies that evaluated changes in compliance with the complete 24-hour bundle following the implementation of the performance improvement program (k = 11).

The size of the boxes is inversely proportional to the size of the result study variance, so that more precise studies have larger boxes. The ES is expressed as odds ratio (OR) and the correspondent 95% confidence interval (CI). An OR above 1.00 (right side of the plot) indicates an association between the intervention and increased compliance. ES = effect size; CI = confidence interval; Sig. = p value.

Fig 6. Forest plots showing individual and overall ES of studies that evaluated changes in compliance with individual 24-hour bundle targets following the implementation of the performance improvement program. (A) Lung protective ventilation (k = 9); (B) Steroids (k = 20); (C) Drotrecogin alfa (activated) (k = 16); (D) Glucose control (k = 13).

The size of the boxes is inversely proportional to the size of the result study variance, so that more precise studies have larger boxes. The ES is expressed as odds ratio (OR) and the correspondent 95% confidence interval (CI). An OR above 1.00 (right side of the plot) indicates an association between the intervention and increased compliance. ES = effect size; CI = confidence interval; Sig. = p value.

Fig 7. Forest plot showing individual and overall ES of studies that evaluated changes in mortality following the implementation of the performance improvement program (k = 48).

The size of the boxes is inversely proportional to the size of the result study variance, so that more precise studies have larger boxes. The ES is expressed as odds ratio (OR) and the correspondent 95% confidence interval (CI). An OR below 1.00 (left side of the plot) indicates an association between the intervention and decreased mortality. ES = effect size; CI = confidence interval; Sig. = p value.