Mortality Changes Associated with Mandated Public Reporting for Sepsis. The Results of the New York State Initiative

Abstract

Rationale: In 2013, the New York State Department of Health (NYSDOH) began a mandatory state-wide initiative to improve early recognition and treatment of severe sepsis and septic shock.

Objectives: This study examines protocol initiation, 3-hour and 6-hour sepsis bundle completion, and risk-adjusted hospital mortality among adult patients with severe sepsis and septic shock.

Methods: Cohort analysis included all patients from all 185 hospitals in New York State reported to the NYSDOH from April 1, 2014, to June 30, 2016. A total of 113,380 cases were submitted to NYSDOH, of which 91,357 hospitalizations from 183 hospitals met study inclusion criteria. NYSDOH required all hospitals to submit and follow evidence-informed protocols (including elements of 3-h and 6-h sepsis bundles: lactate measurement, early blood cultures and antibiotic administration, fluids, and vasopressors) for early identification and treatment of severe sepsis or septic shock.

Measurements and main results: Compliance with elements of the sepsis bundles and risk-adjusted mortality were studied. Of 91,357 patients, 74,293 (81.3%) had the sepsis protocol initiated. Among these individuals, 3-hour bundle compliance increased from 53.4% to 64.7% during the study period (P < 0.001), whereas among those eligible for the 6-hour bundle (n = 35,307) compliance increased from 23.9% to 30.8% (P < 0.001). Risk-adjusted mortality decreased from 28.8% to 24.4% (P < 0.001) in patients among whom a sepsis protocol was initiated. Greater hospital compliance with 3-hour and 6-hour bundles was associated with shorter length of stay and lower risk and reliability-adjusted mortality.

Conclusions: New York's statewide initiative increased compliance with sepsis-performance measures. Risk-adjusted sepsis mortality decreased during the initiative and was associated with increased hospital-level compliance.

Keywords: implementation science; performance improvement; quality; sepsis.

Figure 1.

Compliance with the 3-hour bundle and the 6-hour bundle over time. The regression lines for bundle compliance are based on individual unadjusted logistic regression models with time entered as a square root expression (3-h model) and a quadratic expression (6-h model). Using the 27 monthly observations, 3-hour bundle compliance and 6-hour bundle compliance increase 0.43% per month (95% confidence interval, 0.37–0.49%; P < 0.001) and 0.54% per month (95% confidence interval, 0.49–0.58%; P < 0.001), respectively.

Figure 2.

Change in risk-adjusted mortality over time. Time is entered into the risk-adjusted hospital mortality model as a linear expression. Using the 27 monthly observations, risk-adjusted mortality decreases 0.17% per month (95% confidence interval, 0.167–0.169; P < 0.001).

Figure 3.

Risk-adjusted hospital mortality over time by protocol initiation status. Risk-adjusted mortality improved in patients with a sepsis protocol initiated throughout the study period, but it was stable for patients without a protocol initiated. The difference in mortality between patients treated with and without a sepsis protocol first became significant (P = 0.019) during the third month of the study.