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Relationship Between a Sepsis Intervention Bundle and In-Hospital Mortality Among Hospitalized Patients: A Retrospective Analysis of Real-World Data

Prasad, Priya A. PhD, MPH*†; Shea, Erica R. RN, MS; Shiboski, Stephen PhD; Sullivan, Mary C. RN, MS, CNS; Gonzales, Ralph MD, MSPH*; Shimabukuro, David MDCM§

doi: 10.1213/ANE.0000000000002085
Critical Care and Resuscitation: Original Clinical Research Report

BACKGROUND: Sepsis is a systemic response to infection that can lead to tissue damage, organ failure, and death. Efforts have been made to develop evidence-based intervention bundles to identify and manage sepsis early in the course of the disease to decrease sepsis-related morbidity and mortality. We evaluated the relationship between a minimally invasive sepsis intervention bundle and in-hospital mortality using robust methods for observational data.

METHODS: We performed a retrospective cohort study at the University of California, San Francisco, Medical Center among adult patients discharged between January 1, 2012, and December 31, 2014, and who received a diagnosis of severe sepsis/septic shock (SS/SS). Sepsis intervention bundle elements included measurement of blood lactate; drawing of blood cultures before starting antibiotics; initiation of broad spectrum antibiotics within 3 hours of sepsis presentation in the emergency department or 1 hour of presentation on an inpatient unit; administration of intravenous fluid bolus if the patient was hypotensive or had a lactate level >4 mmol/L; and starting intravenous vasopressors if the patient remained hypotensive after fluid bolus administration. Poisson regression for a binary outcome variable was used to estimate an adjusted incidence-rate ratio (IRR) comparing mortality in groups defined by bundle compliance measured as a binary predictor, and to estimate an adjusted number needed to treat (NNT).

RESULTS: Complete bundle compliance was associated with a 31% lower risk of mortality (adjusted IRR, 0.69, 95% confidence interval [CI], 0.53–0.91), adjusting for SS/SS presentation in the emergency department, SS/SS present on admission (POA), age, admission severity of illness and risk of mortality, Medicaid/Medicare payor status, immunocompromised host status, and congestive heart failure POA. The adjusted NNT to save one life was 15 (CI, 8–69). Other factors independently associated with mortality included SS/SS POA (adjusted IRR, 0.55; CI, 0.32–0.92) and increased age (adjusted IRR, 1.13 per 10-year increase in age; CI, 1.03–1.24).

CONCLUSIONS: The University of California, San Francisco, sepsis bundle was associated with a decreased risk of in-hospital mortality across hospital units after robust control for confounders and risk adjustment. The adjusted NNT provides a reasonable and achievable goal to observe measureable improvements in outcomes for patients diagnosed with SS/SS.

Supplemental Digital Content is available in the text.Published ahead of print May 12, 2017.

From the *Division of General Internal Medicine, School of Medicine, University of California, San Francisco, California; Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, California; Department of Quality, Sepsis Program, University of California, San Francisco, California; and §Department of Anesthesia and Perioperative Care, School of Medicine, University of California, San Francisco, California.

Published ahead of print May 12, 2017.

Accepted for publication February 17, 2017.

Funding: None.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site.

Reprints will not be available from the authors.

Address correspondence to Priya Prasad, PhD, MPH, Division of General Internal Medicine, School of Medicine, University of California, San Francisco, 533 Parnassus Ave, Box 0131, U128, San Francisco, CA 94143. Address e-mail to Priya.Prasad@ucsf.edu.

© 2017 International Anesthesia Research Society
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