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Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality*

Nguyen, H Bryant MD, MS; Corbett, Stephen W. MD, PhD; Steele, Robert MD; Banta, Jim PhD, MPH; Clark, Robin T. BS; Hayes, Sean R.; Edwards, Jeremy; Cho, Thomas W. MD; Wittlake, William A. MD

doi: 10.1097/01.CCM.0000259463.33848.3D
Clinical Investigations

Objective: The purpose of this study was to examine the outcome implications of implementing a severe sepsis bundle in an emergency department as a quality indicator set with feedback to modify physician behavior related to the early management of severe sepsis and septic shock.

Design: Two-year prospective observational cohort.

Setting: Academic tertiary care facility.

Patients: Patients were 330 patients presenting to the emergency department who met criteria for severe sepsis or septic shock.

Interventions: Five quality indicators comprised the bundle for severe sepsis management in the emergency department: a) initiate central venous pressure (CVP)/central venous oxygen saturation (Scvo2) monitoring within 2 hrs; b) give broad-spectrum antibiotics within 4 hrs; c) complete early goal-directed therapy at 6 hrs; d) give corticosteroid if the patient is on vasopressor or if adrenal insufficiency is suspected; and e) monitor for lactate clearance.

Measurements and Main Results: Patients had a mean age of 63.8 ± 18.5 yrs, Acute Physiology and Chronic Health Evaluation II score 29.6 ± 10.6, emergency department length of stay 8.5 ± 4.4 hrs, hospital length of stay 11.3 ± 12.9 days, and in-hospital mortality 35.2%. Bundle compliance increased from zero to 51.2% at the end of the study period. During the emergency department stay, patients with the bundle completed received more CVP/Scvo2 monitoring (100.0 vs. 64.8%, p < .01), more antibiotics (100.0 vs. 89.7%, p = .04), and more corticosteroid (29.9 vs. 16.2%, p = .01) compared with patients with the bundle not completed. In a multivariate regression analysis including the five quality indicators, completion of early goal-directed therapy was significantly associated with decreased mortality (odds ratio, 0.36; 95% confidence interval, 0.17–0.79; p = .01). In-hospital mortality was less in patients with the bundle completed compared with patients with the bundle not completed (20.8 vs. 39.5%, p < .01).

Conclusions: Implementation of a severe sepsis bundle using a quality improvement feedback to modify physician behavior in the emergency department setting was feasible and was associated with decreased in-hospital mortality.

From the Department of Emergency Medicine (HBN, SWC, RS, RTC, SRH, JE, TWC, WAW) and Department of Epidemiology and Biostatistics (JB), Loma Linda University, Loma Linda, CA.

Presented, in part, at the Society of Critical Care Medicine 34th Critical Care Congress, Phoenix, AZ, January 2005, and the American College of Emergency Physicians Scientific Assembly, Washington, DC, September 2005.

The authors received no external funding to perform this study. Dr. Nguyen has received lecture honoraria from Edwards Lifesciences and Eli Lilly and research funding from Edwards Lifesciences. The remaining authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: hbnguyen@llu.edu

© 2007 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins