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The Surviving Sepsis Campaign: Results of an international guideline-based performance improvement program targeting severe sepsis*

Levy, Mitchell M. MD; Dellinger, R Phillip MD; Townsend, Sean R. MD; Linde-Zwirble, Walter T.; Marshall, John C. MD; Bion, Julian MD; Schorr, Christa RN, MSN; Artigas, Antonio MD; Ramsay, Graham MD; Beale, Richard MD; Parker, Margaret M. MD; Gerlach, Herwig MD, PhD; Reinhart, Konrad MD; Silva, Eliezer MD; Harvey, Maurene RN, MPH; Regan, Susan PhD; Angus, Derek C. MD, MPH

doi: 10.1097/CCM.0b013e3181cb0cdc
Special Article

Objective: The Surviving Sepsis Campaign (SSC or “the Campaign”) developed guidelines for management of severe sepsis and septic shock. A performance improvement initiative targeted changing clinical behavior (process improvement) via bundles based on key SSC guideline recommendations.

Design and Setting: A multifaceted intervention to facilitate compliance with selected guideline recommendations in the intensive care unit, emergency department, and wards of individual hospitals and regional hospital networks was implemented voluntarily in the United States, Europe, and South America. Elements of the guidelines were “bundled” into two sets of targets to be completed within 6 hrs and within 24 hrs. An analysis was conducted on data submitted from January 2005 through March 2008.

Subjects: A total of 15,022 subjects.

Measurements and Main Results: Data from 15,022 subjects at 165 sites were analyzed to determine the compliance with bundle targets and association with hospital mortality. Compliance with the entire resuscitation bundle increased linearly from 10.9% in the first site quarter to 31.3% by the end of 2 yrs (p < .0001). Compliance with the entire management bundle started at 18.4% in the first quarter and increased to 36.1% by the end of 2 yrs (p = .008). Compliance with all bundle elements increased significantly, except for inspiratory plateau pressure, which was high at baseline. Unadjusted hospital mortality decreased from 37% to 30.8% over 2 yrs (p = .001). The adjusted odds ratio for mortality improved the longer a site was in the Campaign, resulting in an adjusted absolute drop of 0.8% per quarter and 5.4% over 2 yrs (95% confidence interval, 2.5–8.4).

Conclusions: The Campaign was associated with sustained, continuous quality improvement in sepsis care. Although not necessarily cause and effect, a reduction in reported hospital mortality rates was associated with participation. The implications of this study may serve as an impetus for similar improvement efforts.

From the Division of Pulmonary, Sleep and Critical Care Medicine Care Medicine (MML), Brown University School of Medicine, Rhode Island Hospital, Providence, RI; Department of Medicine (RPD, CS), University of Medicine and Dentistry of New Jersey, Cooper University Hospital, Camden, NJ; The Institute for Healthcare Improvement (SRT), Cambridge, MA; Division of Pulmonary, Sleep, Allergy, and Critical Care Medicine (SRT), University of Massachusetts Medical School, Worcester, MA; ZD Associates LLC (WTL-Z), Perkasie, PA; Department of Surgery (JCM), Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; University Department of Anaesthesia & Intensive Care Medicine (JB), Queen Elizabeth Hospital, Edgbaston, Birmingham, UK; Critical Care Centre (AA), Sabadell Hospital, CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Barcelona, Spain; Mid Essex Hospital Services NHS Trust (GR), London, UK; Guy's and St. Thomas' NHS Foundation Trust (RB), St. Thomas' Hospital, London, UK; Department of Medicine (MMP), Stony Brook University, NY; Vivantes-Klinikum Neukoelln (HG), Berlin, Germany; Clinic for Anesthesiology and Intensive Care (KR), Jena, Germany; Hospital Israelita Albert Einstein (ES), Sao Paolo, Brazil; Department of Medicine (SR), Harvard Medical School and General Medicine Division, Massachusetts General Hospital, Boston, MA; Consultants in Critical Care, Inc. (MH), Glenbrook, NV; CRISMA Laboratory (DCA), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA.

This study was funded, in part, by Eli Lilly and Company, Edwards Lifesciences, Philips Medical Systems, Society of Critical Care Medicine, and European Society of Intensive Care Medicine.

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 (www.ccmjournal.com).

Disclosure Dr. Levy has received grants from Eli Lilly & Co and Philips Medical Systems. Dr. Marshall has consultancies with Eisai, Eli Lilly, Specter Diagnostics, Bayer, Artisan, and Leo Pharma. Dr. Artigas has received grants from Eli Lilly. Dr. Beale has disclosed payment from multiple sources that were paid to his department and institution (details on file with the editorial office). Drs. Reinart and Silva have consultancies with Eli Lilly. Dr. Angus has participation in DSMB, Prowess-Shock, and Eli Lilly. The remaining authors have nothing to disclose.

This article is being simultaneously published in Critical Care Medicine and Intensive Care Medicine.

For information regarding this article, E-mail: Mitchell_Levy@brown.edu

© 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins