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Protocol-Based Resuscitation Bundle to Improve Outcomes in Septic Shock Patients: Evaluation of the Michigan Health and Hospital Association Keystone Sepsis Collaborative*

Thompson, Michael P. PhD; Reeves, Mathew J. PhD; Bogan, Brittany L. MHSA, CPPS; DiGiovine, Bruno MD, MPH; Posa, Patricia J. RN, BSN, MSA; Watson, Sam R. MSA, CPPS

doi: 10.1097/CCM.0000000000001867
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Objectives: To evaluate the impact of a multi-ICU quality improvement collaborative implementing a protocol-based resuscitation bundle to treat septic shock patients.

Design: A difference-in-differences analysis compared patient outcomes in hospitals participating in the Michigan Health & Hospital Association Keystone Sepsis collaborative (n = 37) with noncollaborative hospitals (n = 50) pre- (2010–2011) and postimplementation (2012–2013). Collaborative hospitals were also stratified as high (n = 19) and low (n = 18) adherence based on their overall bundle adherence.

Setting: Eighty-seven Michigan hospitals with ICUs.

Patients: We compared 22,319 septic shock patients in collaborative hospitals compared to 26,055 patients in noncollaborative hospitals using the Michigan Inpatient Database.

Interventions: Multidisciplinary ICU teams received informational toolkits, standardized screening tools, and continuous quality improvement, aided by cultural improvement.

Measurements and Main Results: In-hospital mortality and hospital length of stay significantly improved between pre- and postimplementation periods for both collaborative and noncollaborative hospitals. Comparing collaborative and noncollaborative hospitals, we found no additional reductions in mortality (odds ratio, 0.94; 95% CI, 0.87–1.01; p = 0.106) or length of stay (–0.3 d; 95% CI, –0.7 to 0.1 d; p = 0.174). Compared to noncollaborative hospitals, high adherence hospitals had significant reductions in mortality (odds ratio, 0.84; 95% CI, 0.79–0.93; p < 0.001) and length of stay (–0.7 d; 95% CI, –1.1 to –0.2; p < 0.001), whereas low adherence hospitals did not (odds ratio, 1.07; 95% CI, 0.97–1.19; p = 0.197; 0.2 d; 95% CI, –0.3 to 0.8; p = 0.367).

Conclusions: Participation in the Keystone Sepsis collaborative was unable to improve patient outcomes beyond concurrent trends. High bundle adherence hospitals had significantly greater improvements in outcomes, but further work is needed to understand these findings.

Supplemental Digital Content is available in the text.

1Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI.

2Keystone Center for Patient Safety & Quality, Michigan Health & Hospital Association, Okemos, MI.

3Division of Pulmonary, Critical Care, and Sleep Medicine, Henry Ford Health System, Detroit, MI.

4St. Joseph Mercy Hospital, Ann Arbor, MI.

*See also p. 2275.

The Michigan Health & Hospital Association Keystone Center receives unrestricted donations from Blue Cross Blue Shield Foundation of Michigan.

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 website (

Dr. Thompson disclosed other support and received support for article research from Blue Cross Blue Shield Foundation of Michigan (The Michigan Health & Hospital Association [MHA] Keystone Center receives unrestricted donations). His institution received funding from the Blue Cross Blue Shield Foundation of Michigan (The MHA Keystone Center receives unrestricted donations). Dr. DiGiovine received funding from the Michigan Hospital Association, American Board of Internal Medicine, and Law firm of Silver Golub & Teitell. He has a family disclosure (his wife owns stock in United Medical Systems). Dr. Posa received other support (Surviving Sepsis Campaign Society of Critical Care Medicine-ICU Liberation Collaborative Sage Products Excelsior Medical) and received funding from Michigan Hospital Association, Johns Hopkins Armstrong Institute, and Missouri Patient Safety Organization. She is a Consultant for Advanced Nursing LLC. Dr. Watson’s institution received funding from Cross Blue Shield of Michigan. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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