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Quality Improvement Initiative for Severe Sepsis and Septic Shock Reduces 90-Day Mortality: A 7.5-Year Observational Study*

Scheer, Christian S. MD; Fuchs, Christian MD; Kuhn, Sven-Olaf MD; Vollmer, Marcus MSM; Rehberg, Sebastian MD, PhD; Friesecke, Sigrun MD; Abel, Peter MD; Balau, Veronika MD; Bandt, Christoph PhD; Meissner, Konrad MD, PhD; Hahnenkamp, Klaus MD, PhD; Gründling, Matthias MD

doi: 10.1097/CCM.0000000000002069
Clinical Investigations
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Objective: To investigate the impact of a quality improvement initiative for severe sepsis and septic shock focused on the resuscitation bundle on 90-day mortality. Furthermore, effects on compliance rates for antiinfective therapy within the recommended 1-hour interval are evaluated.

Design: Prospective observational before-after cohort study.

Setting: Tertiary university hospital in Germany.

Patients: All adult medical and surgical ICU patients with severe sepsis and septic shock.

Intervention: Implementation of a quality improvement program over 7.5 years.

Measurements: The primary endpoint was 90-day mortality. Secondary endpoints included ICU and hospital mortality rates and length of stay, time to broad-spectrum antiinfective therapy, and compliance with resuscitation bundle elements.

Main Results: A total of 14,115 patients were screened. The incidence of severe sepsis and septic shock was 9.7%. Ninety-day mortality decreased from 64.2% to 45.0% (p < 0.001). Hospital length of stay decreased from 44 to 36 days (p < 0.05). Compliance with resuscitation bundle elements was significantly improved. Antibiotic therapy within the first hour after sepsis onset increased from 48.5% to 74.3% (p < 0.001). Multivariate analysis revealed blood cultures before antibiotic therapy (hazard ratio, 0.60–0.84; p < 0.001), adequate calculated antibiotic therapy (hazard ratio, 0.53–0.75; p < 0.001), 1–2 L crystalloids within the first 6 hours (hazard ratio 0.67–0.97; p = 0.025), and greater than or equal to 6 L during the first 24 hours (hazard ratio, 0.64–0.95; p = 0.012) as predictors for improved survival.

Conclusions: The continuous quality improvement initiative focused on the resuscitation bundle was associated with increased compliance and a persistent reduction in 90-day mortality over a 7.5-year period. Based on the observational study design, a causal relationship cannot be proven, and respective limitations need to be considered.

Supplemental Digital Content is available in the text.

1Department of Anesthesiology, University Hospital of Greifswald, Greifswald, Germany.

2Department of Mathematics and Computer Science, University of Greifswald, Greifswald, Germany.

3Department of Internal Medicine, University Hospital of Greifswald, Greifswald, Germany.

4Department of Microbiology, University Hospital of Greifswald, Greifswald, Germany.

*See also p. 374.

Dr. Scheer assumes full responsibility for the integrity of the submission as a whole, from inception to published article. He contributed to the literature search and data interpretation. Dr. Fuchs contributed to the data collection and data interpretation. Dr. Kuhn contributed to the data collection and data interpretation and was part of the study management committee. Dr. Vollmer performed the data analysis and contributed to the data interpretation. Dr. Rehberg contributed to the data interpretation and literature search. Dr. Friesecke contributed to the study idea and its initiation and to the data interpretation. She was part of the management committee. Dr. Abel contributed to the study initiation and commented the article. He was part of the management committee. Dr. Balau commented the article and was part of the management committee. Dr. Bandt contributed to the data analysis and data interpretation. He commented the article. Dr. Meissner contributed to the study design and study initiation. He commented and approved the final version. Dr. Hahnenkamp commented, amended, and approved the final version of the article. Dr. Gründling contributed to the literature search and data interpretation. He initiated the study and was part of the management committee. Dr. Gründling has full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis, including and especially any adverse effects. Drs. Scheer Fuchs, Kuhn, Rehberg, Vollmer, Friesecke, and Gründling drafted, amended, and approved the final version.

Drs. Scheer, Fuchs, Kuhn, Vollmer, Rehberg, Friesecke, Abel, Meissner, and Gründling have presented their study on “Sustained reduction of 90-day mortality of severe sepsis and septic shock as a result of a continuous training program for physicians and nursing staff” at XVI Congress of the European Shock Society on September 24–26, 2015. Drs. Scheer, Fuchs, Kuhn, Vollmer, Rehberg, Abel, and Gründling have presented their study on “Sustained reduction of intensive care- and hospital length of stay for severe sepsis and septic shock patients by a continuous quality improvement program over 7.5 years” at XVI Congress of the European Shock Society, September 24–26, 2015.

The work was performed at University Hospital of Greifswald.

Drs. Scheer and Fuchs contributed equally.

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 (http://journals.lww.com/ccmjournal).

Dr. Kuhn reports personal fees from Dräger Medical, Germany, and Lilly Medical during the conduct of the study. His institution received funding from Dräger Medical, Germany; BMBF, Germany; and Lilly Medical. Dr. Gründling reports grants from BMBF, Germany, and personal fees and nonfinancial support from Dräger Medical Deutschland GmbH, Pfizer Deutschland GmbH and Becton, Dickinson and Company during the conduct of the study. He disclosed government work. His institution received funding from grant from BMBF and HICARE; from grants from the BMBF, Germany; and personal fees and nonfinancial support from Dräger Medical Deutschland GmbH, Pfizer Deutschland GmbH and Becton, Dickinson and Company during the conduct of the study. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: christian.scheer@uni-greifswald.de

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