Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and mortality in septic shock patients: Results of a three-year follow-up quasi-experimental study*

Objectives:To describe the effectiveness of the Surviving Sepsis Campaign bundles with regard to both implementation and outcome in patients with septic shock and to determine the contribution of the various elements of the bundles to the outcome. Design:Quasi-experimental study with a historical comparison group. Setting:The three medical–surgical intensive care units of an academic tertiary care center. Patients:A total of 384 adult patients in septic shock were enrolled after the educational intervention (September 2005–August 2008) and 96 patients in the historical group (June 2004–May 2005). Intervention:A hospital-wide quality improvement program based on the implementation of the Surviving Sepsis Campaign guidelines performed between June 2005 and August 2005. Measurements and Results:In-hospital mortality was reduced from 57.3% in the historical group to 37.5% in the intervention group (p = .001). This difference remained significant after controlling for confounding factors (odds ratio, 0.50; 95% confidence interval, 0.28–0.89). The intervention group had also lower length of stay for survivors in the hospital (36.2 ± 34.8 days vs. 41.0 ± 26.3 days; p = .043) and in the intensive care units (8.4 ± 9.8 days vs. 11.0 ± 9.5 days; p = .004). Improvements in survival were related to the number of bundle interventions completed (p for trend <.001). Compliance with six or more interventions of the 6-hr resuscitation bundle was an independent predictor of survival (adjusted odds ratio, 0.30; 95% confidence interval, 0.17–0.53; p <.001). The only single intervention with impact on mortality was the achievement of ScvO2 ≥70% (adjusted odds ratio, 0.62; 95% confidence interval, 0.38–0.99; p = .048). Conclusions:The implementation of the Surviving Sepsis Campaign guidelines was associated with a significant decrease in mortality. The benefits depend on the number of interventions accomplished within the time limits. The 6-hr resuscitation bundle showed greater compliance and effectiveness than the 24-hr management bundle. (Crit Care Med 2010; 38:1036–1043)

[1]  Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock , 2003, Current infectious disease reports.

[2]  G. Van den Berghe,et al.  Intensive insulin therapy in the medical ICU. , 2006, The New England journal of medicine.

[3]  S Greenland,et al.  Re: "The impact of confounder selection criteria on effect estimation. , 1989, American journal of epidemiology.

[4]  F. Gordo,et al.  Sepsis incidence and outcome: Contrasting the intensive care unit with the hospital ward* , 2007, Critical care medicine.

[5]  E. Ruokonen,et al.  Community‐acquired septic shock: early management and outcome in a nationwide study in Finland , 2007, Acta anaesthesiologica Scandinavica.

[6]  Mitchell M. Levy,et al.  2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference , 2003, Intensive Care Medicine.

[7]  D. Mannino,et al.  The epidemiology of sepsis in the United States from 1979 through 2000. , 2003, The New England journal of medicine.

[8]  Daniel Talmor,et al.  Implementation and outcomes of the Multiple Urgent Sepsis Therapies (MUST) protocol* , 2006, Critical care medicine.

[9]  Jesús Blanco,et al.  Incidence, organ dysfunction and mortality in severe sepsis: a Spanish multicentre study , 2008, Critical care.

[10]  A. E. El Solh,et al.  Outcome of Septic Shock in Older Adults After Implementation of the Sepsis “Bundle” , 2008, Journal of the American Geriatrics Society.

[11]  M. Levy,et al.  Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. , 2008, JAMA.

[12]  R. Rossaint,et al.  Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death. , 2005, The New England journal of medicine.

[13]  Scott T. Micek,et al.  Before–after study of a standardized hospital order set for the management of septic shock* , 2006, Critical care medicine.

[14]  M. Levy,et al.  2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference , 2003, Intensive care medicine.

[15]  M. Bauer,et al.  Implementation of an evidence-based “standard operating procedure” and outcome in septic shock* , 2006, Critical care medicine.

[16]  G W Sun,et al.  Inappropriate use of bivariable analysis to screen risk factors for use in multivariable analysis. , 1996, Journal of clinical epidemiology.

[17]  Gary Garber,et al.  The efficacy and safety of recombinant human activated protein C for the treatment of patients with severe sepsis (vol 28, pg 48, 2000) , 2001 .

[18]  F. Gao,et al.  The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study , 2005, Critical care.

[19]  B. Bistrian,et al.  Intensive insulin therapy in critically ill patients. , 2002, The New England journal of medicine.

[20]  J. Parrillo,et al.  Translating research to clinical practice: a 1-year experience with implementing early goal-directed therapy for septic shock in the emergency department. , 2006, Chest.

[21]  Margaret M Parker,et al.  Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock , 2004, Critical care medicine.

[22]  D. Berwick.  About the Institute for Healthcare Improvement , 1993 .

[23]  J Ean,et al.  Efficacy and safety of recombinant human activated protein C for severe sepsis. , 2001, The New England journal of medicine.

[24]  J. Sunderram,et al.  Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: A trend analysis from 1993 to 2003* , 2007, Critical care medicine.

[25]  S. Greenland,et al.  Simulation study of confounder-selection strategies. , 1993, American journal of epidemiology.

[26]  S Greenland,et al.  The impact of confounder selection criteria on effect estimation. , 1989, American journal of epidemiology.

[27]  Brian H Cuthbertson,et al.  Hydrocortisone therapy for patients with septic shock. , 2008, The New England journal of medicine.

[28]  Herwig Gerlach,et al.  Reply to Zandstra and van der Voort , 2004, Intensive Care Medicine.

[29]  Jeffrey A. Kline,et al.  The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: A meta-analysis* , 2008, Critical care medicine.

[30]  E. Rivers,et al.  Early goal-directed therapy prevents organ failure and mortality in severe sepsis and septic shock , 2003 .

[31]  Robert Steele,et al.  Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality* , 2007, Critical care medicine.

[32]  J. Vincent,et al.  Implementation of the Surviving Sepsis Campaign guidelines for severe sepsis and septic shock: we could go faster. , 2008, Journal of critical care.

[33]  C. Sprung,et al.  Sepsis in European intensive care units: Results of the SOAP study* , 2006, Critical care medicine.

[34]  E. Ivers,et al.  Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock , 2001 .