title: Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality.
abstract: 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.
  
  
  METHODS
  Two-year prospective observational cohort.
  
  
  METHODS
  Academic tertiary care facility.
  
  
  METHODS
  Patients were 330 patients presenting to the emergency department who met criteria for severe sepsis or septic shock.
  
  
  METHODS
  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.
  
  
  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.
authors.affiliation: Department of Emergency Medicine, Loma Linda University, Loma Linda, CA, USA. hbnguyen@llu.edu
authors.forename: H Bryant
authors.initials: HB
authors.lastname: Nguyen
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Corbett
authors.forename: Robert
authors.initials: R
authors.lastname: Steele
authors.forename: Jim
authors.initials: J
authors.lastname: Banta
authors.forename: Robin T
authors.initials: RT
authors.lastname: Clark
authors.forename: Sean R
authors.initials: SR
authors.lastname: Hayes
authors.forename: Jeremy
authors.initials: J
authors.lastname: Edwards
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Cho
authors.forename: William A
authors.initials: WA
authors.lastname: Wittlake
mesh_terms: D018806:APACHE; D000368:Aged; D002985:Clinical Protocols; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D019983:Guideline Adherence; D017052:Hospital Mortality; D006785:Hospitals, University / Q000458:organization & administration; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D019984:Quality Indicators, Health Care / Q000458:organization & administration*; D018805:Sepsis / Q000401:mortality* / Q000628:therapy*; D012720:Severity of Illness Index; D012772:Shock, Septic / Q000401:mortality / Q000628:therapy; D016896:Treatment Outcome