title: Factors influencing variability in compliance rates and clinical outcomes among three different severe sepsis bundles.
abstract: BACKGROUND
  While 3 different quality indicator bundles are either approved (Voluntary Hospitals of America [VHA], Institute for Healthcare Improvement [IHI]) or proposed (Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) to rate clinical practices in treatment of severe sepsis, it is suspected that differences in the quality indicators among these bundles may lead to discrepant benchmarking data.
  
  
  OBJECTIVE
  To compare bundle compliance and patient factors associated with it among the IHI, JCAHO, and VHA severe sepsis bundles and explore possible reasons for any observed variability.
  
  
  METHODS
  Using a retrospective, noninterventional design, we evaluated 50 adults (APACHE II score 25 +/- 6, organ failure 2 +/- 1, and shock 52%) with severe sepsis who were admitted consecutively to an intensive care unit at a 450 bed university-affiliated hospital.
  
  
  RESULTS
  Few patients met 100% (IHI 6%, JCAHO 0%, VHA 6%) or 75% or greater (IHI 22%, JCAHO 6%, VHA 22%) of the quality indicators in each bundle. The number of patients who met 50% or more of the quality indicators varied significantly between JCAHO (28%) and both IHI (66%; p < 0.001) and VHA (60%; p < 0.001), but not between IHI and VHA (p = 0.53). Compliance with 50% or more of the quality indicators was more likely to occur when patients had shock (IHI, JCAHO, VHA), an APACHE II score greater than or equal to 25 (VHA), 2 or more organ failures (VHA), or survived hospitalization (IHI). We identified a number of factors that may help explain these differences.
  
  
  CONCLUSIONS
  Differences among the IHI, JCAHO, and VHA severe sepsis bundles lead to variability in bundle compliance rates and the patient factors associated with the variability and may lead to confusion when benchmarking practices among institutions. Future efforts should focus on developing a single valid and reliable bundle that allows providers to improve the quality of sepsis care.
authors.affiliation: School of Pharmacy, Northeastern University, Boston, MA 02115, USA.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Fong
authors.forename: Karen
authors.initials: K
authors.lastname: Cecere
authors.forename: John
authors.initials: J
authors.lastname: Unterborn
authors.forename: Erik
authors.initials: E
authors.lastname: Garpestad
authors.forename: Mark
authors.initials: M
authors.lastname: Klee
authors.forename: John W
authors.initials: JW
authors.lastname: Devlin
mesh_terms: D000328:Adult; D000368:Aged; D002985:Clinical Protocols; D005260:Female; D019983:Guideline Adherence / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic / Q000592:standards*; D019984:Quality Indicators, Health Care / Q000458:organization & administration; D012189:Retrospective Studies; D018805:Sepsis / Q000628:therapy*; D016896:Treatment Outcome