title: Resuscitation bundle compliance in severe sepsis and septic shock: improves survival, is better late than never.
abstract: While clinicians' management of severe sepsis and septic shock has been positively influenced by a number of clinical research studies in the last decade, challenges remain regarding early hemodynamic optimization as envisioned in the Surviving Sepsis Campaign's (SSC) resuscitation bundle (RB). We examined the impact of a hospital-wide continuous quality improvement (CQI) initiative on patients presenting with severe sepsis and septic shock, and the impact of the sepsis RB on patient outcomes when completed beyond the 6-hour recommendation period. The study was an 18-month, prospective cohort study enrolling patients who met the definition of severe sepsis or septic shock. Compliance with the hemodynamic components of the sepsis RB was defined as achieving goal mean arterial pressure (MAP) ≥ 65 mm Hg, central venous pressure (CVP) ≥ 8 mm Hg, and central venous oxygen saturation (ScvO₂) ≥ 70%. Compliance was assessed at 6 hours and 18 hours after diagnosis of severe sepsis or septic shock. In all, 498 patients with severe sepsis and/or septic shock were evaluated to determine the upper limit of the range of hours that compliance with the RB would still improve outcomes. Using 18 hours as a marker, Compliers at 18 hrs and Non-Compliers at 18 hrs were compared. There were 202 patients who had the RB completed in less than or equal to 18 hours. There were 296 patients who did not complete the RB at 18 hours. The Compliers at 18 hrs had a significant 10.2% lower hospital mortality 37.1% (22% relative reduction) compared to the Non-Compliers at 18 hrs hospital mortality of 47.3% (P < .03). When the two groups were adjusted for differences in baseline illness severity, the Compliers at 18 hrs had a greater reduction in predicted mortality of 26.8% versus 9.4%, P < 0.01.
  
  
  CONCLUSIONS
  Initiating the sepsis RB for patients with severe sepsis and/or septic shock decreased mortality. A CQI initiative that monitored the implementation in real-time allowed for improvement in compliance and efficacy of the bundle on outcomes. Multiple studies have shown that compliance to the RB within 6 hours lowers hospital mortality. This study uniquely shows that when bundle completion is extended to 18 hours, the mortality reduction remains significant.
authors.affiliation: Department of Emergency Medicine, Detroit, MI, USA Department of Surgery, Trauma and Surgical Critical Care, Detroit, MI, USA. vcoba1@hfhs.org
authors.forename: Victor
authors.initials: V
authors.lastname: Coba
authors.affiliation: Department of Surgery, Trauma and Surgical Critical Care, Detroit, MI, USA.
authors.forename: Melissa
authors.initials: M
authors.lastname: Whitmill
authors.affiliation: Department of Quality and Safety, Detroit, MI, USA.
authors.forename: Roberta
authors.initials: R
authors.lastname: Mooney
authors.affiliation: Department of Surgery, Trauma and Surgical Critical Care, Detroit, MI, USA.
authors.forename: H Mathilda
authors.initials: HM
authors.lastname: Horst
authors.affiliation: Department of Surgery, Trauma and Surgical Critical Care, Detroit, MI, USA.
authors.forename: Mary-Margaret
authors.initials: MM
authors.lastname: Brandt
authors.affiliation: Department of Medicine, Pulmonary Critical Care and Allergy, Detroit, MI, USA.
authors.forename: Bruno
authors.initials: B
authors.lastname: Digiovine
authors.affiliation: Department of Surgery, Trauma and Surgical Critical Care, Detroit, MI, USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Mlynarek
authors.affiliation: Department of Nursing, Detroit, MI, USA.
authors.forename: Beth
authors.initials: B
authors.lastname: McLellan
authors.affiliation: Department of Nursing, Detroit, MI, USA.
authors.forename: Gail
authors.initials: G
authors.lastname: Boleski
authors.affiliation: Department of Biostatistics and Epidemiology, Detroit, MI, USA.
authors.forename: James
authors.initials: J
authors.lastname: Yang
authors.affiliation: Department of Quality and Safety, Detroit, MI, USA.
authors.forename: William
authors.initials: W
authors.lastname: Conway
authors.affiliation: Department of Quality and Safety, Detroit, MI, USA.
authors.forename: Jack
authors.initials: J
authors.lastname: Jordan
mesh_terms: D018806:APACHE; D000140:Acidosis, Lactic / Q000209:etiology / Q000628:therapy; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D019983:Guideline Adherence / Q000592:standards / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006801:Humans; D007022:Hypotension / Q000209:etiology / Q000628:therapy; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010092:Oximetry; D011446:Prospective Studies; D058996:Quality Improvement; D012151:Resuscitation / Q000379:methods*; D018570:Risk Assessment; D018805:Sepsis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D012772:Shock, Septic / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D061665:Time-to-Treatment; D014481:United States / Q000453:epidemiology; D014662:Vasoconstrictor Agents / Q000627:therapeutic use*
chemical_list: D014662:Vasoconstrictor Agents