title: Do clinical guidelines improve management of sepsis in critically ill elderly patients? A before-and-after study of the implementation of a sepsis protocol.
abstract: OBJECTIVE
  Guidelines for the management of sepsis have been published but not validated for elderly patients, though a prompt work-up and initiation of appropriate therapy are crucial. This study assesses the impact of a sepsis protocol on timelines for therapy and mortality in standardized management.
  
  
  METHODS
  Consecutive patients aged 70 years and older who were diagnosed with sepsis and admitted during the observation periods were included in this before-and-after study at a medical intensive care unit (ICU). Age, sex, and process-of-care variables including timely administration of antibiotics, obtaining blood cultures before the start of antibiotics, documenting central venous pressure, evaluation of central venous blood oxygen saturation, fluid resuscitation, and patient outcome were recorded.
  
  
  RESULTS
  A total of 122 patients were included. Sepsis was diagnosed in 22.9 % of patients prior to the introduction of the protocol and 57.4 % after introduction. Volume therapy was conducted in 63.9 % of the patients (11.5 % preprotocol). Blood culture samples were taken prior to the administration of antibiotics in 67.2 % of patients (4.9 % preprotocol), and antibiotics were applied early in 72.1 % of patients (32.8 % preprotocol). Lactate was set in 77.0 % of patients (11.5 % preprotocol). A central venous catheter was inserted in 88.5 % of patients (68.9 % preprotocol), and the target central venous pressure was achieved in 64.3 % of patients (47.2 % preprotocol). ICU mortality was reduced by 5.2 % and hospital mortality by 6.4 %.
  
  
  CONCLUSIONS
  The use of standardized order sets for the management of sepsis in elderly patients should be strongly recommended for better performance in treatment. Compliance with the protocol was associated with reduced length of stay, reduced mortality, and improved initial appropriate therapy.
authors.affiliation: Department of Emergency and Intensive Care Medicine, Klinikum Nuremberg, Prof.-E.-Nathan-Strasse 1, Nuremberg, Germany. heppner@klinikum-nuernberg.de
authors.forename: Hans Juergen
authors.initials: HJ
authors.lastname: Heppner
authors.forename: Katrin
authors.initials: K
authors.lastname: Singler
authors.forename: Anja
authors.initials: A
authors.lastname: Kwetkat
authors.forename: Steffen
authors.initials: S
authors.lastname: Popp
authors.forename: Adelheid Susanne
authors.initials: AS
authors.lastname: Esslinger
authors.forename: Philipp
authors.initials: P
authors.lastname: Bahrmann
authors.forename: Matthias
authors.initials: M
authors.lastname: Kaiser
authors.forename: Thomas
authors.initials: T
authors.lastname: Bertsch
authors.forename: Cornel Christian
authors.initials: CC
authors.lastname: Sieber
authors.forename: Michael
authors.initials: M
authors.lastname: Christ
mesh_terms: D000368:Aged; D003422:Critical Care / Q000592:standards* / Q000706:statistics & numerical data*; D016638:Critical Illness; D005260:Female; D005858:Germany / Q000453:epidemiology; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic; D015995:Prevalence; D012307:Risk Factors; D018805:Sepsis / Q000401:mortality* / Q000628:therapy*; D016019:Survival Analysis; D015996:Survival Rate; D016896:Treatment Outcome