title: Differences in compliance with Surviving Sepsis Campaign recommendations according to hospital entrance time: day versus night.
abstract: BACKGROUND
  Higher compliance with Surviving Sepsis Campaign (SSC) recommendations has been associated with lower mortality. The authors evaluate differences in compliance with SSC 6-hour bundle according to hospital entrance time (day versus night) and its impact on hospital mortality.
  
  
  METHODS
  Prospective cohort study of all patients with community-acquired severe sepsis admitted to the intensive care unit of a large university tertiary care hospital, over 3.5 years with a follow-up until hospital discharge. Time to compliance with each recommendation of the SSC 6-hour bundle was calculated according to hospital entrance period: day (08:30 to 20:30) versus night (20:30 to 08:30). For the same periods, clinical staff composition and the number of patients attending the emergency department (ED) was also recorded.
  
  
  RESULTS
  In this period 300 consecutive patients were included. Compliance rate was (night vs. day): serum lactate measurement 57% vs. 49% (P = 0.171), blood cultures drawn 59% vs. 37% (P < 0.001), antibiotics administration in the first 3 hours 33% vs. 18% (P = 0.003), central venous pressure >8 mmHg 45% vs. 29% (P = 0.021), and central venous oxygen saturation (SvcO₂) >70%, 7% vs. 2% (P = 0.082); fluids were administered in all patients with hypotension in both periods and vasopressors were administered in patients with hypotension not responsive to fluids in 100% vs. 99%. Time to get specific actions done was also different (night vs. day): serum lactate measurement (4.5 vs. 7 h, P = 0.018), blood cultures drawn (4 vs. 8 h, P < 0.001), antibiotic administration (5 vs. 8 h, P < 0.001), central venous pressure (8 vs. 11 h, P = 0.01), and SvcO₂ monitoring (2.5 vs. 11 h, P = 0.222). The composition of the nursing team was the same around the clock; the medical team was reduced at night with a higher proportion of less differentiated doctors. The number of patients attending the Emergency Department was lower overnight. Hospital mortality rate was 34% in patients entering in the night period vs. 40% in those entering during the day (P = 0.281).
  
  
  CONCLUSIONS
  Compliance with SSC recommendations was higher at night. A possible explanation might be the increased nurse to patient ratio in that period. Adjustment of the clinical team composition to the patients' demand is needed to increase compliance and improve prognosis.
authors.forename: Mónica
authors.initials: M
authors.lastname: Almeida
authors.forename: Orquídea
authors.initials: O
authors.lastname: Ribeiro
authors.forename: Irene
authors.initials: I
authors.lastname: Aragão
authors.forename: Altamiro
authors.initials: A
authors.lastname: Costa-Pereira
authors.forename: Teresa
authors.initials: T
authors.lastname: Cardoso
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence / Q000592:standards* / Q000639:trends; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D010343:Patient Admission / Q000592:standards* / Q000639:trends; D010348:Patient Care Team / Q000592:standards* / Q000639:trends; D011446:Prospective Studies; D018805:Sepsis / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D015996:Survival Rate / Q000639:trends; D013997:Time Factors