title: Effect of performance improvement programs on compliance with sepsis bundles and mortality: a systematic review and meta-analysis of observational studies.
abstract: BACKGROUND
  Several reports suggest that implementation of the Surviving Sepsis Campaign (SSC) guidelines is associated with mortality reduction in sepsis. However, adherence to the guideline-based resuscitation and management sepsis bundles is still poor.
  
  
  OBJECTIVE
  To perform a systematic review of studies evaluating the impact of performance improvement programs on compliance with Surviving Sepsis Campaign (SSC) guideline-based bundles and/or mortality.
  
  
  METHODS
  Medline (PubMed), Scopus and Intercollegiate Studies Institute Web of Knowledge databases from 2004 (first publication of the SSC guidelines) to October 2014.
  
  
  METHODS
  Studies on adult patients with sepsis, severe sepsis or septic shock that evaluated changes in compliance to individual/combined bundle targets and/or mortality following the implementation of performance improvement programs. Interventions may consist of educational programs, process changes or both.
  
  
  METHODS
  Data from the included studies were extracted independently by two authors. Unadjusted binary data were collected in order to calculate odds ratios (OR) for compliance to individual/combined bundle targets. Adjusted (if available) or unadjusted data of mortality were collected. Random-effects models were used for the data synthesis.
  
  
  RESULTS
  Fifty observational studies were selected. Despite high inconsistency across studies, performance improvement programs were associated with increased compliance with the complete 6-hour bundle (OR = 4.12 [95% confidence interval 2.95-5.76], I(2) = 87.72%, k = 25, N = 50,081) and the complete 24-hour bundle (OR = 2.57 [1.74-3.77], I(2) = 85.22%, k = 11, N = 45,846) and with a reduction in mortality (OR = 0.66 [0.61-0.72], I(2) = 87.93%, k = 48, N = 434,447). Funnel plots showed asymmetry.
  
  
  CONCLUSIONS
  Performance improvement programs are associated with increased adherence to resuscitation and management sepsis bundles and with reduced mortality in patients with sepsis, severe sepsis or septic shock.
authors.affiliation: Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Via Tronto 10, 60126 Torrette di Ancona, Italy.
authors.forename: Elisa
authors.initials: E
authors.lastname: Damiani
authors.affiliation: Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Via Tronto 10, 60126 Torrette di Ancona, Italy.
authors.forename: Abele
authors.initials: A
authors.lastname: Donati
authors.affiliation: Department of Anesthesiology and Intensive Care, Modena University Hospital, L.go del Pozzo 71, 41100 Modena, Italy.
authors.forename: Giulia
authors.initials: G
authors.lastname: Serafini
authors.affiliation: Department of Anesthesiology and Intensive Care, Modena University Hospital, L.go del Pozzo 71, 41100 Modena, Italy.
authors.forename: Laura
authors.initials: L
authors.lastname: Rinaldi
authors.affiliation: Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Via Tronto 10, 60126 Torrette di Ancona, Italy.
authors.forename: Erica
authors.initials: E
authors.lastname: Adrario
authors.affiliation: Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Via Tronto 10, 60126 Torrette di Ancona, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Pelaia
authors.affiliation: Department of Anesthesiology and Intensive Care, Modena University Hospital, L.go del Pozzo 71, 41100 Modena, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Busani
authors.affiliation: Department of Anesthesiology and Intensive Care, Modena University Hospital, L.go del Pozzo 71, 41100 Modena, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Girardis
mesh_terms: D000328:Adult; D019983:Guideline Adherence; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D010043:Outcome and Process Assessment, Health Care; D012151:Resuscitation / Q000379:methods; D018570:Risk Assessment; D018805:Sepsis / Q000401:mortality* / Q000628:therapy; D012772:Shock, Septic / Q000401:mortality* / Q000628:therapy