Quality Improvement Initiative for Severe Sepsis and Septic Shock Reduces 90-Day Mortality: A 7.5-Year Observational Study.
OBJECTIVE
To investigate the impact of a quality improvement initiative for severe sepsis and septic shock focused on the resuscitation bundle on 90-day mortality. Furthermore, effects on compliance rates for antiinfective therapy within the recommended 1-hour interval are evaluated.


METHODS
Prospective observational before-after cohort study.


METHODS
Tertiary university hospital in Germany.


METHODS
All adult medical and surgical ICU patients with severe sepsis and septic shock.


METHODS
Implementation of a quality improvement program over 7.5 years.


METHODS
The primary endpoint was 90-day mortality. Secondary endpoints included ICU and hospital mortality rates and length of stay, time to broad-spectrum antiinfective therapy, and compliance with resuscitation bundle elements.


RESULTS
A total of 14,115 patients were screened. The incidence of severe sepsis and septic shock was 9.7%. Ninety-day mortality decreased from 64.2% to 45.0% (p < 0.001). Hospital length of stay decreased from 44 to 36 days (p < 0.05). Compliance with resuscitation bundle elements was significantly improved. Antibiotic therapy within the first hour after sepsis onset increased from 48.5% to 74.3% (p < 0.001). Multivariate analysis revealed blood cultures before antibiotic therapy (hazard ratio, 0.60-0.84; p < 0.001), adequate calculated antibiotic therapy (hazard ratio, 0.53-0.75; p < 0.001), 1-2 L crystalloids within the first 6 hours (hazard ratio 0.67-0.97; p = 0.025), and greater than or equal to 6 L during the first 24 hours (hazard ratio, 0.64-0.95; p = 0.012) as predictors for improved survival.


CONCLUSIONS
The continuous quality improvement initiative focused on the resuscitation bundle was associated with increased compliance and a persistent reduction in 90-day mortality over a 7.5-year period. Based on the observational study design, a causal relationship cannot be proven, and respective limitations need to be considered.
1Department of Anesthesiology, University Hospital of Greifswald, Greifswald, Germany. 2Department of Mathematics and Computer Science, University of Greifswald, Greifswald, Germany. 3Department of Internal Medicine, University Hospital of Greifswald, Greifswald, Germany. 4Department of Microbiology, University Hospital of Greifswald, Greifswald, Germany.
Christian S
CS
Scheer
Christian
C
Fuchs
Sven-Olaf
SO
Kuhn
Marcus
M
Vollmer
Sebastian
S
Rehberg
Sigrun
S
Friesecke
Peter
P
Abel
Veronika
V
Balau
Christoph
C
Bandt
Konrad
K
Meissner
Klaus
K
Hahnenkamp
Matthias
M
Gründling
D000368:Aged; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D064872:Patient Care Bundles; D011446:Prospective Studies; D058996:Quality Improvement; D012151:Resuscitation / Q000379:methods / Q000592:standards; D018805:Sepsis / Q000401:mortality / Q000628:therapy*; D012772:Shock, Septic / Q000401:mortality / Q000628:therapy*