Impact of sepsis care bundles on hospital mortality in 135 consecutive patients with septic shock

Introduction

The purpose of the study was to describe the effectiveness of the Surviving Sepsis Campaign (SSC) bundles with regard to both implementation and outcome in patients with septic shock.

Methods

This was a single-center prospective observational study of patients admitted to the medical–surgical ICU of an urban tertiary care teaching hospital meeting criteria for the international sepsis definitions. Patients were entered in the database from September 2005 to October 2006. After a widespread 2-month educational program, implementation of SSC Resuscitation Bundles (RB) and Management Bundles (MB) were accomplished. We determined the rate of compliance and the prognostic value of the RB, the MB and of each bundle element.

Results

We analyzed 135 consecutive episodes of septic shock. The main sources of infection were: abdomen 39.5%, lung 29.9%, and urinary tract infection 11.1%. Global hospital mortality was 44.4%. Nonsurvivors were older (71 vs 64 years; P = 0.01), and had a higher APACHE II score (25 vs 20; P = 0.000), a higher SOFA score (10 vs 9; P = 0.001) and a higher number or organ dysfunctions at sepsis presentation (4 vs 3; P = 0.007). The rate of compliance with the RB was 38%. There were significant differences in mortality between compliant (C) and noncompliant (NC) groups despite the similar characteristics and the severity of septic shock. The NC group had a 58% mortality rate and the C group 22% (RR 2.6 (95% CI 1.49–4.5, P = 0.001)). The number needed to treat to save one life was 3. The compliance rate with MB was only 20%, and there were no differences in mortality between the C and NC groups (57.9% vs 52.6%). We only found differences in mortality between the C and NC groups in four bundle elements: serum lactate measured before 6 hours (35.2% vs 65.4%; P = 0.007), early broad-spectrum antibiotics (36.2.5% vs 56.1%; P = 0.051), ScvO₂ > 70% (35.7% vs 52.1%; P = 0.057) and activated protein C (65% vs 11% P = 0.000). In the multivariate analysis, activated protein C, early broad-spectrum antibiotics, PaO₂/FiO₂ < 200 and complete RB were associated independently with mortality.

Compliance rates with RB during three consecutive 4.6-month time periods were 28%, 41.4% and 33.3%, respectively. Compliance with MB was unchanged at 20%. The present dataset is underpowered to determine whether implementation of SSC bundles had some effect on mortality reduction.

Conclusion

Implementation of SSC bundles was associated with less adherence than expected. However, septic shock patients receiving the complete resuscitation bundle had substantially lower mortality. Efforts to increase compliance with these interventions should be made. The poor adherence to management bundles probably shows the many uncertainties that remain within this group of interventions.