The impact of protocolized sepsis order set on the process of care in patients with severe sepsis/septic shock

Background

Based on the available evidence, professional societies have published practice guidelines on severe sepsis and septic shock. We started using a paper order set based on the guidelines in our medical intensive care unit (ICU) in October 2005. This prospective study aims to describe the impact of the order set on the process of care.

Materials and methods

We included patients with severe sepsis/septic shock treated in our ICU between October 2005 and April 2007. We collected Acute Physiology and Chronic Health Evaluation (APACHE) III derived severity data, compliance with six elements of early goal-directed therapy and hospital mortality. Compliance with each element was defined as the use of the following within 6 hours of severe sepsis/septic shock: use of central venous pressure, central venous oxygen saturation measurement, adequate fluid resuscitation and appropriate use of vasopressors, inotropes and transfusion of red blood cells. The ICU admission severity of illness and sepsis stage (severe or shock) were entered in a logistic regression model to determine the independent impact of the order set on mortality. P < 0.05 was considered significant.

Results

Of 561 patients (168 severe sepsis and 373 septic shock), 31 were excluded for not authorizing research. The order set was utilized in 328 (61.9%) of 530 patients. There were no significant differences in gender, age, race, and severity of illness at ICU admission between the order set and nonorder set groups. The order set was more likely to be used in patients with septic shock than in those with severe sepsis (67.3% versus 51.4%; P = 0.0004). Compliance with all six elements occurred in 130 (39.6%) of the order set group compared with 50 (24.8%) of the nonorder set group (P = 0.0004). Although mortality did not change, compliance with five of the six elements improved significantly with the order set. Logistic regression analysis showed that shock (odds ratio (OR) = 2.384, 95% confidence interval (CI) = 1.431–3.970; P = 0.0008) and predicted APACHE III mortality (%) (OR = 1.040, 95% CI = 1.031–1.050; P < 0.0001) were associated with mortality, not the order set (OR = 0.742, 95% CI = 0.476–1.157; P = 0.1881).

Conclusion

This study showed that a protocolized order set improves compliance with the standard of care in patients with severe sepsis and septic shock. However, it did not resolve some of the noncompliance problems and did not improve survival.