Sepsis resuscitation bundle compliance in septic shock: improves survival and yet better late than never

Introduction

Improvements in survival for acute myocardial infarction, trauma, and stroke have been realized through continuous quality improvement (CQI) initiatives that include early identification and implementation of time-sensitive therapies at the earliest stage of disease presentation. In addition, challenges in the management of severe sepsis and septic shock remain in regards to implementation of an early sepsis resuscitation bundle (RB) in order to maximize outcome benefit. We examined the impact of a hospital-wide CQI initiative on septic RB compliance and outcome and investigated the mortality benefits beyond the 6-hour recommendation period.

Methods

Prospective cohort study of patients who met the definition of severe sepsis or septic shock over an 18-month period. Current sepsis RB being MAP ≥65, CVP ≥8 and SvO₂ ≥70% goals met within 6 hours and 18 hours upon presentation.

Results

The 498 severe sepsis and septic shock patients were enrolled and examined at what time period would the RB still be effective. Using a time cut-off, the Compliers at 18 hours and NonCompliers at 18 hours were then compared. There were 202 patients who had the RB completed in less than or equal to 18 hours (Compliers at 18 hours). There were 296 patients who never completed the RB within 18 hours (NonCompliers at 18 hours). The Compliers at 18 hours had a significant 10.2% lower hospital mortality at 37.1% (22% relative reduction) compared with the NonCompliers at 18 hours hospital mortality of 47.3% (P < 0.03). Adjusting for differences in baseline illness severity, the Compliers at 18 hours had a greater reduction in predicted mortality of 26.8% vs 9.4%, P < 0.01. Compliance started at 30.4% and finished at 63%.

Conclusions

A CQI initiative for severe sepsis and septic shock with particular emphasis on the RB significantly improved bundle compliance and decreased hospital mortality. It has been previously shown that compliance to the RB within 6 hours improves outcome; however, when the time of bundle completion is extended to 18 hours, the mortality benefits are still significant.