Differences in compliance with Surviving Sepsis Campaign recommendations according to hospital entrance time: day versus night

Introduction

Higher compliance with Surviving Sepsis Campaign (SSC) recommendations has been associated with lower mortality. The authors evaluate differences in compliance with SSC 6-hour bundle according to hospital entrance time (day versus night) and its impact on hospital mortality.

Methods

Prospective cohort study of all patients with community-acquired severe sepsis admitted to the intensive care unit of a large university tertiary care hospital, over 3.5 years with a follow-up until hospital discharge. Time to compliance with each recommendation of the SSC 6-hour bundle was calculated according to hospital entrance period: day (08:30 to 20:30) versus night (20:30 to 08:30). For the same periods, clinical staff composition and the number of patients attending the emergency department (ED) was also recorded.

Results

In this period 300 consecutive patients were included. Compliance rate was (night vs. day): serum lactate measurement 57% vs. 49% (P = 0.171), blood cultures drawn 59% vs. 37% (P < 0.001), antibiotics administration in the first 3 hours 33% vs. 18% (P = 0.003), central venous pressure >8 mmHg 45% vs. 29% (P = 0.021), and central venous oxygen saturation (SvcO₂) >70%, 7% vs. 2% (P = 0.082); fluids were administered in all patients with hypotension in both periods and vasopressors were administered in patients with hypotension not responsive to fluids in 100% vs. 99%. Time to get specific actions done was also different (night vs. day): serum lactate measurement (4.5 vs. 7 h, P = 0.018), blood cultures drawn (4 vs. 8 h, P < 0.001), antibiotic administration (5 vs. 8 h, P < 0.001), central venous pressure (8 vs. 11 h, P = 0.01), and SvcO₂ monitoring (2.5 vs. 11 h, P = 0.222). The composition of the nursing team was the same around the clock; the medical team was reduced at night with a higher proportion of less differentiated doctors. The number of patients attending the Emergency Department was lower overnight. Hospital mortality rate was 34% in patients entering in the night period vs. 40% in those entering during the day (P = 0.281).

Conclusion

Compliance with SSC recommendations was higher at night. A possible explanation might be the increased nurse to patient ratio in that period. Adjustment of the clinical team composition to the patients'' demand is needed to increase compliance and improve prognosis.     

Late compliance with the sepsis resuscitation bundle: impact on mortality

Early compliance with the sepsis resuscitation bundle has been suggested to reduce mortality. However, few data are available about the impact of late compliance with the bundle on outcomes. The aim of this study was to assess whether the completion of the resuscitation bundle within the first 6 h after admission to the intensive care unit (ICU), but beyond the specific time limit of the various bundle interventions, is related to an improvement in survival. This prospective, cohort study included 753 patients recruited from September 2005 until August 2010 with severe sepsis/septic shock in the three medical-surgical ICUs of a tertiary academic medical center. We assessed the compliance with the different tasks included in the resuscitation bundle. Furthermore, we ascertained within the first 6 h after ICU admission the compliance with those tasks not carried out within their specific time limits; we have termed this variable "bundle improvement in the ICU." Septic shock was present in 88.1%. The overall in-hospital mortality was 31.6%. In 51.5%, there was bundle improvement in the ICU; this variable was associated with a lower risk of mortality (adjusted hazard ratio, 0.52 [95% confidence interval, 0.34-0.78]). That association was observed only when the time from severe sepsis onset to ICU admission was 6 h or less. Importantly, similar results were found after excluding all patients with severe sepsis (rapid responders) and those with refractory shock (nonresponders). The task with highest improvement was the achievement of central venous oxygen saturation 70% or greater in 39% of patients. Compliance with the resuscitation bundle even beyond the recommended time is associated with improvement in survival in patients with severe sepsis/septic shock.     

Surviving the first hours in sepsis: getting the basics right (an intensivist's perspective)

Severe sepsis is a major cause of morbidity and mortality, claiming between 36?000 and 64?000 lives annually in the UK, with a mortality rate of 35%. International guidelines for the management of severe sepsis were published in 2004 by the Surviving Sepsis Campaign and condensed into two Care Bundles. In 2010, the Campaign published results from its improvement programme showing that, although an absolute mortality reduction of 5.4% was seen over a 2 year period in line with increasing compliance with the Bundles, reliability was not achieved and Bundle compliance reached only 31%. This article explores current challenges in sepsis care and opportunities for further improvements. Basic care tasks [microbiological sampling and antibiotic delivery within 1 h, fluid resuscitation, and risk stratification using serum lactate (or alternative)] are likely to benefit patients most, yet are unreliably performed. Barriers include lack of awareness and robust process, the lack of supporting controlled trials, and complex diagnostic criteria leading to recognition delays. Reliable, timely delivery of more complex life-saving tasks (such as early goal-directed therapy) demands greater awareness, faster recognition and initiation of basic care, and more effective collaboration between clinicians and nurses on the front line, in critical care and in specialist support services, such as microbiology and infectious diseases. Organizations such as Survive Sepsis, the Surviving Sepsis Campaign and the Global Sepsis Alliance are working to raise awareness and promote further improvement initiatives. Future developments will focus on sepsis biomarkers and microarray techniques to rapidly screen for pathogens, risk stratification using genetic profiling, and the development of novel therapeutic agents targeting immunomodulation.     

Surviving sepsis: a guide to the guidelines

The revised Surviving Sepsis Campaign (SSC) guidelines for the management of severe sepsis and septic shock have recently been published. These guidelines represent the end product of an intense process and provide a template approach to the early resuscitation and support of patients with sepsis, based on a synthesis of evidence that has been shown to improve the outcome of the septic patient. The SSC guidelines arose from a recognition that care of the septic patient was suboptimal for at least three reasons. First, the entity of sepsis was frequently not diagnosed in a timely fashion, allowing the process to evolve into a life-threatening syndrome of major physiologic organ system dysfunction. Secondly, even when sepsis was recognized, the urgency of treatment was underappreciated – and so haemodynamic resuscitation was tentative, and the administration of effective antibiotic therapy was often delayed. Finally, treatment was often suboptimal, and failed to take advantage of emerging insights into optimal approaches to patient management. The revised guidelines are far from perfect, but they represent the best available synthesis of contemporary knowledge in this area and as such should be promoted.     

Surviving sepsis campaign: a critical reappraisal

In 2002, the declaration of Barcelona launched a worldwide campaign that proposed to decrease in sepsis-related mortality by the introduction of evidence-based medicine into the management of sepsis. This paved the way for the publication of a wide selection of recommendations entitled the Surviving Sepsis Campaign (SSC) Guidelines. Whereas most of the medical community received the guidelines with enthusiasm, dissonant voices were made public just after its publication, and in recent years, the SSC guidelines were a source of intense debate, resulting in a recent revision of the guidelines. In the midst of a large controversy, it is evident that a critical reappraisal of the SSC guidelines is timely. In our opinion, whereas many relevant aspects of the SSC guidelines have been discussed, there are three major limitations that deserve a closer look, and they are sepsis as a public health issue, the weight of the evidence behind the recommendations, and the absence of recommendations related to the prevention of sepsis. In conclusion, although we recognize that the SSC is a valuable initiative, many of its present aspects must be revised to provide a clear message for clinicians taking care of sepsis patients at bedside. New guidelines should be based on solid evidence, have no interference from the pharmaceutical or medical equipment industry, and should have a stronger preventive and public health approach.     

Teaching quality improvement in the classroom and clinic: getting it wrong and getting it right

The world in which today's graduates will provide care is changing, as are expectations about caregivers' performance. Learning how to improve quality of care must occur during, and as part of, learning about patient care. In this article, I describe a continuous quality improvement learning program that was integrated into nursing students' education and a study evaluating the students' experiences with the implementation of the program through open-ended questions and focus groups. The program consisted of three parts: participating in a personal improvement project; observing and describing a patient process from the patient's perspective; and working in teams with process improvement in clinical practice. The findings indicated the students learned improvement methods and tools during their personal improvement projects, but their ability to translate that knowledge into action, and thereby improve patient care, was insufficiently developed through coaching, reflection, and role modeling. In other words, the experience was not integrated into the students' general education. In addition, faculty and clinical staff did not seem to be adequately informed and had limited knowledge of the students' clinical improvement projects.     

Surviving sepsis campaign: research priorities for sepsis and septic shock

Objective

To identify research priorities in the management, epidemiology, outcome and underlying causes of sepsis and septic shock.

Design

A consensus committee of 16 international experts representing the European Society of Intensive Care Medicine and Society of Critical Care Medicine was convened at the annual meetings of both societies. Subgroups had teleconference and electronic-based discussion. The entire committee iteratively developed the entire document and recommendations.

Methods

Each committee member independently gave their top five priorities for sepsis research. A total of 88 suggestions (ESM 1 - supplemental table 1) were grouped into categories by the committee co-chairs, leading to the formation of seven subgroups: infection, fluids and vasoactive agents, adjunctive therapy, administration/epidemiology, scoring/identification, post-intensive care unit, and basic/translational science. Each subgroup had teleconferences to go over each priority followed by formal voting within each subgroup. The entire committee also voted on top priorities across all subgroups except for basic/translational science.

Results

The Surviving Sepsis Research Committee provides 26 priorities for sepsis and septic shock. Of these, the top six clinical priorities were identified and include the following questions: (1) can targeted/personalized/precision medicine approaches determine which therapies will work for which patients at which times?; (2) what are ideal endpoints for volume resuscitation and how should volume resuscitation be titrated?; (3) should rapid diagnostic tests be implemented in clinical practice?; (4) should empiric antibiotic combination therapy be used in sepsis or septic shock?; (5) what are the predictors of sepsis long-term morbidity and mortality?; and (6) what information identifies organ dysfunction?

Conclusions

While the Surviving Sepsis Campaign guidelines give multiple recommendations on the treatment of sepsis, significant knowledge gaps remain, both in bedside issues directly applicable to clinicians, as well as understanding the fundamental mechanisms underlying the development and progression of sepsis. The priorities identified represent a roadmap for research in sepsis and septic shock.

     

严重脓毒症和脓毒性休克的急诊集束化治疗依从性调查分析

目的 调查严重脓毒症和脓毒性休克在急诊患者中的发生率以及针对严重脓毒症和脓毒性休克早期集束化治疗的依从性.方法 选择2009年5月至6月由救护车送至上海交通大学医学院附属瑞金医院急诊科的患者为调查对象,统计严重脓毒症和脓毒性休克的发生率,对符合诊断标准的患者分别统计早期复苏集束化治疗各项指标完成的依从性.结果 共纳入急诊就诊患者917例,其中符合严重脓毒症和脓毒性休克诊断标准者96例,发生率为10.47%.在符合诊断标准的患者中,早期复苏集束化治疗、使用抗菌药物前留取病原学标本、2 h内放置深静脉导管并监测中心静脉压(CVP)与中心静脉血氧饱和度(ScvO2)、3 h内使用广谱抗菌药物、6 h内早期目标导向治疗(EGDT)达标、12 h内乳酸下降或原乳酸≤2 mmol/L的依从性分别为1.04%、3.12%、2.08%、83.33%、1.04%、23.96%,急诊内科各指标的依从性依次为1.19%、3.57%、2.38%、83.33%、1.19%、26.19%,急诊外科各指标的依从性依次为0、0、0、83.33%、0、8.33%,急诊内、外科依从性比较差异均无统计学意义(均P＞0.05).结论 严重脓毒症和脓毒性休克在急诊就诊患者中占相当比例,但医师的认识不足;早期集束化治疗依从性较低,需加大指南的教育及执行程度.

Abstract：

Objective To evaluate the occurrence of severe sepsis and septic shock and the rate of compliance with sepsis bundle in patients with severe sepsis and septic shock in emergency department.Methods A prospective study was conducted on consecutive adult patients who were sent to Emergency Department of Ruijin Hospital, Shanghai Jiaotong University School of Medicine by ambulance from May to June in 2009. The occurrence of severe sepsis and septic shock, and the number of the patients in whom who met the criteria of compliance with sepsis bundle were analyzed. Results Nine hundred and seventeen patients who were sent to the emergency department by ambulance in that period were enrolled in the study.The number of patients with severe sepsis and septic shock was 96. The incidence of severe sepsis and septic shock was 10.47%. Among these patients, the number of patients in whom the sepsis bundle was complied,i.e. sepsis bundle, appropriate cultures were taken before antimicrobial therapy, placement of central venous catheter and monitoring of central venous pressure(CVP)as well as central venous oxygen saturation (ScvO2)within 2 hours, antibiotic therapy within 3 hours, early goal-directed therapy(EGDT)within 6 hours, and lactate clearance in 12 hours reached 1.04%, 3. 12%, 2.08%, 83. 33%, 1.04%, 23.96%.The results were 1.19%, 3. 57%, 2.38%, 83.33%, 1.19%, 26.19% and 0, 0, 0, 83.33%, 0, 8. 33% in medical and surgical emergency department respectively. There was no statistical difference between the two divisions(all P＞0. 05). Conclusion The incidence of severe sepsis and septic shock was high in emergency department, but the rate of recognition of it and the compliance with sepsis bundle were inadequate. It is urgently necessary to enhance the learning and implementation of the guideline.     

An audit of compliance with the sepsis resuscitation care bundle in patients admitted to A&E with severe sepsis or septic shock

Severe sepsis and septic shock are syndromes resulting in a systemic inflammatory response and the dysfunction of one or more organs following infection. The Surviving Sepsis Campaign is an international effort to reduce mortality in severe sepsis and septic shock by 25% by 2009 using a care bundle approach. It comprises evidenced-based interventions to be carried out within 6h of onset of sepsis. We conducted a prospective observational audit of 32 consecutive adult patients with severe sepsis or septic shock admitted via the A&E of a district general hospital. The compliance rate against each element, and overall compliance to the 6-h bundle were obtained. Patients' ages ranged from 55 to 75 years with 53% being male. Overall compliance was 19%. Arterial lactate was undertaken 100% of the time, and only just over half received an appropriate fluid challenge. Administration of an antibiotic was also very slow. Local recommendations include improvements to the track and trigger scoring system in A&E to improve recognition of sick patients, ensuring the doctor responsible for prescribing the antibiotic will administer it, and increasing awareness of the surviving sepsis campaign via education and training of all A&E staff. Given current evidence greater compliance to the care bundle may well improve patient outcomes for this client group.