Implementation of the Surviving Sepsis Campaign one-hour bundle in a short stay unit: A quality improvement project

ObjectiveTo improve timely sepsis care by implementing the 2018 Surviving Sepsis Campaign one-hour interventions.DesignTen-month prospective quality improvement project.SettingA 38-bed short stay unit within an 800-bed hospital in New York City.ParticipantsPatients admitted to the short stay unit who screened positive for sepsis.InterventionA sepsis implementation tool was created from the 2018 Surviving Sepsis Campaign guidelines. Sepsis champions delivered education on sepsis recognition, treatment, and management, and the sepsis implementation tool to the healthcare staff.Process and outcome measuresTime to first lactate, blood cultures × 2, antibiotic administration, length of stay and mortality were tracked weekly for five months.ResultsFrom May 6, 2019 to October 1, 2019, 32 patients were diagnosed with sepsis. Initial lactate and blood cultures were completed on every patient within 1one-hour of sepsis diagnosis. Administration of antibiotics within one-hour reached 100% after week four and was sustained.ConclusionUse of a registered nurse-initiated sepsis implementation tool in a short stay unit led to the completion of blood cultures, initial lactate, and antibiotic administration within one-hour. Key factors to support this practice improvement were increasing registered nurse, physician and physician assistant sepsis knowledge, registered nurse and physician/physician assistant early collaboration, increased staffing and intravenous access equipment.     

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.     

An audit of ward nurses' knowledge of sepsis

Many of the patients with sepsis admitted to intensive care and high dependency units develop severe sepsis/septic shock in general hospital wards. If the Surviving Sepsis Campaign's aim of a 25% reduction in mortality from sepsis is to be achieved by 2009, then it is essential that registered nurses are aware of the standard definitions of sepsis, and the recommendations for its initial management. The aim of this study was to audit ward nurses' knowledge of sepsis against standard definitions and evidence-based management guidelines. An audit was carried out in one acute hospital to assess ward nurses' knowledge of sepsis. Seventy-three registered nurses from medical, surgical and orthopaedic wards completed a questionnaire about the signs and symptoms of sepsis and its initial management. The results showed that some ward nurses appeared to have a poor knowledge of the signs and symptoms of sepsis, severe sepsis/septic shock and some aspects of its initial management. Following the results of the audit, a variety of educational initiatives were introduced to raise awareness of the standard definitions and the surviving sepsis management guidelines. In conclusion, targeted education must be provided for nurses working in general wards if the Surviving Sepsis Campaign is to achieve its aim of a 25% reduction in mortality by 2009.     

A multicenter,prospective evaluation of quality of care and mortality in Japan based on the Surviving Sepsis Campaign guidelines

To elucidate the standard Surviving Sepsis Campaign (SSC) guidelines-based quality of care and mortality related to severe sepsis in Japan, we conducted a multicenter, prospective, observational study using a new web-based database between June 1, 2010, and December 31, 2011. A total of 1104 patients with severe sepsis were enrolled from 39 Japanese emergency and critical care centers. All-cause hospital mortality was 29.3% in patients with severe sepsis and 40.7% in patients with septic shock. Pulmonary, renal, hepatic, and hematological dysfunctions were associated with significantly higher mortality, and hematological dysfunction, especially coagulopathy, was associated with the highest odds ratio for mortality. Compliance with severe sepsis bundles in our study was generally low compared with that in a previous international sepsis registry study, and glycemic control was associated with lowest odds ratio for mortality. Despite higher complication rates of multiple organ dysfunction syndrome and low compliance with severe sepsis bundles on the whole, mortality in our study was similar to that in the international sepsis registry study. From these results, we concluded that our prospective multicenter study was successful in evaluating SSC guidelines-based standard quality of care and mortality related to severe sepsis in Japan. Although mortality in Japan was equivalent to that reported worldwide in the above-mentioned international sepsis registry study, compliance with severe sepsis bundles was low. Thus, there is scope for improvement in the initial treatment of severe sepsis and septic shock in Japanese emergency and critical care centers.     

Sepsis与感染性休克的急诊救治及流程优化

Sepsis及感染性休克是临床常见的综合症,与患者预后密切相关。早期救治对Sepsis及感染性休克至关重要。急诊医师在早期诊断Sepsis、评价危险因素和早期复苏方面均起到至关重要的作用。目前证据表明,“Sepsis的集束化治疗”能够改善此类患者预后,2018年4月“拯救Sepsis运动”再次更新了相关推荐意见,提出了“1 h集束化治疗目标”,这对急诊医师提出了更高的要求。本文拟从救治流程、具体处理及可能的政策指导方面讨论Sepsis及感染性休克的急诊优化治疗,以期提高指南依从性和治疗质量,由此改善此类患者的预后。     

Surviving sepsis: a trust‐wide approach. A multi‐disciplinary team approach to implementing evidence‐based guidelines

Aim: To share an experience of examining the true extent of the number of patients with severe sepsis being admitted, and the overall compliance with existing treatment guidelines in a district general hospital (DGH). Background: Because of its aggressive, multi‐factorial nature, sepsis is a rapid killer. Mortality associated with severe sepsis remains unacceptably high: 30–50%. When shock is present, mortality is reported to be even higher: 50–60%. The rapid diagnosis and management of sepsis is vital to successful treatment. The International Surviving Sepsis Campaign (SSC) was developed to help meet the challenges of sepsis and to improve its management, diagnosis and treatment. The overall aim is to reduce mortality from sepsis by 25% by 2009. Data sources and methods: Data on the number of patients admitted with severe sepsis to the DGH were previously unknown. The aim of the baseline audits was to determine the true extent of the problem and baseline mortality rates, resulting in an action plan to provide evidence‐based care to patients with sepsis regardless of where in the hospital they were located. Results: It was found that 11% of the patients audited presented with signs of severe sepsis and demonstrated elements of poor compliance with some elements of existing treatment guidelines as set out by the resuscitation component of the Surviving Sepsis Care Bundle. Conclusion: As an international campaign introduced predominantly within critical care, within this DGH the SSC teams' innovative approach has resulted in:

• ? Better educated staff;
• ? Objectives agreed within multi‐disciplinary teams;
• ? The appropriate assessment of resources;
• ? Standardization of practice in terms of patients presenting with severe sepsis.

     

A Blueprint for a Sepsis Protocol

Despite numerous advances in medicine, sepsis remains an unconquered challenge. Although outcomes have improved slightly over decades, the unacceptably high mortality rate of 30%–50% for severe sepsis and septic shock continues. However, after years of unsuccessful clinical trials, several investigations over the last few years have reported survival benefit in the treatment of sepsis. Physicians now have several proven therapies to treat sepsis, but have yet to implement them on a widespread, systematic basis. This led 11 international professional societies spanning multiple specialties and continents to come together to create the Surviving Sepsis Campaign. The product of their work is an international effort organized to improve care of patients with sepsis and includes consensus, evidence‐based guidelines for care that improves survival in septic patients, and an action plan for change. Given the clear role of early identification and treatment in stopping the sepsis cascade, therapy must start early in the emergency department (ED) and continue throughout the hospital course. The first of the recommendations by the Surviving Sepsis Campaign is the aggressive resuscitation strategy of early goal‐directed therapy (EGDT). EGDT is reported to reduce absolute mortality by a staggering 16%. The use of recombinant activated protein C was demonstrated to confer a 6% absolute survival benefit. Steroid supplementation in adrenal insufficiency produced a 10% benefit. Additionally, early and appropriate use of antibiotics remains a cornerstone of therapy. Although no randomized trial will be performed, the effects are undisputed. Finally, although predominantly intensive care unit therapies, tight glucose control and low‐tidal‐volume ventilation strategies have also led to improved survival. Armed with these new therapies, the medical community must rise to this call to action. Clinicians must change the approach to this disease, as well as the way the septic patient is viewed. Although complex and challenging, these therapies must be brought to the patient's bedside. We propose and describe the Multiple Urgent Sepsis Therapies (MUST) protocol as a practical way to implement a comprehensive treatment plan using available evidence‐based therapies.     

The Surviving Sepsis Campaign: raising awareness to reduce mortality

Sepsis affects 18 million people worldwide every year, and on average each case costs more than US$22 000 to treat. Despite this there is no consensus on the clinical definition of sepsis, and successful diagnosis and treatment is difficult. The Barcelona Declaration, issued by the Surviving Sepsis Campaign in October 2002, outlines a six-point plan to reduce the relative mortality of sepsis by 25% over the next 5 years. The Campaign organizers are currently producing evidence-based guidelines on source control and management of sepsis, as well as a policy document on how sepsis is managed around the world.     

医疗资源配置对脓毒症发生发展的影响及对策

脓毒症是机体感染后出现的炎症、免疫等异常反应, 可导致严重的组织器官功能受损, 是目前临床常见且棘手的危重症之一。随着对因、对症集束治疗策略的不断完善, 脓毒症病死率有所下降; 但因人口老龄化、生活方式改变、各种并存慢性病发病率升高, 脓毒症的发病率也显著上升且病理过程更加复杂化, 每年总死亡人数明显增加。目前, 脓毒症已成为全球沉重的医疗负担, 这一问题在医疗资源配置落后地区尤为突出。本文将阐述医疗资源配置对脓毒症流行病学、医务人员监测诊治水平和医院管理成本等方面的影响, 进而就如何降低医疗资源配置落后对脓毒症发生发展的不良影响, 以及如何提高"拯救脓毒症运动"指南的依从性提出相应对策。     

The Sepsis Six: helping patients to survive sepsis

Sepsis kills more people than lung cancer, and more people than bowel and breast cancer put together. The costs to the NHS are significant; it is estimated that in Europe, patients with severe sepsis cost healthcare funders around 7.6 billion euros per year (Daniels et al, 2007). Costs in the United States are estimated at $16 billion annually (Angus et al, 2001), and in the United Kingdom up to 46% of intensive care unit (ICU) bed days are used by patients with severe sepsis (Padkin et al, 2003), with each ICU bed costing around pounds sterling1700 per day. In 2002 an international campaign was launched: the Surviving Sepsis Campaign. The main aim of this campaign is to reduce mortality from sepsis by 25% by 2009. A lot of the early work has concentrated on improving sepsis care in intensive care units, but many patients on general wards develop sepsis, and the need to educate nurses throughout all areas of the hospital has been recognized. In September 2007 a new part of the campaign was launched called Survive Sepsis, which aims to deliver sepsis education to ward nurses and junior doctors. This article discusses how to recognize severe sepsis and explains how nurses can dramatically improve a patient's chance of survival by ensuring that six simple things (Sepsis Six) are done in the first hour.     

Bench-to-bedside review: The initial hemodynamic resuscitation of the septic patient according to Surviving Sepsis Campaign guidelines – does one size fit all?

The Surviving Sepsis Campaign guidelines for the management of severe sepsis and septic shock recommend that the initial hemodynamic resuscitation be done according to the protocol used by Rivers and colleagues in their well-known early goal-directed therapy (EGDT) study. However, it may well be that their patients were much sicker on admission than many other septic patients. Compared with other populations of septic patients, the patients of Rivers and colleagues had a higher incidence of severe comorbidities, a more severe hemodynamic status on admission (excessively low central venous oxygen saturation [ScvO2], low central venous pressure [CVP], and high lactate), and higher mortality rates. Therefore, it may well be that these patients arrived to the hospital in late untreated hypovolemic sepsis, which may have been due, in part at least, to low socioeconomic status and reduced access to health care. The EGDT protocol uses target values for CVP and ScvO2 to guide hemodynamic management. However, filling pressures do not reliably predict the response to fluid administration, while the ScvO2 of septic patients is characteristically high due to decreased oxygen extraction. For all these reasons, it seems that the hemodynamic component of the Surviving Sepsis Campaign guidelines cannot be applied to all septic patients, particularly those who develop sepsis during their hospital stay.     

从“拯救Sepsis运动”指南变迁看血流动力学的巨变

血流动力学治疗是Sepsis救治必不可少的内容。从2004年开始, "拯救Sepsis运动(Surviving Sepsis Campaign, SSC)"指南先后经历了4次变迁, 每一次变迁均是前期基础上的进一步完善。在SSC指南的变迁过程中, 血流动力学治疗策略的制定和实施发生着重要改变。临床对于Sepsis血流动力学治疗认识的逐步深刻也是血流动力学巨变的过程, 有利于治疗调控更为精准。     

Improvements in the outcome of children with meningococcal disease

Recent years have seen a marked reduction in the mortality of children with meningococcal disease in paediatric intensive care units (PICU); the reasons for this improvement are multifactorial. The mortality rates for critically ill children overall have improved and reasons for this are probably increased centralisation of PICU services and that fewer critically ill children are now looked after on adult units. Specific treatment pathways for sepsis have improved with the publication of clinical guidelines for children and initiatives such as the Surviving Sepsis Campaign. There is a continuing need to focus on the care delivered to children before reaching PICU and to minimise the morbidity suffered by survivors of this disease.     

Bench-to-bedside review: The initial hemodynamic resuscitation of the septic patient according to Surviving Sepsis Campaign guidelines – does one size fit all?

The Surviving Sepsis Campaign guidelines for the management of severe sepsis and septic shock recommend that the initial hemodynamic resuscitation be done according to the protocol used by Rivers and colleagues in their well-known early goal-directed therapy (EGDT) study. However, it may well be that their patients were much sicker on admission than many other septic patients. Compared with other populations of septic patients, the patients of Rivers and colleagues had a higher incidence of severe comorbidities, a more severe hemodynamic status on admission (excessively low central venous oxygen saturation [ScvO₂], low central venous pressure [CVP], and high lactate), and higher mortality rates. Therefore, it may well be that these patients arrived to the hospital in late untreated hypovolemic sepsis, which may have been due, in part at least, to low socioeconomic status and reduced access to health care. The EGDT protocol uses target values for CVP and ScvO₂ to guide hemodynamic management. However, filling pressures do not reliably predict the response to fluid administration, while the ScvO₂ of septic patients is characteristically high due to decreased oxygen extraction. For all these reasons, it seems that the hemodynamic component of the Surviving Sepsis Campaign guidelines cannot be applied to all septic patients, particularly those who develop sepsis during their hospital stay.     

Physiological monitoring for critically ill patients: testing a predictive model for the early detection of sepsis.

OBJECTIVE: To assess the predictive value for the early detection of sepsis of the physiological monitoring parameters currently recommended by the Surviving Sepsis Campaign. METHODS: The Project IMPACT data set was used to assess whether the physiological parameters of heart rate, mean arterial pressure, body temperature, and respiratory rate can be used to distinguish between critically ill adult patients with and without sepsis in the first 24 hours of admission to an intensive care unit. RESULTS: All predictor variables used in the analyses differed significantly between patients with sepsis and patients without sepsis. However, only 2 of the predictor variables, mean arterial pressure and high temperature, were independently associated with sepsis. In addition, the temperature mean for hypothermia was significantly lower in patients without sepsis. The odds ratio for having sepsis was 2.126 for patients with a temperature of 38 degrees C or higher, 3.874 for patients with a mean arterial blood pressure of less than 70 mm Hg, and 4.63 times greater for patients who had both of these conditions. CONCLUSIONS: The results support the use of some of the guidelines of the Surviving Sepsis Campaign. However, the lowest mean temperature was significantly less for patients without sepsis than for patients with sepsis, a finding that calls into question the clinical usefulness of using hypothermia as an early predictor of sepsis. Alone the group of variables used is not sufficient for discriminating between critically ill patients with and without sepsis.     

Sepsis Screening in Triage to Decrease Door-to-Antibiotic Time

IntroductionIdentifying patients with sepsis at triage can lead to a decrease in door-to-antibiotic time. Our community hospital emergency department’s mean door-to-antibiotic time was 105.3 minutes, falling short of the Surviving Sepsis Campaign guideline’s benchmark goal of 60 minutes. One of the most common reasons for treatment delays was that patients with sepsis were not identified upon entrance to the emergency department. A solution to the delay was to implement a practice improvement project by having the triage nurse screen all patients for sepsis upon entrance to the emergency department.MethodsA sepsis-screening tool was used to identify patients with sepsis and was based on systemic inflammatory response syndrome (SIRS) criteria. Patients screening positive were prioritized for ED bed space. The change in process allowed more rapid ED physician evaluation and antibiotic administration. Manual chart abstraction was used to calculate door-to-antibiotic time and included 12 months of preintervention data and 2 months of postintervention data.ResultsDoor-to-antibiotic time improved from a baseline of 105.3 minutes to 71.9 minutes.OutcomeThe simple change in patient throughput improved door-to-antibiotic time with minimal obstacles. The sepsis-screening tool implemented at triage decreased the door-to-antibiotic time by 33.4 minutes, without affecting triage time, and enhanced patient throughput of potentially septic patients.     

Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock

Objective To develop management guidelines for severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis.Design The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. The modified Delphi methodology used for grading recommendations built upon a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along 5 levels to create recommendation grades from A–E, with A being the highest grade. Pediatric considerations were provided to contrast adult and pediatric management.Participants Participants included 44 critical care and infectious disease experts representing 11 international organizations.Results A total of 46 recommendations plus pediatric management considerations.Conclusions Evidence-based recommendations can be made regarding many aspects of the acute management of sepsis and septic shock that will hopefully translate into improved outcomes for the critically ill patient. The impact of these guidelines will be formally tested and guidelines updated annually, and even more rapidly when some important new knowledge becomes available.Electronic Supplementary Material Supplementary material is available in the online version of this articel at This article is published jointly with Critical Care MedicineChairs: R. Phillip Dellinger, MD*; Henry Masur, MD; Jean M. Carlet, MD; Herwig Gerlach, MD, PhD**. Committee members: Richard J. Beale, MD**; Marc Bonten, MD; Christian Brun-Buisson, MD; Thierry Calandra, MD; Joseph A. Carcillo, MD; Jonathan Cohen, MD**; Catherine Cordonnier, MD; E. Patchen Dellinger, MD; Jean-Francois Dhainaut, MD, PhD; Roger G. Finch, MD; Simon Finfer, MD; Francois A. Fourrier, MD; Juan Gea-Banacloche MD; Maurene A. Harvey, RN, MPH**; Jan A. Hazelzet, MD; Steven M. Hollenberg, MD; James H. Jorgensen, PhD; Didier Keh, MD; Mitchell M. Levy*, MD; Ronald V. Maier, MD; Dennis G. Maki, MD; John J. Marini, MD; John C. Marshall, MD; Steven M. Opal, MD; Tiffany M. Osborn, MD; Margaret M. Parker, MD**; Joseph E. Parrillo, MD; Graham Ramsay, MD*; Andrew Rhodes, MD; Jonathan E. Sevransky, MD; Charles L. Sprung, MD, JD**; Antoni Torres, MD; Jeffery S. Vender, MD; Jean-Louis Vincent, MD, PhD**; Janice L. Zimmerman, MD. Associate members: E. David Bennett, MD; Pierre-Yves Bochud, MD; Alain Cariou, MD; Glenn S. Murphy, MD; Martin Nitsun, MD; Joseph W. Szokol, MD; Stephen Trzeciak, MD; Christophe Vinsonneau, MD. *Executive Committee, Surviving Sepsis Campaign. **Steering Committee, Surviving Sepsis Campaign.Sponsoring organizations: American Association of Critical-Care Nurses; American College of Chest Physicians; American College of Emergency Physicians; American Thoracic Society; Australian and New Zealand Intensive Care Society; European Society of Clinical Microbiology and Infectious Diseases; European Society of Intensive Care Medicine; European Respiratory Society; International Sepsis Forum; Society of Critical Care Medicine; Surgical Infection Society.The Surviving Sepsis Campaign is administered jointly by the European Society of Intensive Care Medicine, International Sepsis Forum, and the Society of Critical Care Medicine, and is supported in part by unrestricted educational grants from Baxter Bioscience, Edwards Lifesciences, and Eli Lilly and Company (majority sponsor).The authors and the publisher have exercised great care to ensure that drug dosages, formulas, and other information presented in this book are accurate and in accord with the professional standards in effect at the time of publication. Readers are, however, advised to always check the manufacturers product information sheet that is packaged with the respective products to be fully informed of changes in recommended dosages, contraindications, and the like before prescribing or administering any drug.     

Recently published papers: Novel therapies in chronic obstructive pulmonary disease, cardiac chemicals and intensive care outcomes

Severe sepsis and septic shock are among the most serious health conditions and are associated with unwelcome clinical, social, and economic outcomes. With the introduction of the Surviving Sepsis Campaign guidelines, the campaign leaders aimed to reduce mortality from severe sepsis by at least one quarter by 2009 by means of a six-point action plan, namely, building awareness among health care professionals, improving early and accurate disease recognition and diagnosis, increasing the use of appropriate treatments and interventions, education, getting better post-intensive care unit access, and developing standard processes of care. However, adherence to these recommendations is a first but crucial step in obtaining these goals. A comprehensive evaluation of both, adherence to a sepsis program and whether this results in better outcomes for patients, is therefore essential to guide informed decision-making regarding the implementation of such an evidence-based protocol.     

The DISPARITY Study: do gender differences exist in Surviving Sepsis Campaign resuscitation bundle completion,completion of individual bundle elements,or sepsis mortality?

Purpose

Women in the emergency department are less likely to receive early goal directed therapy, but gender differences in the Surviving Sepsis Campaign (SSC) bundle completion have not been studied [1]. We hypothesized that women have lower SSC resuscitation bundle completion rates.

Materials and methods

This was a retrospective, observational study in a large urban academic ED at a national SSC site. Consecutive patients (age > 18 years) admitted to intensive care with severe sepsis or septic shock and entered into the SSC database from October 2005 to February 2012 were included. Data on overall and individual bundle elements were exported from the database. Bivariate analyses were performed with chi-square tests and t-tests. Multiple logistic regression was then performed with gender as an effect modifier.

Results

Eight hundred fourteen patients were enrolled. The mean age was 66 years;, 44.8% were women. There was no association between gender and bundle completion (aOR 0.83, 95% CI 0.58-1.16), controlling for age, race, Sequential Organ Failure Assessment, congestive heart failure, and coagulopathy. In-hospital mortality did not differ by gender. Women were less likely to receive antibiotics within 3 hours (60.5% vs. 68.8%, p = 0.01) and less likely to reach a target ScvO₂ > 70 (31.3% vs. 39.5%, P = .05).

Conclusions

There were no gender disparities in bundle completion or in-hospital mortality. Further research is needed to examine individual bundle elements and gender specific factors that may affect bundle completion and mortality.