Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality*

TLDR

The study aimed to assess the impact of implementing a severe sepsis bundle in the emergency department as a quality indicator set with feedback to influence physician behavior. A two‑year prospective observational cohort of 330 patients at an academic tertiary care facility evaluated a bundle of five quality indicators—CVP/ScvO₂ monitoring within 2 h, broad‑spectrum antibiotics within 4 h, early goal‑directed therapy at 6 h, corticosteroids for vasopressor‑dependent or suspected adrenal insufficiency, and lactate clearance monitoring. Bundle completion rose to 51.2 % and was linked to lower in‑hospital mortality (20.8 % vs.

Abstract

The purpose of this study was to examine the outcome implications of implementing a severe sepsis bundle in an emergency department as a quality indicator set with feedback to modify physician behavior related to the early management of severe sepsis and septic shock.Two-year prospective observational cohort.Academic tertiary care facility.Patients were 330 patients presenting to the emergency department who met criteria for severe sepsis or septic shock.Five quality indicators comprised the bundle for severe sepsis management in the emergency department: a) initiate central venous pressure (CVP)/central venous oxygen saturation (Scvo2) monitoring within 2 hrs; b) give broad-spectrum antibiotics within 4 hrs; c) complete early goal-directed therapy at 6 hrs; d) give corticosteroid if the patient is on vasopressor or if adrenal insufficiency is suspected; and e) monitor for lactate clearance.Patients had a mean age of 63.8 +/- 18.5 yrs, Acute Physiology and Chronic Health Evaluation II score 29.6 +/- 10.6, emergency department length of stay 8.5 +/- 4.4 hrs, hospital length of stay 11.3 +/- 12.9 days, and in-hospital mortality 35.2%. Bundle compliance increased from zero to 51.2% at the end of the study period. During the emergency department stay, patients with the bundle completed received more CVP/Scvo2 monitoring (100.0 vs. 64.8%, p < .01), more antibiotics (100.0 vs. 89.7%, p = .04), and more corticosteroid (29.9 vs. 16.2%, p = .01) compared with patients with the bundle not completed. In a multivariate regression analysis including the five quality indicators, completion of early goal-directed therapy was significantly associated with decreased mortality (odds ratio, 0.36; 95% confidence interval, 0.17-0.79; p = .01). In-hospital mortality was less in patients with the bundle completed compared with patients with the bundle not completed (20.8 vs. 39.5%, p < .01).Implementation of a severe sepsis bundle using a quality improvement feedback to modify physician behavior in the emergency department setting was feasible and was associated with decreased in-hospital mortality.