Surviving Sepsis Campaign Guidelines Bundle: Studying How Improved Compliance Might Affect Outcomes

By Kathryn Radigan, MD

Attending Physician, Division of Pulmonary and Critical Care, Stroger Hospital of Cook County, Chicago

Dr. Radigan reports no financial relationships relevant to this field of study.

SYNOPSIS: Improved compliance with the Surviving Sepsis Campaign guidelines bundle was associated with a non-statistically significant decrease in the in-hospital mortality of severe sepsis patients.

SOURCE: Grek A, Booth S, Festic E, et al. Sepsis and Shock Response Team: Impact of a multidisciplinary approach to implementing Surviving Sepsis Campaign guidelines and surviving the process. Am J Med Qual 2016 Nov 10. [Epub ahead of print].

Although the Surviving Sepsis Campaign guidelines (SSCG) suggest a standardized, seven-element bundle to reduce sepsis mortality, national compliance rates are low. Grek et al hypothesized that improved compliance with SSCG would result in better outcomes in patients who suffer severe sepsis or septic shock. From December 2011 to March 2012, the authors conducted a baseline retrospective chart review of 25 consecutive patients discharged with the diagnosis of sepsis, severe sepsis, or septic shock. For each of these patients, compliance data were recorded for each of the seven bundle elements, including: initial lactate measurement followed by repeat if > 4; blood culture drawn prior to antibiotics; antibiotics within three hours of admission; fluid bolus of 30 mL/kg; placement of central venous line if lactate > 4; central venous pressure (CVP); and central venous oxygen saturation (ScvO₂) measurement. After data collection was completed on the initial 25 patients, data that included the same seven-element bundle were then collected prospectively for one year for all 116 patients who activated triggers, identifying them as patients in the ED with severe sepsis or septic shock. The primary outcome was to improve compliance with the seven-element bundle by 30%. This goal was to be achieved through high-impact interventions, including education, early identification of sepsis, and the development of a multidisciplinary team, the Sepsis and Shock Response Team (SSRT), which ensured early resuscitation of severe septic patients. Secondary outcomes, including hospital mortality and central line-associated bloodstream infection (CLABSI) rates, were measured and reported by the Infectious Disease and Infection Prevention and Control Committee.

Baseline data from the initial 25 consecutive patients with a diagnosis of sepsis, severe sepsis, and septic shock revealed poor compliance with the sepsis bundle. Lactate was measured in only 40% of patients, 76% received blood cultures prior to antibiotics, 60% received antibiotics within three hours of arrival, and only 33% received a fluid bolus of at least 30 mL/kg. None of the 25 patients were subjected to central line placement, CVP, or ScvO₂ measurements. There was 0% compliance for all elements of the bundle. After bundle implementation, 146 patients met the diagnosis of sepsis, severe sepsis, or septic shock criteria. Compliance for all elements of the bundle improved at three- and six-month intervals. At six months, all-or-none compliance was 51%. Additionally, there was 100% compliance with lactate measurements, along with 50% improvement with respect to antibiotics administered by three hours, fluid bolus administration, and blood cultures obtained prior to antibiotic administration. Overall, sepsis mortality for the study institution before and after the study period improved. Although not statistically significant, the overall observed/expected (O/E) sepsis mortality index decreased from 0.763 pre-SSRT to 0.642 post-SSRT implementation (P = 0.159); similarly, O/E sepsis mortality index for ED admits also decreased pre-SSRT from 0.745 to 0.591 post-SSRT (P = 0.069). For patients who were diagnosed with severe sepsis, there also was a drop in pre-SSRT O/E index from 0.864 to 0.701 post-SSRT (P = 0.102), with an O/E mortality index among ED admits showing a similar decrease from 0.884 to 0.662 (P = 0.049). CLABSI rates did not change during the study period.

COMMENTARY

Severe sepsis accounts for almost 10% of all deaths.¹ Ever since Rivers et al published the benefits of early goal-directed therapy (EGDT), the Surviving Sepsis Campaign guidelines were designed to implement a standardized, seven-element bundle to foster adherence to the guidelines, with the goal to reduce mortality by 25% over five years.² Unfortunately, adherence to bundles generally is exceedingly poor, and improved outcomes are challenging without adherence. Through their study, Grek et al could improve adherence to the bundle, which led to a trend toward reduction in overall mortality in patients presenting to the ED.

How did the researchers make a difference? To improve compliance with the bundle, quality improvement (QI) methodology was used to develop high-impact interventions. On initiation of the project, key stakeholders were identified and formed a multidisciplinary QI team. An SSRT was called to evaluate ED patients within 15 minutes to ensure completion of the bundle and expedite transfer to the ICU. The team consisted of an ICU physician, a fellow or resident, an advance practice provider (APP), nursing supervisor, and pharmacist. This was one of the most fundamental benefits to the project, as it created a spirit of consensus, cooperation, and teamwork. As appreciated in other studies, a multidisciplinary team approach to early recognition and treatment of sepsis is important.^3,4 Unfortunately, the main barrier for initiation of these teams is culture change, which takes consistent follow-up, teamwork, and recurring interventions. During analysis, the team defined the three drivers for the effective treatment of sepsis. These included identifying severe sepsis and septic shock, standardizing quantitative resuscitation, and triage decisions.

Monitoring compliance also was key in making a difference in outcomes. Monitoring compliance during and after each intervention was followed closely with feedback to each individual provider through monthly staff meetings and biweekly emails. A sniffer computer algorithm was developed to improve early identification of systemic inflammatory response syndrome (SIRS) and sepsis. The alert triggered a text page to the lead nurse in the ED who would identify the ED physician once the trigger was verified and the sepsis resuscitation checklist was followed. A severe sepsis and septic shock activation flow sheet addressing triage and treatment was posted in the ED and ICU. Provider pocket cards addressing clinician roles for patients were created for nurses, fellows, residents, APPs, and ICU physicians. An internal SSRT website was developed detailing implementation plans, compliance data, and included an electronic suggestion box to invite feedback and suggestions. The team also included simulation center training targeting sepsis activation and standardized treatment protocols. Interestingly, the CVP and ScVO₂ measurements had the lowest compliance rates most likely due to the coinciding release of the PROCESS, ARISE, and PROMISE trials.^5-7

Multiple interventions, including education, early identification of sepsis, and the development of a multidisciplinary team to ensure early resuscitation of severe septic patients, led to dramatically improved adherence to the SSCG, with a decrease in the in-hospital mortality of severe sepsis patients presenting to the ED. Of course, improved adherence to the SSCG takes significant work with interdisciplinary collaboration and response infrastructure. Many of these same strategies may be adopted within our own hospitals with similar results. Although this study was promising, it must be interpreted cautiously, as its results were based on a small sample size without a randomized design. Future studies are needed to delineate the benefits of additional interventions that may be used to improve bundle compliance.

REFERENCES

1. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001;29:1303-1310.
2. Barochia AV, Cui X, Eichacker PQ. The Surviving Sepsis Campaign’s revised sepsis bundles. Curr Infect Dis Rep 2013;15:385-393.
3. Sebat F, Musthafa AA, Johnson D, et al. Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years. Crit Care Med 2007;35:2568-2575.
4. Funk D, Sebat F, Kumar A. A systems approach to the early recognition and rapid administration of best practice therapy in sepsis and septic shock. Curr Opin Crit Care 2009;15:301-307.
5. Pro CI, Yealy DM, Kellum JA, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014;370:1683-1693.
6. Investigators A, Group ACT, Peake SL, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014;371:1496-1506.
7. Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 2015;372:1301-1311.