Elsevier

Journal of Critical Care

Volume 23, Issue 4, December 2008, Pages 455-460
Journal of Critical Care

A Focus on Sepsis
Implementation of the Surviving Sepsis Campaign guidelines for severe sepsis and septic shock: We could go faster

https://doi.org/10.1016/j.jcrc.2007.08.003Get rights and content

Abstract

Purpose

The aim of this study is to evaluate the feasibility of applying sepsis bundles in the intensive care unit (ICU) and their effect on outcomes.

Methods

In this prospective, observational study in a 31-bed capacity department of intensive care, we measured the time taken to perform sepsis bundle interventions in 69 consecutive patients with severe sepsis or septic shock.

Results

Compliance with the 6-hour bundle was obtained in 44 (72%) of 61 patients; these patients had a lower mortality rate (16% vs 41%, P = .04) and shorter ICU stay (median [range], 5 [3-10] vs 9 [6-19] days, P = .01) than other patients. Compliance with the 24-hour bundle was obtained in 30 (67%) of 44 eligible patients. The mortality rate and duration of ICU stay were not significantly lower in the 24-hour compliant as compared with the noncompliant group (23% vs 33% and 6 [4-11] vs 9 [6-25] days, respectively; P value is not significant). Patients who complied with the 24-hour sepsis bundle after only 12 hours had a lower mortality rate (10% vs 39%, P = .036) and shorter stay (6 [4-10] vs 9 [6-25] days, P = .055) than those who were compliant after 24 hours.

Conclusions

Correct application of the sepsis bundles was associated with reduced mortality and length of ICU stay. Earlier implementation of the 24-hour management bundle could result in better outcomes.

Introduction

Severe sepsis and septic shock are major problems in critically ill patients. In the recent European Sepsis Occurrence in Acutely ill Patients study [1], which collected data on septic adult patients in 198 intensive care units (ICUs) from 24 European countries, ICU mortality was 32% for patients with severe sepsis and 54% when septic shock was present. Recent guidelines provided by the Surviving Sepsis Campaign (SSC) [2] provide an important tool for the management of patients with severe sepsis and septic shock. The next phase of the SSC involves the practical application of the guidelines and assessment of their effectiveness in improving outcomes, with the final aim being able to decrease the relative mortality from sepsis by 25% over 5 years. For this purpose, and to simplify the complex application of the guidelines, the concept of the “sepsis bundle” has been developed [3], a “bundle” being a group of interventions related to a disease process that, when executed together, result in better outcomes than when implemented individually. Two bundles have currently been proposed: a 6-hour resuscitation bundle and a 24-hour management bundle (http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis) (Table 1).

A recent study by Gao et al [4] showed that compliance with the 6-hour sepsis bundle was associated with a more than 2-fold decrease in hospital mortality (49% vs 23%), and compliance with the 24-hour bundle showed a trend to reduced mortality; however, compliance with both bundles was not very high (52% for the 6-hour bundle and 30% for the 24-hour bundle). These results raise several important questions. First, what compliance rates can be achieved for each bundle? Second, is it possible to reduce the time delays for the various bundle components, and if so, does it make a difference? Third, do some interventions affect the feasibility of the bundles more than others do?

The aim of this study was to evaluate whether the bundle approach to sepsis management is reliable and easy to implement in a large department of intensive care, and if its implementation can have an impact on outcome. We also investigated the feasibility of individual interventions and whether earlier application of some interventions may be associated with improved outcomes.

Section snippets

Patients

The study was conducted in the medical-surgical department of intensive care of Erasme University Hospital; this department has 31 beds and a 4-bed stabilization room (“shock lab”). All consecutive adult (≥18 years old) patients admitted between May 1 and November 30, 2005, with a diagnosis of severe sepsis or septic shock were enrolled. Severe sepsis was defined as the presence of an infection with at least one organ dysfunction, and septic shock as fluid-refractory hypotension (mean arterial

Results

The study included 69 consecutive patients with severe sepsis or septic shock, 8 of whom were excluded because of missing data (Fig. 1). The baseline characteristics of the remaining 61 patients are shown in Table 2. Thirty-six (59%) patients had septic shock and needed vasopressors; 44 (72%) patients were candidates for the management bundle. The overall ICU mortality rate was 23% (14/61); the hospital mortality rate was 30% (18/61).

Discussion

The primary purpose of this study was to evaluate the feasibility of applying the sepsis bundles. Although we found that both the resuscitation and the management bundle could be easily applied, the 6-hour bundle was not applied in 28% of the patients and the 24-hour bundle in 32% of patients.

The second purpose of our study was to analyze which interventions, in particular, were delayed. The variables that seemed to influence compliance with the resuscitation bundle were the time of insertion

Conclusions

In this observational study, we found both the resuscitation and the management bundle feasible and easy to apply at the bedside. Compliance with the 6-hour bundle was associated with a reduction in ICU mortality and length of stay, whereas for the 24-hour bundle, a stricter time limit for the interventions (12 hours) could result in a better impact on outcome.

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    Many pathways in literature include the 3-hour and the 6-hour sepsis bundle, introduced in the 2004 Surviving Sepsis Campaign (SSC) [53], which guides diagnostic and treatment strategies within time frames of respectively 3 and 6 hours (Supplementary Table S2). Introduction and compliance with these two bundles was associated with a lower mortality in sepsis patients [54,55]. In 2018 the SSC replaced them with a single ‘hour-1 bundle,’ with the explicit intention to begin resuscitation and management immediately [56,57].

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