Delay Within the 3-Hour Surviving Sepsis Campaign Guideline on Mortality for Patients With Severe Sepsis and Septic Shock. (Shildt)

Pruinelli L, et al. Delay Within the 3-Hour Surviving Sepsis Campaign Guideline on Mortality for Patients With Severe Sepsis and Septic Shock. Crit Care Med. 2018 Apr;46(4):500-505.

OBJECTIVES: To specify when delays of specific 3-hour bundle Surviving Sepsis Campaign guideline recommendations applied to severe sepsis or septic shock become harmful and impact mortality.

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Improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospital… (Betters)

Barnes-Daly MA, Phillips G, Ely EW. Improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospitals: Implementing PAD Guidelines Via the ABCDEF Bundle in 6,064 Patients. Crit Care Med. 2017 Feb; 45(2):171-178.

OBJECTIVES: To track compliance by an interprofessional team with the Awakening and Breathing Coordination, Choice of drugs, Delirium monitoring and management, Early mobility, and Family engagement (ABCDEF) bundle in implementing the Pain, Agitation, and Delirium guidelines. The aim was to study the association between ABCDEF bundle compliance and outcomes including hospital survival and delirium-free and coma-free days in community hospitals.

DESIGN: A prospective cohort quality improvement initiative involving ICU patients.

SETTING: Seven community hospitals within California’s Sutter Health System.

PATIENTS: Ventilated and nonventilated general medical and surgical ICU patients enrolled between January 1, 2014, and December 31, 2014.

MEASUREMENTS AND MAIN RESULTS: Total and partial bundle compliance were measured daily. Random effects regression was used to determine the association between ABCDEF bundle compliance accounting for total compliance (all or none) or for partial compliance (“dose” or number of bundle elements used) and outcomes of hospital survival and delirium-free and coma-free days, after adjusting for age, severity of illness, and presence of mechanical ventilation. Of 6,064 patients, a total of 586 (9.7%) died before hospital discharge. For every 10% increase in total bundle compliance, patients had a 7% higher odds of hospital survival (odds ratio, 1.07; 95% CI, 1.04-1.11; p < 0.001). Likewise, for every 10% increase in partial bundle compliance, patients had a 15% higher hospital survival (odds ratio, 1.15; 95% CI, 1.09-1.22; p < 0.001). These results were even more striking (12% and 23% higher odds of survival per 10% increase in bundle compliance, respectively, p < 0.001) in a sensitivity analysis removing ICU patients identified as receiving palliative care. Patients experienced more days alive and free of delirium and coma with both total bundle compliance (incident rate ratio, 1.02; 95% CI, 1.01-1.04; p = 0.004) and partial bundle compliance (incident rate ratio, 1.15; 95% CI, 1.09-1.22; p < 0.001).

CONCLUSIONS: The evidence-based ABCDEF bundle was successfully implemented in seven community hospital ICUs using an interprofessional team model to operationalize the Pain, Agitation, and Delirium guidelines. Higher bundle compliance was independently associated with improved survival and more days free of delirium and coma after adjusting for age, severity of illness, and presence of mechanical ventilation.

Impact of Source Control in Patients With Severe Sepsis and Septic Shock. (Betters)

Martínez ML, et al. Impact of Source Control in Patients With Severe Sepsis and Septic Shock. Crit Care Med. 2017 Jan;45(1):11-19.

OBJECTIVES: Time to clearance of pathogens is probably critical to outcome in septic shock. Current guidelines recommend intervention for source control within 12 hours after diagnosis. We aimed to determine the epidemiology of source control in the management of sepsis and to analyze the impact of timing to source control on mortality.

DESIGN: Prospective observational analysis of the Antibiotic Intervention in Severe Sepsis study, a Spanish national multicenter educational intervention to improve antibiotherapy in sepsis.

SETTING: Ninety-nine medical-surgical ICUs in Spain.

PATIENTS: We enrolled 3,663 patients with severe sepsis or septic shock during three 4-month periods between 2011 and 2013.

INTERVENTIONS: Source control and hospital mortality.

MEASUREMENTS AND MAIN RESULTS: A total of 1,173 patients (32%) underwent source control, predominantly for abdominal, urinary, and soft-tissue infections. Compared with patients who did not require source control, patients who underwent source control were older, with a greater prevalence of shock, major organ dysfunction, bacteremia, inflammatory markers, and lactic acidemia. In addition, compliance with the resuscitation bundle was worse in those undergoing source control. In patients who underwent source control, crude ICU mortality was lower (21.2% vs 25.1%; p = 0.010); after adjustment for confounding factors, hospital mortality was also lower (odds ratio, 0.809 [95% CI, 0.658-0.994]; p = 0.044). In this observational database analysis, source control after 12 hours was not associated with higher mortality (27.6% vs 26.8%; p = 0.789).

CONCLUSIONS: Despite greater severity and worse compliance with resuscitation bundles, mortality was lower in septic patients who underwent source control than in those who did not. The time to source control could not be linked to survival in this observational database.

Protocolized Treatment Is Associated With Decreased Organ Dysfunction in Pediatric Severe Sepsis. (Duke)

Balamuth F, et al. Protocolized Treatment Is Associated With Decreased Organ Dysfunction in Pediatric Severe Sepsis. Pediatr Crit Care Med. 2016 Sep;17(9):817-22.

OBJECTIVES: To determine whether treatment with a protocolized sepsis guideline in the emergency department was associated with a lower burden of organ dysfunction by hospital day 2 compared to nonprotocolized usual care in pediatric patients with severe sepsis.

DESIGN: Retrospective cohort study.

SETTING: Tertiary care children’s hospital from January 1, 2012, to March 31, 2014.

SUBJECTS: Patients older than 56 days old and younger than 18 years old with international consensus defined severe sepsis and who required PICU admission within 24 hours of emergency department arrival were included.

MEASUREMENTS AND MAIN RESULTS: The exposure was the use of a protocolized emergency department sepsis guideline. The primary outcome was complete resolution of organ dysfunction by hospital day 2. One hundred eighty nine subjects were identified during the study period. Of these, 121 (64%) were treated with the protocolized emergency department guideline and 68 were not. There were no significant differences between the groups in age, sex, race, number of comorbid conditions, emergency department triage level, or organ dysfunction on arrival to the emergency department. Patients treated with protocolized emergency department care were more likely to be free of organ dysfunction on hospital day 2 after controlling for sex, comorbid condition, indwelling central venous catheter, Pediatric Index of Mortality-2 score, and timing of antibiotics and IV fluids (adjusted odds ratio, 4.2; 95% CI, 1.7-10.4).

CONCLUSIONS: Use of a protocolized emergency department sepsis guideline was independently associated with resolution of organ dysfunction by hospital day 2 compared to nonprotocolized usual care. These data indicate that morbidity outcomes in children can be improved with the use of protocolized care.