The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis

Mitchell M Levy, R Phillip Dellinger, Sean R Townsend, Walter T Linde-Zwirble, John C Marshall, Julian Bion, Christa Schorr, Antonio Artigas, Graham Ramsay, Richard Beale, Margaret M Parker, Herwig Gerlach, Konrad Reinhart, Eliezer Silva, Maurene Harvey, Susan Regan, Derek C Angus, Mitchell M Levy, R Phillip Dellinger, Sean R Townsend, Walter T Linde-Zwirble, John C Marshall, Julian Bion, Christa Schorr, Antonio Artigas, Graham Ramsay, Richard Beale, Margaret M Parker, Herwig Gerlach, Konrad Reinhart, Eliezer Silva, Maurene Harvey, Susan Regan, Derek C Angus

Abstract

Objective: The Surviving Sepsis Campaign (SSC or "the Campaign") developed guidelines for management of severe sepsis and septic shock. A performance improvement initiative targeted changing clinical behavior (process improvement) via bundles based on key SSC guideline recommendations on process improvement and patient outcomes.

Design and setting: A multifaceted intervention to facilitate compliance with selected guideline recommendations in the ICU, ED, and wards of individual hospitals and regional hospital networks was implemented voluntarily in the US, Europe, and South America. Elements of the guidelines were "bundled" into two sets of targets to be completed within 6 h and within 24 h. An analysis was conducted on data submitted from January 2005 through March 2008.

Main results: Data from 15,022 subjects at 165 sites were analyzed to determine the compliance with bundle targets and association with hospital mortality. Compliance with the entire resuscitation bundle increased linearly from 10.9% in the first site quarter to 31.3% by the end of 2 years (P<0.0001). Compliance with the entire management bundle started at 18.4% in the first quarter and increased to 36.1% by the end of 2 years (P = 0.008). Compliance with all bundle elements increased significantly, except for inspiratory plateau pressure, which was high at baseline. Unadjusted hospital mortality decreased from 37 to 30.8% over 2 years (P = 0.001). The adjusted odds ratio for mortality improved the longer a site was in the Campaign, resulting in an adjusted absolute drop of 0.8% per quarter and 5.4% over 2 years (95% CI, 2.5-8.4%).

Conclusions: The Campaign was associated with sustained, continuous quality improvement in sepsis care. Although not necessarily cause and effect, a reduction in reported hospital mortality rates was associated with participation. The implications of this study may serve as an impetus for similar improvement efforts.

Figures

Fig. 1
Fig. 1
Resuscitation and management bundles as provided for Campaign participants’ use
Fig. 2
Fig. 2
Compliance and mortality change over time: a change in the percentage of patients compliant with all elements of the resuscitation bundle (dotted line) and the management bundle (solid line) over 2 years of data collection (*P < 0.01 compared to first quarter). Note that both Y axes are truncated at 40% to emphasize relative change over time as opposed to absolute change; b change in hospital mortality over time (*P < 0.01 compared to first quarter)

References

    1. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29:1303–1310. doi: 10.1097/00003246-200107000-00002.
    1. Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979–2000. N Engl J Med. 2003;348:1546–1554. doi: 10.1056/NEJMoa022139.
    1. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M, Early Goal-Directed Therapy Collaborative Group Early goal directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368–1377. doi: 10.1056/NEJMoa010307.
    1. Annane D, Sébille V, Charpentier C, Bollaert PE, François B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troché G, Chaumet-Riffaud P, Bellissant E. Effect of treatment with low doses of hydrocortisone and fludricortisone on mortality in patients with septic shock. JAMA. 2002;288:862–871. doi: 10.1001/jama.288.7.862.
    1. Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, Steingrub JS, Garber GE, Helterbrand JD, Ely EW, Fisher CJ, Jr, Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study group Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001;344:699–709. doi: 10.1056/NEJM200103083441001.
    1. Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359–1367. doi: 10.1056/NEJMoa011300.
    1. The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342:1301–1308. doi: 10.1056/NEJM200005043421801.
    1. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342:1471–1477. doi: 10.1056/NEJM200005183422002.
    1. Ely EW, Baker AM, Dunagan DP, Burke HL, Smith AC, Kelly PT, Johnson MM, Browder RW, Bowton DL, Haponik EF. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med. 1996;335:1864–1869. doi: 10.1056/NEJM199612193352502.
    1. Bellomo R, Chapman M, Finfer S, Hickling K, Myburgh J. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zealand intensive care society (ANZICS) clinical trials group. Lancet. 2000;356:2139–2143. doi: 10.1016/S0140-6736(00)03495-4.
    1. Townsend SR, Schorr C, Levy MM, Dellinger RP. Reducing mortality in severe sepsis: The Surviving Sepsis Campaign. Clin Chest Med. 2008;29:721–733. doi: 10.1016/j.ccm.2008.06.011.
    1. Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM, Surviving Sepsis Campaign Management Guidelines Committee Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004;32:858–873. doi: 10.1097/01.CCM.0000117317.18092.E4.
    1. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL (2008) Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med 34:17–60, erratum 34:783–785
    1. Surviving Sepsis Campaign implementation and the appropriate role of industry. . Accessed 5 Dec 2009
    1. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282:1458–1465. doi: 10.1001/jama.282.15.1458.
    1. Sinuff T, Eva KW, Meade M, Dodek P, Heyland D, Cook D. Clinical practice guidelines in the intensive care unit: a survey of Canadian clinicians’ attitudes. Can J Anaesth. 2007;54:728–736. doi: 10.1007/BF03026869.
    1. Cook DJ, Meade MO, Hand LE, McMullin JP. Toward understanding evidence uptake: semirecumbency for pneumonia prevention. Crit Care Med. 2002;30:1472–1477. doi: 10.1097/00003246-200207000-00012.
    1. Sinuff T, Kahnamoui K, Cook DJ, Giacomini M. Practice guidelines as multipurpose tools: a qualitative study of noninvasive ventilation. Crit Care Med. 2007;35:776–782. doi: 10.1097/01.CCM.0000256848.47911.77.
    1. Sinuff T, Muscedere J, Cook D, Dodek P, Heyland D. Canadian Critical Care Trials Group. Ventilator-associated pneumonia: improving outcomes through guideline implementation. J Crit Care. 2008;23:118–125. doi: 10.1016/j.jcrc.2007.11.013.
    1. Sinuff T, Cook D, Giacomini M, Heyland D, Dodek P. Facilitating clinician adherence to guidelines in the intensive care unit: a multicenter, qualitative study. Crit Care Med. 2007;35:2083–2089. doi: 10.1097/01.ccm.0000281446.15342.74.
    1. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008;337:963–965. doi: 10.1136/bmj.a1714.
    1. Vandijck DM, Labeau SO, Blot SI. Facilitating clinician adherence to guidelines in the intensive care unit. Crit Care Med. 2008;36:655. doi: 10.1097/01.CCM.0000300546.17009.A7.
    1. Berwick DM. The science of improvement. JAMA. 2008;299:1182–1184. doi: 10.1001/jama.299.10.1182.
    1. Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieving ultrasafe health care. Ann Intern Med. 2005;142:756–764.
    1. Levy MM, Pronovost PJ, Dellinger RP, Townsend SR, Resar RK, Clemmer TP, Ramsay G. Sepsis change bundles: converting guidelines into meaningful change in behavior and clinical outcome. Crit Care Med. 2004;32(suppl):S595–S597. doi: 10.1097/01.CCM.0000147016.53607.C4.
    1. Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf. 2005;31:243–248.
    1. Severe sepsis bundles. Resuscitation bundle. . Accessed 5 Dec 2009
    1. Severe sepsis bundles. Management bundle. . Accessed 5 Dec 2009
    1. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G; SCCM/ESICM/ACCP/ATS/SIS (2003) 2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference. Crit Care Med 31:1250–1256
    1. Townsend S, Dellinger RP, Levy MM, Ramsay G, editors. Implementing the Surviving Sepsis Campaign. Mount Prospect: Society of Critical Care Medicine; 2005.
    1. . Accessed 12 Aug 2009
    1. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–2732. doi: 10.1056/NEJMoa061115.
    1. Shapiro NI, Howell MD, Talmor D, Lahey D, Ngo L, Buras J, Wolfe RE, Weiss JW, Lisbon A. Implementation and outcomes of the Multiple Urgent Sepsis Therapies (MUST) protocol. Crit Care Med. 2006;34:1025–1032. doi: 10.1097/01.CCM.0000206104.18647.A8.
    1. El Solh AA, Akinnusi ME, Alsawalha LN, Pineda LA. Outcome of septic shock in older adults after implementation of the sepsis “bundle”. J Am Geriatr Soc. 2008;56:272–278. doi: 10.1111/j.1532-5415.2007.01529.x.
    1. Nguyen HB, Corbett SW, Steele R, Banta J, Clark RT, Hayes SR, Edwards J, Cho TW, Wittlake WA. Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality. Crit Care Med. 2007;35:1105–1112. doi: 10.1097/01.CCM.0000259463.33848.3D.
    1. Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, Suppes R, Feinstein D, Zanotti S, Taiberg L, Gurka D, Kumar A, Cheang M. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34:1589–1596. doi: 10.1097/01.CCM.0000217961.75225.E9.
    1. The NICE-SUGAR Study Investigators Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283–1297. doi: 10.1056/NEJMoa0810625.
    1. Ferrer R, Artigas A, Levy MM, Blanco J, González-Díaz G, Garnacho-Montero J, Ibáñez J, Palencia E, Quintana M, Torre-Prados MV, Edusepsis Study Group Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. JAMA. 2008;299:2294–2303. doi: 10.1001/jama.299.19.2294.

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