Multicenter Implementation of a Treatment Bundle for Patients with Sepsis and Intermediate Lactate Values

Abstract

Rationale: Treatments for patients with sepsis with intermediate lactate values (≥2 and <4 mmol/L) are poorly defined.

Objectives: To evaluate multicenter implementation of a treatment bundle (including timed intervals for antibiotics, repeat lactate testing, and intravenous fluids) for hemodynamically stable patients with sepsis and intermediate lactate values in the emergency department.

Methods: We evaluated patients in annual intervals before and after bundle implementation in March 2013. We evaluated bundle compliance and compared outcome measures across groups with multivariable logistic regression. Because of their perceived risk for iatrogenic fluid overload, we also evaluated patients with a history of heart failure and/or chronic kidney disease.

Measurements and main results: We identified 18,122 patients with sepsis and intermediate lactate values, including 36.1% treated after implementation. Full bundle compliance increased from 32.2% in 2011 to 44.9% after bundle implementation (P < 0.01). Hospital mortality was 8.8% in 2011, 9.3% in 2012, and 7.9% in 2013 (P = 0.02). Treatment after bundle implementation was associated with an adjusted hospital mortality odds ratio of 0.81 (95% confidence interval, 0.66-0.99; P = 0.04). Decreased hospital mortality was observed primarily in patients with a heart failure and/or kidney disease history (P < 0.01) compared with patients without this history (P > 0.40). This corresponded to notable changes in the volume of fluid resuscitation in patients with heart failure and/or kidney disease after implementation.

Conclusions: Multicenter implementation of a treatment bundle for patients with sepsis and intermediate lactate values improved bundle compliance and was associated with decreased hospital mortality. These decreases were mediated by improved mortality and increased fluid administration among patients with a history of heart failure and/or chronic kidney disease.

Keywords: hospital mortality; quality improvement; resuscitation; sepsis.

Figures

Figure 1.

Monthly full bundle compliance before and after implementation and hospital mortality rates by implementation period. The year markers along the x-axis indicate March of that year.

Figure 2.

Kernel density plot showing the distribution of fluids administered, based on medication administration records, to patients stratified by their history of heart failure or kidney disease before and after bundle implementation. The top panel shows patients with a history of heart failure and/or kidney disease, and the bottom panel shows patients without such history. The solid lines represent estimated densities before bundle implementation, and the dashed lines represent estimated densities after bundle implementation.