Intensive care unit and hospital mortality in patients with obstructive sleep apnea.

INTRODUCTION: Obstructive sleep apnea (OSA) is a common disorder affecting between 5% and 24% of men and women. The prevalence of OSA in the intensive care unit (ICU) population is unknown. This study was undertaken to determine the prevalence of OSA in patients admitted to the ICU and to determine if OSA is an independent predictor of mortality. METHODS: This is a retrospective study using an Acute Physiology and Chronic Health Evaluation III database cross-referenced to a comprehensive clinical database to identify patients with and without OSA admitted to medical, surgical, and mixed ICUs at a large academic medical center. RESULTS: Between January 2003 and December 2005, 15077 patients were admitted to the ICUs; and of these, 1183 (7.8%) had a physician-documented diagnosis of OSA. Eight hundred thirty-five (71%) patients had polysomnographic testing at our institution with a documented apnea-hypopnea index more than 5 per hour. Patients with OSA were younger (59.1 ± 14.0 vs 62.3 ± 18.0), male (58.9% vs 53.7%), and had lower Acute Physiology and Chronic Health Evaluation III scores (45.3 ± 24.1 vs 54.9 ± 27.7). Predicted mortality (10.3% ± 16.4% vs 16.3 ± 21.7), median ICU length of stay (1.13 vs 1.50 days), ICU mortality (2.4% vs 6.2%), and hospital mortality (3.9% vs 11.4%) were all reduced in patients with OSA, P values < .001. When adjusted for the severity of illness, OSA was independently associated with decreased hospital mortality, (0.408; 95% confidence interval, 0.298-0.557). CONCLUSIONS: Obstructive sleep apnea is common in patients admitted to the ICU. Obstructive sleep apnea was associated with a reduction in both ICU and hospital mortality.

Transpulmonary hypothermia: a novel method of rapid brain cooling through augmented heat extraction from the lungs.

AIM: Delay in instituting neuroprotective measures after cardiac arrest increases death and decreases neuronal recovery. Current hypothermia methods are slow, ineffective, unreliable, or highly invasive. We report the feasibility of rapid hypothermia induction in swine through augmented heat extraction from the lungs. METHODS: Twenty-four domestic crossbred pigs (weight, 50-55kg) were ventilated with room air. Intraparenchymal brain temperature and core temperatures from pulmonary artery, lower esophagus, bladder, rectum, nasopharynx, and tympanum were recorded. In eight animals, ventilation was switched to cooled helium-oxygen mixture (heliox) and perfluorocarbon (PFC) aerosol and continued for 90min or until target brain temperature of 32°C was reached. Eight animals received body-surface cooling with water-circulating blankets; eight control animals continued to be ventilated with room air. RESULTS: Brain and core temperatures declined rapidly with cooled heliox-PFC ventilation. The brain reached target temperature within the study period (mean [SD], 66 [7.6]min) in only the transpulmonary cooling group. Cardiopulmonary functions and poststudy histopathological examination of the lungs were normal. CONCLUSION: Transpulmonary cooling is novel, rapid, minimally invasive, and an effective technique to induce therapeutic hypothermia. High thermal conductivity of helium and vaporization of PFC produces rapid cooling of alveolar gases. The thinness and large surface area of alveolar membrane facilitate rapid cooling of the pulmonary circulation. Because of differences in thermogenesis, blood flow, insulation, and exposure to the external environment, the brain cools at a different rate than other organs. Transpulmonary hypothermia was significantly faster than body surface cooling in reaching target brain temperature.

Predicting 1-year mortality rate for patients admitted with an acute exacerbation of chronic obstructive pulmonary disease to an intensive care unit: an opportunity for palliative care.

The objective of this study was to develop a model to aid clinicians in better predicting 1-year mortality rate for patients with an acute exacerbation of chronic obstructive pulmonary disease admitted to the medical intensive care unit (ICU) with the goal of earlier initiation of palliative care and end-of-life communications in this patient population. This retrospective cohort study included patients from a medical ICU from April 1, 1995, to November 30, 2009. Data collected from the Acute Physiology and Chronic Health Evaluation III database included demographic characteristics; severity of illness scores; noninvasive and invasive mechanical ventilation time; ICU and hospital length of stay; and ICU, hospital, and 1-year mortality. Statistically significant univariate variables for 1-year mortality were entered into a multivariate model, and the independent variables were used to generate a scoring system to predict 1-year mortality rate. At 1-year follow-up, 295 of 591 patients died (50%). Age and hospital length of stay were identified as independent determinants of mortality at 1 year by using multivariate analysis, and the predictive model developed had an area under the operating curve of 0.68. Bootstrap analysis with 1000 iterations validated the model, age, and hospital length of stay, entered the model 100% of the time (area under the operating curve=0.687; 95% CI, 0.686-0.688). A simple model using age and hospital length of stay may be informative for providers willing to identify patients with chronic obstructive pulmonary disease with high 1-year mortality rate who may benefit from end-of-life communications and from palliative care.

Elevated cardiac troponin T levels in critically ill patients with sepsis.

BACKGROUND: It is known that troponin elevations have prognostic importance in critically ill patients. We examined whether cardiac troponin T elevations are independently associated with in-hospital, short-term (30 days), and long-term (3 years) mortality in intensive care unit (ICU) patients admitted with sepsis, severe sepsis, and septic shock after adjusting for the severity of disease with the Acute Physiology, Age and Chronic Health Evaluation III system. METHODS: We studied the Mayo Clinic's Acute Physiology, Age and Chronic Health Evaluation III database and cardiac troponin T levels from patients admitted consecutively to the medical ICU. Between January 2001 and December 2006, 926 patients with sepsis had cardiac troponin T measured at ICU admission. In-hospital, short-term, and long-term all-cause mortality were determined. RESULTS: Among study patients, 645 (69.7%) had elevated cardiac troponin T levels and 281 (30.3%) had undetectable cardiac troponin T. During hospitalization, 15% of the patients with troponin T <0.01 ng/mL died compared with 31.9% of those with troponin T ≥ 0.01 ng/mL (P < .0001). At 30 days, mortality was 31% and 17% in patients with and without elevations, respectively (P < .0001). The Kaplan-Meier probability of survival at 1-, 2-, and 3-year follow-ups was 68.1%, 56.3%, and 46.8% with troponin T ≥ 0.01 ng/mL, respectively, and 76.4%, 69.1%, and 62.0% with troponin T <0.01 µg/L, respectively (P < .0001). After adjustment for severity of disease and baseline characteristics, cardiac troponin T levels remained associated with in-hospital and short-term mortality but not with long-term mortality. CONCLUSIONS: In patients with sepsis who are admitted to an ICU, cardiac troponin T elevations are independently associated with in-hospital and short-term mortality but not long-term mortality.

The impact of rapid response team on outcome of patients transferred from the ward to the ICU: a single-center study.

OBJECTIVES: To determine the impact of rapid response team implementation on the outcome of patients transferred from the regular hospital ward and nonward locations to the ICU. DESIGN: Retrospective before-after cohort study. SETTING: The study was performed in two ICUs, one surgical and one medical, of a tertiary medical center. PATIENTS: We included 4,890 patients transferred from the hospital ward to two ICUs and 15,855 patients admitted from nonward locations. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data on each patient were abstracted from the Acute Physiology and Chronic Health Evaluation III and the administrative hospital and rapid response team databases. The study period was divided into pre-rapid response team and rapid response team. A 24/7 critical care consult service and cardiac arrest teams were available for ward patient care during both periods. A total of 20,745 patients were admitted to the two study ICUs, of whom 4,890 were from the ward (2,466 and 2,424 during the pre-rapid response team and rapid response team periods, respectively). The first ICU day severity of illness was higher for the pre-rapid response team period. A multiple logistic regression model that included predicted mortality as a covariate suggested that availability of rapid response team was associated with an increased risk of hospital death in patients transferred to the ICU from the regular ward, odds ratio (95% CI) of 1.273 (1.089-1.490). For the nonward patients, the availability of rapid response team was similarly associated with increased risk of death. The ICU length of stay was shorter during the rapid response team period both in ward transfer and in nonward transfer patients. CONCLUSIONS: Rapid response team implementation is associated with increased numbers of ICU admissions and rates, and transfer from the ward of less severely ill patients. However, rapid response team implementation did not improve the severity-of-illness-adjusted outcome of patients transferred from the ward. Implementation of rapid response team in an institution with a 24/7 ICU consult service may have unforeseen costs without obvious benefit. Our findings highlight that institutions should evaluate the impact of rapid response team on patient outcome and make modifications specific to their practices.

Intensivist/patient ratios in closed ICUs: a statement from the Society of Critical Care Medicine Taskforce on ICU Staffing.

OBJECTIVES: Increases in the number, size, and occupancy rates of ICUs have not been accompanied by a commensurate growth in the number of critical care physicians leading to a workforce shortage. Due to concern that understaffing may exist, the Society of Critical Care Medicine created a taskforce to generate guidelines on maximum intensivists/patient ratios. DATA SOURCES: A multidisciplinary taskforce conducted a review of published literature on intensivist staffing and related topics, a survey of pulmonary/Critical Care physicians, and held an expert roundtable conference. DATA EXTRACTION: A statement was generated and revised by the taskforce members using an iterative consensus process and submitted for review to the leadership council of the Society of Critical Care Medicine. For the purposes of this statement, the taskforce limited its recommendations to ICUs that use a "closed" model where the intensivists control triage and patient care. DATA SYNTHESIS AND CONCLUSIONS: The taskforce concluded that while advocating a specific maximum number of patients cared for is unrealistic, an approach that uses the following principles is essential: 1) proper staffing impacts patient care; 2) large caseloads should not preclude rounding in a timely fashion; 3) staffing decisions should factor surge capacity and nondirect patient care activities; 4) institutions should regularly reassess their staffing; 5) high staff turnover or decreases in quality-of-care indicators in an ICU may be markers of overload; 6) telemedicine, advanced practice professionals, or nonintensivist medical staff may be useful to alleviate overburdening the intensivist, but should be evaluated using rigorous methods; 7) in teaching institutions, feedback from faculty and trainees should be sought to understand the implications of potential understaffing on medical education; and 8) in academic medical ICUs, there is evidence that intensivist/patient ratios less favorable than 1:14 negatively impact education, staff well-being, and patient care.

Thrombocytopenia in adult patients with sepsis: incidence, risk factors, and its association with clinical outcome.

BACKGROUND: Sepsis is a major risk factor for the development of thrombocytopenia, but few studies have specifically evaluated prognostic importance of thrombocytopenia in patients with sepsis. We investigated the incidence, risk factors, and prognostic importance of thrombocytopenia in adult patients admitted to the intensive care unit (ICU) with sepsis. METHODS: A retrospective analysis of patients admitted with severe sepsis/septic shock from December 2007 to January 2009 to a 24-bed medical ICU was done. RESULTS: A total of 304 patients were included in the study. The patients' mean (±SD) age was 68.8 (±15.8) years. The majority (93.7%) had septic shock, and pneumonia was the most common infection (38.8%). Thrombocytopenia developed in 145 patients (47.6%): 77 (25.3%) at ICU admission and 68 (22.3%) during their hospital course. The median (IQR) duration of thrombocytopenia was 4.4 (1.9-6.9) days. Patients who developed thrombocytopenia had more episodes of major bleeding (14.4% vs. 3.7%, P < 0.01) and received more transfusions. Patients with thrombocytopenia had a higher incidence of acute kidney injury (44.1% vs. 29.5%, P < 0.01), prolonged vasopressor support (median (IQR): 37 (17-76) vs. 23 (13-46) h, P < 0.01), and longer ICU stay (median (IQR): 3.1 (1.6-7.8) vs. 2.1 (1.2-4.4) days, P < 0.01). The 28-day mortality was similar between patients with and without thrombocytopenia (32.4% vs. 24.5%, P = 0.12). However, while 15 of 86 patients (17.4%) who resolved their thrombocytopenia died, 32 of 59 patients (54.2%) whose thrombocytopenia did not resolve died (P < 0.01). The association between non-resolution of thrombocytopenia and mortality remained significant after adjusting for age, APACHE III score and compliance with a sepsis resuscitation bundle (P < 0.01). CONCLUSIONS: Thrombocytopenia is common in patients who are admitted to the ICU with severe sepsis and septic shock. Patients with thrombocytopenia had more episodes of major bleeding, increased incidence of acute kidney injury, and prolonged ICU stay. Non-resolution of thrombocytopenia, but not thrombocytopenia itself, was associated with increased 28-day mortality.

Clinical spectrum, frequency, and significance of myocardial dysfunction in severe sepsis and septic shock.

OBJECTIVE: To determine the frequency and spectrum of myocardial dysfunction in patients with severe sepsis and septic shock using transthoracic echocardiography and to evaluate the impact of the myocardial dysfunction types on mortality. PATIENTS AND METHODS: A prospective study of 106 patients with severe sepsis or septic shock was conducted from August 1, 2007, to January 31, 2009. All patients underwent transthoracic echocardiography within 24 hours of admission to the intensive care unit. Myocardial dysfunction was classified as left ventricular (LV) diastolic, LV systolic, and right ventricular (RV) dysfunction. Frequency of myocardial dysfunction was calculated, and demographic, hemodynamic, and physiologic variables and mortality were compared between the myocardial dysfunction types and patients without cardiac dysfunction. RESULTS: The frequency of myocardial dysfunction in patients with severe sepsis or septic shock was 64% (n=68). Left ventricular diastolic dysfunction was present in 39 patients (37%), LV systolic dysfunction in 29 (27%), and RV dysfunction in 33 (31%). There was significant overlap. The 30-day and 1-year mortality rates were 36% and 57%, respectively. There was no difference in mortality between patients with normal myocardial function and those with left, right, or any ventricular dysfunction. CONCLUSION: Myocardial dysfunction is frequent in patients with severe sepsis or septic shock and has a wide spectrum including LV diastolic, LV systolic, and RV dysfunction types. Although evaluation for the presence and type of myocardial dysfunction is important for tailoring specific therapy, its presence in patients with severe sepsis and septic shock was not associated with increased 30-day or 1-year mortality.

Comparison of APACHE III, APACHE IV, SAPS 3, and MPM0III and influence of resuscitation status on model performance.

BACKGROUND: There are few comparisons among the most recent versions of the major adult ICU prognostic systems (APACHE [Acute Physiology and Chronic Health Evaluation] IV, Simplified Acute Physiology Score [SAPS] 3, Mortality Probability Model [MPM]0III). Only MPM0III includes resuscitation status as a predictor. METHODS: We assessed the discrimination, calibration, and overall performance of the models in 2,596 patients in three ICUs at our tertiary referral center in 2006. For APACHE and SAPS, the analyses were repeated with and without inclusion of resuscitation status as a predictor variable. RESULTS: Of the 2,596 patients studied, 283 (10.9%) died before hospital discharge. The areas under the curve (95% CI) of the models for prediction of hospital mortality were 0.868 (0.854-0.880), 0.861 (0.847-0.874), 0.801 (0.785-0.816), and 0.721 (0.704-0.738) for APACHE III, APACHE IV, SAPS 3, and MPM0III, respectively. The Hosmer-Lemeshow statistics for the models were 33.7, 31.0, 36.6, and 21.8 for APACHE III, APACHE IV, SAPS 3, and MPM0III, respectively. Each of the Hosmer-Lemeshow statistics generated P values < .05, indicating poor calibration. Brier scores for the models were 0.0771, 0.0749, 0.0890, and 0.0932, respectively. There were no significant differences between the discriminative ability or the calibration of APACHE or SAPS with and without "do not resuscitate" status. CONCLUSIONS: APACHE III and IV had similar discriminatory capability and both were better than SAPS 3, which was better than MPM0III. The calibrations of the models studied were poor. Overall, models with more predictor variables performed better than those with fewer. The addition of resuscitation status did not improve APACHE III or IV or SAPS 3 prediction.

Perceived effects of attending physician workload in academic medical intensive care units: a national survey of training program directors.

BACKGROUND: Increases in the size and number of American intensive care units have not been accompanied by a comparable increase in the critical care physician workforce, raising concerns that intensivists are becoming overburdened by workload. This is especially concerning in academic intensive care units where attending physicians must couple teaching duties with patient care. METHODS: We performed an in-person and electronic survey of the membership of the Association of Pulmonary and Critical Care Medicine Program Directors, soliciting information about patient workload, other hospital and medical education duties, and perceptions of the workplace and teaching environment of their intensive care units. RESULTS: Eighty-four out of a total 121 possible responses were received from program directors or their delegates, resulting in a response rate of 69%. The average daily (SD) census (as perceived by the respondents) was 18.8 ± 8.9 patients, and average (SD) maximum service size recalled was 24.1 ± 9.9 patients. Twenty-seven percent reported no policy setting an upper limit for the daily census. Twenty-eight percent of respondents felt the average census was "too many" and 71% felt the maximum size was "too many." The median (interquartile range) patient-to-attending physician ratio was 13 (10-16). When categorized according to this median, respondents from intensive care units with high patient/physician ratios (n = 31) perceived significantly more time constraints, more stress, and difficulties with teaching trainees than respondents with low patient/physician ratios (n = 40). The total number of non-nursing healthcare workers per patient was similar in both groups, suggesting that having more nonattending physician staff does not alleviate perceptions of overwork and stress in the attending physician. CONCLUSIONS: Academic intensive care unit physicians that direct fellowship programs frequently perceived being overburdened in the intensive care unit. Understaffing intensive care units with attending physicians may have a negative impact on teaching, patient care, and workforce stability.

A scoring model of factors associated with Candida glabrata candidemia among critically ill patients.

Candida species, including Candida glabrata (CG), are common causes of bloodstream infections among intensive care unit (ICU) patients. Many CG isolates have decreased susceptibility to fluconazole. Constructing a scoring model of factors associated with CG candidemia in ICU patients that can be used if fluconazole susceptibility testing is not readily available. We identified patients with candidemia that were admitted to the ICU of the Mayo Clinic in Rochester, Minnesota from 1998 to 2006. Using patient demographical and clinical data abstracted via chart review, a multivariable logistic regression model was developed to distinguish those with CG candidemia. We identified 246 patients with candidemia including 68 CG cases. Multivariable analysis identified four independent factors associated with CG candidemia: absence of renal failure, less than 7 days in the hospital, abdominal surgery and fluconazole use. The predictive ability of the model, based on the c-statistic, was 0.727. In a large ICU cohort, a scoring model that included four risk factors, which are readily ascertainable at the bedside, was created to distinguish candidemia due to CG from other causes of candidemia. The identification of risk factors associated with CG candidemia could aid physicians in the selection of the optimal initial antifungal therapy.

Risk factors and outcome of pulmonary complications after autologous hematopoietic stem cell transplant.

BACKGROUND: Most reports addressing pulmonary complications (PCs) in hematopoietic stem cell transplant (HSCT) recipients have focused on allogeneics. This study describes the PCs, their risk factors, and the impact on mortality in autologous recipients. METHODS: We reviewed the medical records of 1,243 adult autologous HSCT recipients. We collected pretransplant and posttransplant data and data on PC after transplant and long-term mortality. RESULTS: Four hundred eighty-seven PC developed in 343 patients (27.6%): 173 infectious (13.9%), 127 noninfectious (10.2%), and 43 both infectious and noninfectious (3.5%). Bacterial, fungal, and viral pneumonias were the most common infectious complications. The main noninfectious complications were acute pulmonary edema (APE) (59 [4.7%]), diffuse alveolar hemorrhage (DAH) (26 [2.1%]), peri-engraftment respiratory distress syndrome (PERDS) (31 [2.5%]), and idiopathic pneumonia syndrome (IPS) (12 [1.0%]). Independent factors associated with PC included diffusing capacity of lung for carbon monoxide and indications for transplant. Factors associated with mortality included sex, history of pulmonary disease, disease status at the time of transplant, FVC, Karnofsky score, and underlying diagnosis. A Cox proportional hazards regression model with separate time-dependent predictors for the first 1 month, 1 to 2 months, 2 to 6 months, and 6 or more months showed an association with mortality at hazard ratios (HRs) of 32.39, 10.13, 4.29, and 0.98, respectively, compared with persons without PC. CONCLUSIONS: More than 25% of autologous HSCT recipients develop PCs within 1 year of transplant. Most of the complications are infections. The most common noninfectious complications are APE, DAH, PERDS, and IPS. PCs increase the risk of death, with HR as high as 32.

Intensive care of the cancer patient: recent achievements and remaining challenges.

A few decades have passed since intensive care unit (ICU) beds have been available for critically ill patients with cancer. Although the initial reports showed dismal prognosis, recent data suggest that an increased number of patients with solid and hematological malignancies benefit from intensive care support, with dramatically decreased mortality rates. Advances in the management of the underlying malignancies and support of organ dysfunctions have led to survival gains in patients with life-threatening complications from the malignancy itself, as well as infectious and toxic adverse effects related to the oncological treatments. In this review, we will appraise the prognostic factors and discuss the overall perspective related to the management of critically ill patients with cancer. The prognostic significance of certain factors has changed over time. For example, neutropenia or autologous bone marrow transplantation (BMT) have less adverse prognostic implications than two decades ago. Similarly, because hematologists and oncologists select patients for ICU admission based on the characteristics of the malignancy, the underlying malignancy rarely influences short-term survival after ICU admission. Since the recent data do not clearly support the benefit of ICU support to unselected critically ill allogeneic BMT recipients, more outcome research is needed in this subgroup. Because of the overall increased survival that has been reported in critically ill patients with cancer, we outline an easy-to-use and evidence-based ICU admission triage criteria that may help avoid depriving life support to patients with cancer who can benefit. Lastly, we propose a research agenda to address unanswered questions.

Nicotine replacement therapy in critically ill patients: a prospective observational cohort study.

OBJECTIVE: Smokers admitted to the intensive care unit may receive nicotine replacement therapy to prevent nicotine withdrawal. However, recent studies have questioned the safety of this practice. The objective of this study was to determine the impact of nicotine replacement therapy on the outcomes of critically ill patients. DESIGN: Prospective observational cohort. SETTING: The medical intensive care unit of a tertiary academic hospital. PATIENTS: Active smokers admitted to the intensive care unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After excluding 2,411 patients who did not meet the study inclusion criteria, 330 were included in the study, of which 174 patients received and 156 did not receive nicotine replacement therapy. There were no significant differences in the unadjusted hospital mortality between the two groups: 14 patients (7.8%; 95% confidence interval, 4-12) died in the nicotine replacement therapy group as compared with ten patients (6.3%; 95% confidence interval, 2.6-10.3) in the nonnicotine replacement therapy group (p = .59). After adjusting for severity of illness and propensity score for administration of nicotine replacement therapy on intensive care unit admission, nicotine replacement therapy was not associated with increased hospital mortality (odds ratio, 1.4; 95% confidence interval, 0.5-3.9; p = .51). LIMITATIONS: Single-center observational study. CONCLUSIONS: Nicotine replacement therapy is not associated with increased hospital mortality in critically ill patients. However, we were not able to demonstrate any clinically significant benefit from its use in the intensive care unit setting.

Severity of illness scoring systems in the intensive care unit.

OBJECTIVE: Adult intensive care unit prognostic models have been used for predicting patient outcome for three decades. The goal of this review is to describe the different versions of the main adult intensive care unit prognostic models and discuss their potential roles. DATA SOURCE: PubMed search and review of the relevant medical literature. SUMMARY: The main prognostic models for assessing the overall severity of illness in critically ill adults are Acute Physiology and Chronic Health Evaluation, Simplified Acute Physiology Score, and Mortality Probability Model. Simplified Acute Physiology Score and Mortality Probability Model have been updated to their third versions and Acute Physiology and Chronic Health Evaluation to its fourth version. The development of prognostic models is usually followed by internal and external validation and performance assessment. Performance is assessed by area under the receiver operating characteristic curve for discrimination and Hosmer-Lemeshow statistic for calibration. The areas under the receiver operating characteristic curve of Simplified Acute Physiology Score 3, Acute Physiology and Chronic Health Evaluation IV, and Mortality Probability Model0 III were 0.85, 0.88, and 0.82, respectively, and all these three fourth-generation models had good calibration. The models have been extensively used for case-mix adjustment in clinical research and epidemiology, but their role in benchmarking, performance improvement, resource use, and clinical decision support has been less well studied. CONCLUSIONS: The fourth-generation Acute Physiology and Chronic Health Evaluation, Simplified Acute Physiology Score 3, Acute Physiology and Chronic Health Evaluation IV, and Mortality Probability Model0 III adult prognostic models, perform well in predicting mortality. Future studies are needed to determine their roles for benchmarking, performance improvement, resource use, and clinical decision support.

Septic shock: a multidisciplinary response team and weekly feedback to clinicians improve the process of care and mortality.

OBJECTIVE: To evaluate the impact of weekly feedback to clinicians and the activation of a sepsis response team on the process of care and hospital mortality in patients with severe sepsis or septic shock. DESIGN: Prospective, interventional cohort study. SETTING: The medical intensive care unit of a tertiary, academic medical center. STUDY SUBJECTS: Patients with severe sepsis or septic shock consecutively treated in a medical intensive care unit. INTERVENTIONS: Daily auditing and weekly feedback, and sepsis response team activation. MEASUREMENTS AND MAIN RESULTS: During a 33-month study period, from January 2007 through September 2009, we performed daily screening of patients for severe sepsis or septic shock. Study periods were divided into baseline (screening only), daily auditing with weekly feedback, and sepsis response team activation. Comparisons among the three periods were made by using univariate and multiple logistic regression analyses. Compliance with the overall sepsis resuscitation bundle and its individual elements and hospital mortality were used as outcome measures. A total of 984 episodes of severe sepsis and septic shock were identified during the study periods, severe sepsis in 52 (5.3%) and septic shock in 932 (94.7%). The compliance rate with all elements of the sepsis resuscitation bundle increased from 12.7% at baseline to 37.7% and 53.7% during the weekly feedback and sepsis response team activation periods, respectively (p < .001). Overall hospital mortality rate was 30.3%, 28.3%, and 22.0% during baseline, weekly feedback, and sepsis response team periods, respectively (p = .029). Multiple logistic regression analysis showed that the sepsis response team was associated with reduced risk of hospital death (odds ratio, 0.657; 95% confidence interval, 0.456-0.945; p = .023) whereas hepatic cirrhosis, hepatic failure, leukemia, multiple myeloma, transfer from the same hospital ward, do-not-resuscitate status at the recognition of severe sepsis/septic shock, and lactate level were associated with increased risk of death. CONCLUSIONS: In septic shock, the activation of the sepsis response team in combination with weekly feedback increases the compliance with the process of care and reduces hospital mortality rate.