Resuscitation bundle compliance in severe sepsis and septic shock: improves survival, is better late than never.

UNLABELLED: While clinicians' management of severe sepsis and septic shock has been positively influenced by a number of clinical research studies in the last decade, challenges remain regarding early hemodynamic optimization as envisioned in the Surviving Sepsis Campaign's (SSC) resuscitation bundle (RB). We examined the impact of a hospital-wide continuous quality improvement (CQI) initiative on patients presenting with severe sepsis and septic shock, and the impact of the sepsis RB on patient outcomes when completed beyond the 6-hour recommendation period. The study was an 18-month, prospective cohort study enrolling patients who met the definition of severe sepsis or septic shock. Compliance with the hemodynamic components of the sepsis RB was defined as achieving goal mean arterial pressure (MAP) ≥ 65 mm Hg, central venous pressure (CVP) ≥ 8 mm Hg, and central venous oxygen saturation (ScvO2) ≥ 70%. Compliance was assessed at 6 hours and 18 hours after diagnosis of severe sepsis or septic shock. In all, 498 patients with severe sepsis and/or septic shock were evaluated to determine the upper limit of the range of hours that compliance with the RB would still improve outcomes. Using 18 hours as a marker, Compliers at 18 hrs and Non-Compliers at 18 hrs were compared. There were 202 patients who had the RB completed in less than or equal to 18 hours. There were 296 patients who did not complete the RB at 18 hours. The Compliers at 18 hrs had a significant 10.2% lower hospital mortality 37.1% (22% relative reduction) compared to the Non-Compliers at 18 hrs hospital mortality of 47.3% (P < .03). When the two groups were adjusted for differences in baseline illness severity, the Compliers at 18 hrs had a greater reduction in predicted mortality of 26.8% versus 9.4%, P < 0.01. CONCLUSIONS: Initiating the sepsis RB for patients with severe sepsis and/or septic shock decreased mortality. A CQI initiative that monitored the implementation in real-time allowed for improvement in compliance and efficacy of the bundle on outcomes. Multiple studies have shown that compliance to the RB within 6 hours lowers hospital mortality. This study uniquely shows that when bundle completion is extended to 18 hours, the mortality reduction remains significant.

A tight glycemic control initiative in a surgical intensive care unit and hospitalwide.

BACKGROUND: In 2002, tight glycemic control (TGC) was mandated at Henry Ford Hospital (Detroit) to reduce surgical site infections (SSIs). THE FIVE STEPS FOR IMPROVEMENT: The TGC initiative was developed in terms of the five primary steps of the Institute for Healthcare Improvement (IHI) framework for leadership for improvement to drive practice change and maintain continuous improvement. In terms of Steps 1-3 (set direction, establish the foundation, and build will), in April 2002 the chief executive officer of the Henry Ford Hospital (Detroit) announced a hospitalwide initiative to reduce SSIs. For steps 4 and 5 (generate ideas and execute change), the 40-bed surgical intensive care unit (SICU) was designated the practice-change setting. TGC protocols were implemented in cardiothoracic patients, followed by all SICU patients, with target glucose ranges moving from the initial < 150 mg/dL to 80-110 mg/dL. Results showed decreases in SSIs and mortality. The project's success led initiation of hospitalwide TGC in the next two years. RESPONDING TO A CHANGING EVIDENCE BASE: In 2009, as studies began to show that the recommended glucose target of 80-110 mg/dL was not associated with clinical improvement in ICU patients and perhaps may cause harm (increased mortality), the target ranges were modified. LESSONS LEARNED: Barriers to adoption of new practice change must be integrated into the planning process. Leadership champions are required across multiple levels of the organization to drive change to the bedside for effective and lasting improvement. CONCLUSIONS: A universal TGC protocol continues to be used throughout the hospital, with modifications and next-generation improvements occurring as evidence arises.