Managing Sepsis — Early Goal-Directed Therapy Saves Lives, Again

Implementation of a bundle of five quality indicators for early management of severe sepsis was associated with reduced mortality.
Although there are outcome data supporting the Surviving Sepsis Campaign guideline components, little is known about the feasibility of implementing a comprehensive treatment protocol for sepsis ("severe sepsis bundle") in an emergency department. In a prospective observational study, researchers examined compliance and outcomes at a single ED that implemented a severe sepsis bundle with physician feedback.
The bundle consisted of five quality indicators:

Initiation of central venous pressure and central venous oxygen saturation monitoring within 2 hours
Administration of broad-spectrum antibiotics within 4 hours
Completion of early goal-directed therapy (EGDT) within 6 hours
Administration of corticosteroid therapy for patients receiving vasopressors or with suspected adrenal insufficiency
Monitoring of lactate clearance

The 2-year project was divided into a pre-implementation phase in which education and infrastructure were established, an observational phase in which physicians were given the tools to implement the program, and a quality initiative phase in which department feedback was provided.
During the 2-year study period, 330 patients (mean age, 63.8) presented with severe sepsis or septic shock. The mean ED length of stay (LOS) was 8.5 hours, mean hospital LOS was 11.3 days, and in-hospital mortality was 35.2%. Bundle compliance increased progressively from 0% to 51.2%. In-hospital mortality was significantly lower in patients who had all bundle components completed than in those who did not (20.8% vs. 39.5%). After the authors adjusted for oxygen debt, bundle completion still was associated with increased survival. In multivariate logistic regression analysis, EGDT was the sole quality indicator associated with lower mortality (odds ratio, 0.36). Administration of fluids, vasopressors, transfusions, and inotropes was similar in the groups with and without bundle completion.
Comment: This observational study of a well-designed quality improvement program demonstrates that bundle completion resulted in an absolute reduction in mortality of nearly 19%. EGDT is the most important of the measures, and other studies have shown that it can be successfully implemented in an ED. Every ED should implement EGDT for patients with severe sepsis or septic shock. EGDT can be initiated by a shock team or an intensive care unit team or by ED personnel.
— Tiffany M. Osborn, MD
Published in Journal Watch Emergency Medicine July 20, 2007
Citation(s):
Nguyen HB et al. 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 Apr; 35:1105-12.