226 and glucose control) included the baseline subject char- Hospitals contributed data for a mean duration of acteristics as well as these elements. The model assessing 15.6 months (median of 14 months). Table 2 includes site the administration of drotrecogin alfa in subjects with and patient characteristics. multiple organ failures also included the baseline subject characteristics and the base set of bundle elements. The model assessing plateau pressure control in mechanically Change in achievement of bundle targets over time ventilated subjects also included the baseline subject characteristics and the base set of bundle elements. The Compliance rates for achieving all bundle targets over model assessing the administration of drotrecogin alfa, time—both the overall bundles and the individual ele- low-dose steroids, CVP [8, and ScvO2 [70 in subjects in ments within both bundles—increased over time, shock despite ﬂuids also included the baseline subject although both basal achievement rates and the magnitude characteristics and the base set of bundle elements. of improvement varied considerably across targets To demonstrate that a decrease in hospital mortality (Table 3). Compliance with the initial 6-h bundle targets over time was not associated with entering less severely increased linearly from 10.9% of subjects in the ﬁrst site ill patients in the database at individual sites, a logistic quarter to 31.3% by the end of 2 years in the campaign, regression model was constructed. It contained all sub- achieving statistical signiﬁcance by the second quarter jects entered over the maximum of 2 years of data (10.9 vs. 14.9%, P \ 0.0001) (Fig. 2). The ability to collection and the baseline subject characteristics for the achieve the entire 24-h management bundle targets started quarter of participation for up to eight quarters. Because higher, at 18.4% in the ﬁrst quarter, and increased to sites could enter the Campaign at any time, the possibility 36.1% by the end of 2 years, but did not achieve statis- that decreased hospital mortality over time was associated tical signiﬁcance until the fourth quarter (18.4 vs. 21.5%, with a global decrease in mortality for the same severity P = 0.008). of illness was investigated by constructing a logistic regression model for hospital mortality using the ﬁrst quarter of data collection from each site, including the Changes in hospital mortality baseline subject characteristics and the calendar quarter (1 for the ﬁrst quarter of 2005 through 13 for the ﬁrst quarter Unadjusted hospital mortality decreased from 37.0% in of 2008). the ﬁrst quarter in the Campaign to 30.8% by 2 years (P = 0.001). On average, unadjusted mortality decreased by 0.91% (95% CI 0.42–1.40%) for each quarter in the Statistical analysis Campaign. The results of the multivariable model examining the effect of time in the Campaign on hospital We compared raw rates including hospital mortality and mortality are summarized in Table 4. The model ﬁt well bundle compliance using Fisher’s exact test. We expres- (Hosmer and Lemeshow C statistic of 18.1 with 18 sed the effects of predictor variables on hospital mortality degrees of freedom, P = 0.34 accounted for 36.6% of using odds ratios, including 95% conﬁdence intervals for variation in the data, with a v2 dispersion of 1.04). In both risk-adjusted results. We assessed logistic regression the unadjusted and adjusted models, the chance of death model ﬁt using the Hosmer–Lemeshow C statistic, the v2 decreased the longer a site was in the Campaign, resulting dispersion, the proportion of log-likelihood accounted for in an adjusted absolute drop of 0.8% per quarter and 5.4% by the model, and an examination of model residuals. We over the ﬁrst 2 years (95% CI, 2.5–8.4%). In contrast, the constructed the databases in Access and FoxPro (Micro- model examining the ﬁrst quarter of data from all sites did soft Corp., Redmond, WA) and conducted analyses in not ﬁnd a secular trend, associated with calendar time, to DataDesk (Data Description, Ithaca, NY) and SAS (SAS be signiﬁcantly associated with mortality (P = 0.23). The Institute, Cary, NC). model ﬁt well (Hosmer and Lemeshow C statistic of 16.6 with 18 degrees of freedom, P = 0.55, accounted for 18.4% of variation in the data, with a v2 dispersion of 1.05). Results Between January 2005 and March 2008, 15,775 subjects Relationship between bundle targets and hospital at 252 qualifying sites were entered into the SSC database mortality (see Supplemental Table 1 online). Excluding hospitals that contributed fewer than 20 subjects, the ﬁnal sample After adjustment for baseline characteristics, administra- consisted of 15,022 patients at 165 hospitals (a median of tion of broad-spectrum antibiotics (OR 0.86, 95% CI 57 and range of 20–471 subjects per hospital). Data from 0.79–0.93, P \ 0.0001), obtaining blood cultures before up to eight quarters were analyzed from each site. their initiation (OR 0.76, 95% CI 0.70–0.83, P \ 0.0001),