GUIDELINE BUNDLES ADHERENCE AND MORTALITY IN SEVERE SEPSIS AND SEPTIC SHOCK: RESULTS OF A NATIONAL PATIENT SAFETY PROGRAM IN THE NETHERLANDS
Authors: van Zanten A R H 
Published: March 2014

Introduction

Implementation of Surviving Sepsis Campaign bundles have been associated with reduced mortality in severe sepsis and septic shock patients. Case-mix adjusted mortality evaluations have not been performed to compare hospitals participating in sepsis bundle programs to those not participating.

Most related studies have important limitations such as lack of correction for severity of illness of patients included, and not having control groups. Recently, unadjusted in-hospital mortality differences were reported in ICUs participating in SSC initiatives in Europe versus the USA that disappeared after case-mix adjustment, indicating the importance of case-mix adjustment. Positive effects of previous reports could be due to inclusion of patients with lower risk of mortality caused by increased awareness and recognition of sepsis or to general quality improving initiatives. Therefore, causality of observed effects due to bundle technology implementation could not be demonstrated.

In-hospital mortality among severe sepsis and septic shock ICU patients in The Netherlands was 34.8% (first half of 2009). We aimed to achieve an individual bundle target adherence >80% and a relative mortality reduction of at least 15% (absolute mortality reduction 5.2%) at the end of 2012.

Methods

Design

Prospective multicenter cohort study in participating and non-participating centers.

Setting

82 ICUs in The Netherlands.

Participants

In total 213,677 adult ICU patients admitted to all ICUs among which 8,387 severe sepsis patients at 52 participating ICUs and 8,031 severe sepsis patients at 30 non-participating ICUs. Participation was voluntary and non-funded.

Exposure

A national program to screen patients for severe sepsis and septic shock and implement Surviving Sepsis Campaign bundles to complete within 6 and 24 hours after ICU admission.

Evaluation

Main Outcomes and Measures Bundle target adherence and case-mix adjusted in-hospital mortality were evaluated through odds ratios of time since program initiation by logistic GEE-analyses (July 2009 through January 2013). Time effects were compared in screened sepsis patients and sepsis patients in non-participating ICUs, and non-sepsis patients in participating and non-participating ICUs. Outcomes were adjusted for age, gender, admission type, severity of illness and sepsis diagnosis location.

Results

Participation duration was associated with improved bundle target adherence (aOR per month=1.024 (1.016–1.031)) and decreased in-hospital mortality (aOR per month=0.992 (0.986–0.997) equivalent to 5.8% adjusted absolute (and 16.7% relative) mortality reduction over 3.5 yrs. Mortality reduced in screened patients with other diagnoses (1.9% over 3.5 yrs, aOR per month=0.995 (0.9906–0.9996)), and did not change in non-screened patients in participating ICUs, nor in patients with sepsis or other diagnoses in non-participating ICUs.

Discussion

Implementation of a national sepsis program resulted in improved adherence to sepsis bundles in severe sepsis and septic shock patients and was associated with reduced adjusted in-hospital mortality only in participating ICUs, suggesting direct impact of sepsis screening and bundle application on in-hospital mortality.

This is the first national bundle technology program proving that effects are obtained only in participating centers and not due to general improvements in patient care or effects on case-mix selection due to increased awareness. Our results underline the importance of bundle technology.

Declaration of competing interests

None.