Evidence from America and Europe suggests that successful implementation of a 6-hour severe sepsis bundle including early goal-directed therapy is associated with significant outcome benefit. This study examines the impact of implementing such bundle in multiple Asian countries.
The study is a multi-national, prospective interventional cohort of adult severe sepsis or septic shock patients presenting to the emergency department (ED) of 8 hospitals in Korea, India, Taiwan, Singapore, and China. Implementation of the bundle was divided into 3-month phases of Baseline, Education, and Quality Improvement from July 1, 2008 to March 31, 2009. Components of the bundle included 1) CVP/ScvO2 monitoring within 2 hours; 2) Antibiotics within 3 hours; 3) Achieving CVP > 8 mm Hg, MAP > 65 mm Hg, and ScvO2 > 70% within 6 hours; and 4) Lactate clearance.
Two hundred seventy four patients were enrolled with 62.0+/−17.9 yrs old, APACHE II 22.1+/−8.5, lactate 4.6+/−3.2 mmol/L, 69.3% septic shock, 54.0% vasopressor requirement, 51.5% mechanical ventilation, and 28.1% in-hospital mortality. ED length of stay was 12.5+/−26.7 hours and hospital length of stay 14.0+/−15.4 days. Compliance to all items of the bundle was 11.9, 19.4, and 28.6% (p=0.01) over the three phases of implementation. Time to antibiotic administration was 1.4+/−1.4, 1.4+/−1.6, and 1.7+/−1.8 hours (p=0.06); and time to hemodynamic monitoring 5.3+/−9.1, 5.2+/−9.5, and 3.4+/−5.3 hours (p=0.07), respectively. In those patients who received the entire bundle, mortality was 18.8% compared to 30.1% mortality in those patients who only received some components of the bundle (p=0.04).
Baseline compliance to the 6-hour severe sepsis bundle is low in Asia and similar to other published data in Europe and America. Through education and quality improvement efforts, improved compliance and outcome benefit was achieved. Continued adherence to the bundle implementation will likely increase the standard of care for severe sepsis and septic shock patients in Asia.
Further studies are needed to examine strategies required to increase and maintain compliance to the bundle for severe sepsis and septic shock.
Chih-huang Li, Consultant fee, speaker bureau, advisory committee, etc. Consultant fee and speaker bureau for Edwards Lifesciences.; No Product/Research Disclosure Information