Review the patterns of implementation of a sepsis bundle and identify the characteristics associated with incomplete implementation.
Data was prospectively obtained from MediQual databases as well as a retrospective chart review of a sample of patients with a principle discharge diagnosis of severe sepsis or septic shock (IDC-9 78522, 99592). The mortality rate was compared before (2004–2005) and after (2007–2008) implementation of a sepsis bundle. Implementation of the sepsis bundle was assessed by bundle orders used, >20ml/kg fluid bolus in first hour, serum lactate measured, central line placed, volume status after 6 hours, ScvO2 measured, timely first dose of antibiotics, assessment for drotrecogin alfa (activated), and lung protective ventilation.
There was a decrease in the mortality rate (69/155) 44.5% (2004–2005) to (202/540) 37.4% (2007–2008) which was not statistically significant (p=0.06). Thirty-two charts were reviewed. Discharge diagnosis was severe sepsis (62%) and septic shock (38%). Septic sources: lung (53%), urine (38%), GI (9%), wound (3%) and other (9%). Bundle order forms were used in 28%. A fluid bolus of >20ml/kg in the first hour was given in 28%. A serum lactate was not done in 50%. Central line was placed in 63%. Central venous pressures were not >8 mmHg 6 hours after identification in 22%. ScvO2 was not checked in 88%. The first antibiotic dose was given within the first 4 hours in 64% and >7 hours after identification of sepsis in 35%. 87% of the patients were not assessed for use of drotrecogin alfa (activated). Lung protective ventilation was not used in 22% identified with ALI/ARDS. There was lack of implementation of all sepsis bundle orders in 84%. Delays in identifying sepsis occurred in 64%.
Variability in the degree of implementation of bundle practices is the most significant barrier. Delays in diagnosis and implementation, in particular with antibiotic use and resuscitation, also impact overall care quality.
Sepsis bundle implementation that fails to improve outcome may be related to delays and implementation of all bundle components.
Benjamin Mosher, No Financial Disclosure Information; No Product/Research Disclosure Information