PURPOSE: To determine whether a disease-specific order set improves adherence to evidence-based management of severe sepsis and septic shock.
METHODS: All patients treated in the Medical Intensive Care Unit (MICU) for severe sepsis or septic shock over a nine month period were evaluated prospectively. Adherence to evidence-based management was determined 6 hours after initiation of treatment. Parameters included resuscitation to a central venous pressure (CVP) >8cmH2O, mean arterial pressure >65 mmHg, mixed venous oxygen saturation (ScvO2) >70%, and appropriate use of vasopressors, corticosteroid replacement, antibiotics, activated protein C (APC), blood transfusion, and inotropes. Patients not authorizing review of their records were excluded. Order set introduction occurred simultaneously in the Emergency Department (ED) and MICU four months after study initiation.
RESULTS: One-hundred and ninety-six patients were enrolled, 72 prior and 124 after order set introduction. Two patients were excluded. There was no difference in gender, APACHE III score, or predicted MICU mortality between the groups. Age was higher (74 vs 66 years, p<0.01) after order set implementation. The order set was utilized in 91 (73%) of eligible patients. Antibiotics were administered within 3h of ED presentation and within 1h of MICU admission in 89% of patients after the order set vs 58% before (p<0.01); CVP measured in 88% vs 74% (p=0.03); goal CVP achieved in 75% vs 50% (<0.01); corticosteroid replacement given to 92% vs 57% of eligible patients (<0.01). There were no statistically significant differences in measurement of ScvO2 (89% vs 78%, p=0.07), achievement of goal ScvO2 (77% vs 70%, p=0.18), adequacy of vasopressor (88% vs 94%, p=0.12), inotrope (65% vs 57%, p=0.26), blood transfusion (88% vs 85%, p=0.42) or APC use (32% vs 58.3% of the eligible patients, p=0.13), or MICU (25.4% vs 29.2%, p=0.59) or hospital mortality (34.5% vs 40.3%, p=0.42).
CONCLUSION: A disease-specific order set for severe sepsis and septic shock improves adherence to some but not all evidence-based practices.
CLINICAL IMPLICATIONS: Introduction of an order set improves adherence to evidence-based management of severe sepsis and septic shock.
DISCLOSURE: John Mullon, None.