Feasibility and efficacy of sepsis management guidelines in a pediatric intensive care unit in Saudi Arabia: a quality improvement initiative

Objectives

Evaluation of feasibility and effectiveness of Surviving Sepsis Campaign (SSC) Guidelines implementation at a Pediatric Intensive Care Unit (PICU) in Saudi Arabia to reduce severe sepsis associated mortality.

Design

Retrospective data analysis for a prospective quality improvement (QI) initiative.

Settings

PICU at King Saud University Medical City, Saudi Arabia.

Participants

Children ≤14 years of age admitted to the PICU from July 2010 to March 2011 with suspected or proven sepsis. Comparisons were made to a previously admitted group of patients with sepsis from October 2009 to June 2010.

Interventions

Adaptation and implementation of the Surviving Sepsis Campaign-Clinical Practice Guidelines (SSC-CPGs) through AGREE instrument and ADAPTE process.

Main Outcome Measures

We reported pre- and post-implementation outcome of interest for this QI initiative, annual sepsis-related mortality rate. Furthermore, we reported follow-up of annual mortality rate until December 2016.

Results

Sixty-five patients was included in the study (42 in post-guidelines implementation group and 23 in pre-guidelines implementation group). Mortality was insignificantly lower in the post-implementation group (26.2% vs. 47.8%; P = 0.079). However, when adjusted for severity, identified by number of failing organs in the multivariate regression analysis, the mortality difference was favorable for the post-implementation group (P = 0.006). The lower sepsis-related mortality rate was also sustained, with an average mortality rate of 15.11% for the subsequent years (2012-16).

Conclusions

Adaptation and implementation of SSC Guidelines in our setting support its feasibility and potential benefits. However, a larger study is recommended to explore detailed compliance rates.

Validation of Test Performance and Clinical Time Zero for an Electronic Health Record Embedded Severe Sepsis Alert

BACHGROUND

Increasing use of EHRs has generated interest in the potential of computerized clinical decision support to improve treatment of sepsis. Electronic sepsis alerts have had mixed results due to poor test characteristics, the inability to detect sepsis in a timely fashion and the use of outside software limiting widespread adoption. We describe the development, evaluation and validation of an accurate and timely severe sepsis alert with the potential to impact sepsis management.

OBJECTIVE

To develop, evaluate, and validate an accurate and timely severe sepsis alert embedded in a commercial EHR.

METHODS

The sepsis alert was developed by identifying the most common severe sepsis criteria among a cohort of patients with ICD 9 codes indicating a diagnosis of sepsis. This alert requires criteria in three categories: indicators of a systemic inflammatory response, evidence of suspected infection from physician orders, and markers of organ dysfunction. Chart review was used to evaluate test performance and the ability to detect clinical time zero, the point in time when a patient develops severe sepsis.

RESULTS

Two physicians reviewed 100 positive cases and 75 negative cases. Based on this review, sensitivity was 74.5%, specificity was 86.0%, the positive predictive value was 50.3%, and the negative predictive value was 94.7%. The most common source of end-organ dysfunction was MAP less than 70 mm/Hg (59%). The alert was triggered at clinical time zero in 41% of cases and within three hours in 53.6% of cases. 96% of alerts triggered before a manual nurse screen.

CONCLUSION

We are the first to report the time between a sepsis alert and physician chart-review clinical time zero. Incorporating physician orders in the alert criteria improves specificity while maintaining sensitivity, which is important to reduce alert fatigue. By leveraging standard EHR functionality, this alert could be implemented by other healthcare systems.

Design and conduct of the activated protein C and corticosteroids for human septic shock (APROCCHSS) trial

Background

We aimed at assessing the benefit-to-risk ratio of activated protein C (drotrecogin-alfa activated, DAA) and corticosteroids, given alone or in combination, in patients with septic shock.

Methods

We implemented an investigator-led, publicly funded, multicenter, randomized according to a 2 × 2 factorial design, placebo-controlled, double-blind trial in four parallel groups in which adults with persistent septic shock and no contraindication to DAA were assigned to either DAA alone (24 mg/kg/h for 96 h), or hydrocortisone (50 mg intravenous bolus q6 for 7 days) and fludrocortisone (50 µg once daily through the nasogastric tube for 7 days) alone, or their respective combinations, or their respective placebos. Primary endpoint was 90-day mortality rate. Follow-up duration was 6 months. Statistical analysis was planned to be performed in intent-to-treat once after all participants completed 180-day follow-up and according to the 2 × 2 factorial design.

Results

The first patient was recruited in September 2008. The trial was suspended on October 25, 2011, owing to the withdrawal from the market of DAA. At this time, 411 patients had been enrolled. On May 17, 2012, the continuation of the trial on two parallel groups was approved by all legal authorities with the aim of investigating the benefit-to-risk ratio of corticosteroids. On June 30, 2014, the trial was suspended again by the study sponsor upon request of the independent data and safety monitoring board. Recruitment restarted on October 7, 2014, after any safety concern was ruled out. Finally, the trial was completed on June 23, 2015, with the recruitment of 1241 patients.

Conclusions

This report details the design, statistical plan and conduct of a randomized controlled trial of hydrocortisone and fludrocortisone in septic shock.

Trial registration The trial was registered at ClinicalTrials.gov under NCT00625209

Implementation of a Meningitis Care Bundle in the Emergency Room Reduces Mortality Associated With Acute Bacterial Meningitis

BACKGROUND

Prompt administration of antibiotics, adjunctive steroid therapy, and optimization of antibiotic delivery to cerebrospinal fluid (CSF) are factors associated with improved outcome of patients hospitalized for acute bacterial meningitis (ABM). However, the impact of a bundle of these procedures has not been reported.

OBJECTIVE

To assess mortality and neurological sequelae at hospital discharge in a cohort of patients with ABM managed according to a predefined bundle.

METHODS

Prospective study of all the patients hospitalized for ABM in two provinces of Northern Italy, over two consecutive periods (2005-2009, 2010-2013). The bundle included: i) supportive care if needed; ii) immediate administration of dexamethasone and 3rd generation cephalosporin; and iii) addition of levofloxacin if turbid CSF. Patients managed according to the bundle were compared with a historical group of patients cared for ABM before the bundle was implemented.

RESULTS

Overall, 85 patients with ABM were managed according to the bundle and were compared with 92 historical controls. In-hospital mortality rates for bundle and control group were 4.7% and 14.1% (p=0.04). Among survivors, 13.5% and 18.9% (p=0.4) of bundle and control-group patients presented neurological sequelae. The only variable associated with mortality at multivariate analysis was ICU admission (HR 3.65). After adjusting for ICU admission, patients managed according with the ABM bundle had significantly lower mortality rate compared to historical controls.

CONCLUSIONS

Use of a bundled protocol and antibiotics with excellent CSF penetration for the initial management of ABM in emergency department is feasible and associated with significant reduction in mortality.

The Surviving Sepsis Campaign: past, present and future

The Surviving Sepsis Campaign (SSC) was created in 2002 and consists of severe sepsis management guidelines and a sepsis performance improvement program. The second revision of the guidelines, published in 2013, are sponsored by 30 international scientific organizations and contain changes in recommendations for fluids and vasopressor administration. The new 3- and 6-hour sepsis 'bundles' (sets of care elements) include a software program that can be downloaded free from the Surviving Sepsis Campaign website (www.survivingsepsis.org). The traditional intensive care unit and emergency department champion-driven sepsis performance improvement program continues internationally with the kick off of a new grant-funded hospital floor sepsis performance improvement initiative.

Early identification and management of patients with severe sepsis and septic shock in the emergency department

Severe sepsis and septic shock have great relevance to Emergency Medicine physicians because of their high prevalence, morbidity, and mortality. Treatment is time-sensitive, depends on early identification risk stratification, and has the potential to significantly improve patient outcomes. In this article, we review the pathophysiology of, and evidence basis for, the emergency department management of severe sepsis and septic shock.

The DISPARITY Study: do gender differences exist in Surviving Sepsis Campaign resuscitation bundle completion, completion of individual bundle elements, or sepsis mortality?

PURPOSE

Women in the emergency department are less likely to receive early goal directed therapy, but gender differences in the Surviving Sepsis Campaign (SSC) bundle completion have not been studied [1]. We hypothesized that women have lower SSC resuscitation bundle completion rates.

MATERIALS AND METHODS

This was a retrospective, observational study in a large urban academic ED at a national SSC site. Consecutive patients (age>18 years) admitted to intensive care with severe sepsis or septic shock and entered into the SSC database from October 2005 to February 2012 were included. Data on overall and individual bundle elements were exported from the database. Bivariate analyses were performed with chi-square tests and t-tests. Multiple logistic regression was then performed with gender as an effect modifier.

RESULTS

Eight hundred fourteen patients were enrolled. The mean age was 66 years;, 44.8% were women. There was no association between gender and bundle completion (aOR 0.83, 95% CI 0.58-1.16), controlling for age, race, Sequential Organ Failure Assessment, congestive heart failure, and coagulopathy. In-hospital mortality did not differ by gender. Women were less likely to receive antibiotics within 3 hours (60.5% vs. 68.8%, p=0.01) and less likely to reach a target ScvO2>70 (31.3% vs. 39.5%, P=.05).

CONCLUSIONS

There were no gender disparities in bundle completion or in-hospital mortality. Further research is needed to examine individual bundle elements and gender specific factors that may affect bundle completion and mortality.

Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study

PURPOSE

To evaluate whether a multifaceted, centrally coordinated quality improvement program in a network of hospitals can increase compliance with the resuscitation bundle and improve clinical and economic outcomes in an emerging country setting.

METHODS

This was a pre- and post-intervention study in ten private hospitals (1,650 beds) in Brazil (from May 2010 to January 2012), enrolling 2,120 patients with severe sepsis or septic shock. The program used a multifaceted approach: screening strategies, multidisciplinary educational sessions, case management, and continuous performance assessment. The network administration and an external consultant provided performance feedback and benchmarking within the network. The primary outcome was compliance with the resuscitation bundle. The secondary outcomes were hospital mortality, hospital and ICU length of stay, quality-adjusted life year (QALY) gain, and cost-effectiveness.

RESULTS

The proportion of patients who received all the required items for the resuscitation bundle improved from 13% [95% confidence interval (CI) 8-18%] at baseline to 62% (95% CI 54-69%) in the last trimester (p < 0.001). Hospital mortality decreased from 55% (95% CI 48-62%) to 26% (95% CI 19-32%, p < 0.001). Full compliance with the resuscitation bundle was associated with lower risk of hospital mortality (propensity weighted corrected risk ratio 0.74; 95% CI 0.56-0.94, p = 0.02). There was a reduction in the total cost per patient from 29.3 (95% CI 23.9-35.4) to 17.5 (95% CI 14.3-21.1) thousand US dollars from baseline to the last 3 months (mean difference -11,815; 95% CI -18,604 to -5,338). The mean QALY increased from 2.63 (95% CI 2.15-3.14) to 4.06 (95% CI 3.58-4.57). For each QALY, the full compliance saves US$5,383.

CONCLUSIONS

A multifaceted approach to severe sepsis and septic shock patients in an emerging country setting led to high compliance with the resuscitation bundle. The intervention was cost-effective and associated with a reduction in mortality.

Clinical pathway intervention compliance and effectiveness when used in the treatment of patients with severe sepsis and septic shock at an Intensive Care Unit in Spain

The purpose of this quasi-experimental study was to assess levels of compliance with the intervention bundles contained in a clinical pathway used in the treatment of patients with severe sepsis and septic shock, and to analyze the pathway's impact on survival and duration of hospital stays. We used data on 125 patients in an Intensive Care Unit, divided into a control group (N=84) and an intervention group (N=41). Levels of compliance increased from 13.1% to 29.3% in 5 resuscitation bundle interventions and from 14.3% to 22% in 3 monitoring bundle interventions. In-hospital mortality at 28 days decreased by 11.2% and the duration of hospital stay was reduced by 5 days. Although compliance was low, the intervention enhanced adherence to the instructions given in the clinical pathway and we observed a decline in mortality at 28 days and shorter hospital stays.

The Surviving Sepsis Campaign's Revised Sepsis Bundles

The Surviving Sepsis Campaign (SSC) sepsis care bundles have recently been revised. The original 6-h resuscitation bundle which included rapid antibiotic administration and hemodynamic support with early goal-directed therapy (EGDT) has been divided into two bundles; one including antibiotic and fluid support to be completed within 3 h, and the other including vasopressor support and measures of central venous pressure and oxygen saturation to be completed within 6 h. The original 24-h management bundle targeting glucose control, administration of corticosteroids and recombinant human activated protein C (rhAPC), and limitation of plateau airway pressures during mechanical ventilation is no longer recommended. Past and recent reports by the SSC and others have suggested that compliance with the original bundles was low and their impact unclear. Examination of the revised bundles in the context of issues and questions arising with the original ones suggest that while compliance with new 3-h bundle will be high, compliance with the 6-h bundle will continue to be low.

Lack of clinically evident signs of organ failure affects ED treatment of patients with severe sepsis

BACKGROUND

It is not known whether lack of recognition of organ failure explains the low compliance with the "Surviving Sepsis Campaign" (SSC) guidelines. We evaluated whether compliance was higher in emergency department (ED) sepsis patients with clinically recognizable signs of organ failure compared to patients with only laboratory signs of organ failure.

METHODS

Three hundred twenty-three ED patients with severe sepsis and septic shock were prospectively included. Multivariable binary logistic regression was used to assess if clinical and biochemical signs of organ failure were associated with compliance to a SSC-based resuscitation bundle. In addition, two-way analysis of variance was used to investigate the relation between the predisposition, infection, response and organ failure (PIRO) score (3 groups: 1-7, 8-14, 15-24) as a measure of illness severity and time to antibiotics with disposition to ward or ICU as effect modifier.

RESULTS

One hundred twenty-five of 323 included sepsis patients with new-onset organ failure were admitted to the ICU, and in all these patients the SSC resuscitation bundle was started. Respiratory difficulty, hypotension and altered mental status as clinically recognizable signs of organ failure were independent predictors of 100% compliance and not illness severity per se. Corrected ORs (95% CI) were 3.38 (1.08-10.64), 2.37 (1.07-5.23) and 4.18 (1.92-9.09), respectively. Septic ED patients with clinically evident organ failure were more often admitted to the ICU compared to a ward (125 ICU admissions, P < 0.05), which was associated with shorter time to antibiotics [ward: 127 (113-141) min; ICU 94 (80-108) min (P = 0.005)].

CONCLUSIONS

The presence of clinically evident compared to biochemical signs of organ failure was associated with increased compliance with a SSC-based resuscitation bundle and admission to the ICU, suggesting that recognition of severe sepsis is an important barrier for successful implementation of quality improvement programs for septic patients. In septic ED patients admitted to the ICU, the time to antibiotics was shorter compared to patients admitted to a normal ward.

Alternative methods to central venous pressure for assessing volume status in critically ill patients

INTRODUCTION

Early goal-directed therapy increases survival in persons with sepsis but requires placement of a central line. We evaluate alternative methods to measuring central venous pressure (CVP) to assess volume status, including peripheral venous pressure (PVP) and stroke volume variation (SVV), which may facilitate nurse-driven resuscitation protocols.

METHODS

Patients were enrolled in the emergency department or ICU of an academic medical center. Measurements of CVP, PVP, SVV, shoulder and elbow position, and dichotomous variables Awake, Movement, and Vented were measured and recorded 7 times during a 1-hour period. Regression analysis was used to predict CVP from PVP and/or SVV, shoulder/elbow position, and dichotomous variables.

RESULTS

Twenty patients were enrolled, of which 20 had PVP measurements and 11 also had SVV measurements. Multiple regression analysis demonstrated significant predictive relationships for CVP using PVP (CVP = 6.7701 + 0.2312 × PVP - 0.1288 × Shoulder + 12.127 × Movement - 4.4805 × Neck line), SVV (CVP = 14.578 - 0.3951 × SVV + 18.113 × Movement), and SVV and PVP (CVP = 4.2997 - 1.1675 × SVV + 0.3866 × PVP + 18.246 × Awake + 0.1467 × Shoulder = 0.4525 × Elbow + 15.472 × Foot line + 10.202 × Arm line).

DISCUSSION

PVP and SVV are moderately good predictors of CVP. Combining PVP and SVV and adding variables related to body position, movement, ventilation, and sleep/wake state further improves the predictive value of the model. The models illustrate the importance of standardizing patient position, minimizing movement, and placing intravenous lines proximally in the upper extremity or neck.

Association between hospital volume and network membership and an analgesia, sedation and delirium order set quality score: a cohort study

Introduction

Protocols for the delivery of analgesia, sedation and delirium care of the critically ill, mechanically ventilated patient have been shown to improve outcomes but are not uniformly used. The extent to which elements of analgesia, sedation and delirium guidelines are incorporated into order sets at hospitals across a geographic area is not known. We hypothesized that both greater hospital volume and membership in a hospital network are associated with greater adherence of order sets to sedation guidelines.

Methods

Sedation order sets from all nonfederal hospitals without pediatric designation in Washington State that provided ongoing care to mechanically ventilated patients were collected and their content systematically abstracted. Hospital data were collected from Washington State sources and interviews with ICU leadership in each hospital. An expert-validated score of order set quality was created based on the 2002 four-society guidelines. Clustered multivariable linear regression was used to assess the relationship between hospital characteristics and the order set quality score.

Results

Fifty-one Washington State hospitals met the inclusion criteria and all provided order sets. Based on expert consensus, 21 elements were included in the analgesia, sedation and delirium order set quality score. Each element was equally weighted and contributed one point to the score. Hospital order set quality scores ranged from 0 to 19 (median = 8, interquartile range 6 to 14). In multivariable analysis, a greater number of acute care days (P = 0.01) and membership in a larger hospital network (P = 0.01) were independently associated with a greater quality score.

Conclusions

Hospital volume and membership in a larger hospital network were independently associated with a higher quality score for ICU analgesia, sedation and delirium order sets. Further research is needed to determine whether greater order-set quality is associated with improved outcomes in the critically ill. The development of critical care networks might be one strategy to improve order set quality scores.

Retinal oximeter for the blue-green oximetry technique

Retinal oximetry offers potential for noninvasive assessment of central venous oxyhemoglobin saturation (SO(2)) via the retinal vessels but requires a calibrated accuracy of ±3% saturation in order to be clinically useful. Prior oximeter designs have been hampered by poor saturation calibration accuracy. We demonstrate that the blue-green oximetry (BGO) technique can provide accuracy within ±3% in swine when multiply scattered light from blood within a retinal vessel is isolated. A noninvasive on-axis scanning retinal oximeter (ROx-3) is constructed that generates a multiwavelength image in the range required for BGO. A field stop in the detection pathway is used in conjunction with an anticonfocal bisecting wire to remove specular vessel reflections and isolate multiply backscattered light from the blood column within a retinal vessel. This design is tested on an enucleated swine eye vessel and a retinal vein in a human volunteer with retinal SO(2) measurements of ∼1 and ∼65%, respectively. These saturations, calculated using the calibration line from earlier work, are internally consistent with a standard error of the mean of ±2% SO(2). The absolute measures are well within the expected saturation range for the site (-1 and 63%). This is the first demonstration of noninvasive on-axis BGO retinal oximetry.