4/14/2013

Does the 6 Hour Resuscitation Protocol Reduce Mortality?

Lauren Platt, RN, BSN, MSN Candidate University of Central Florida

In adult patients diagnosed with sepsis, how does initiation of the 6

Hour Resuscitation sepsis protocol

to guide care compared to standard, non-protocolized care affect mortality rates?

Sepsis:
Infection

11th leading cause of death in U.S. Hospitalization rates have doubled

Temperature > 38 or < 36 C

Leukocytes > 12,000 or < 4,000

The bodys inflammatory response to infection

from 2000 to 2008 Mortality rates up to 46% Treatment cost estimated at $ 15

RR > 20 Or vented

HR > 90

billion and rising

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Increase in sepsis related hospitalizations: Aging population use of invasive procedures Immunosuppressive drugs Transplantation microbial resistance

Literature Search
CINAHL Medline Google Scholar Cochrane ERIC
(122 articles)

Key Terms
Sepsis protocol Mortality Septic shock Bundles Early goal directed therapy Order sets

Inclusion Criteria Exclusion Criteria

Adult population Diagnosis of sepsis 6 hour protocol English language Published 2000 2013 No assessment of mortality Duplications
One Cohort Level IV

Two Quasiexperimental Level III

One Meta-Analysis Level I

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1. Mortality
SERUM LACTATE LEVEL BLOOD CULTURES ANTIBIOTIC ADMINISTRATION FLUID RESUSCITATION VASOPRESSOR ADMINISTRATION CVP 8 SCVO2 70

2. ICU LOS 3. Hospital LOS 4. Protocol Compliance

Mortality: Three studies found a reduction in mortality when the 6

Hour Resuscitation sepsis protocol was used.

ICU LOS: Three of the four studies assessed ICU LOS. It is unclear if the 6 Hour Resuscitation sepsis protocol can be linked to reduction in ICU LOS
MacRedmond et al. (2010) Control 8 days Intervention 7 days (p = .87) Shiramizo et al. (2011) Control 16 62.7 days Intervention 30 141.4 days Memon et al. (2012)
Historical 8.2

MacRedmond et al. (2010) Hospital Mortality - Control 51.4% - Intervention 27% (ARR 24%, 95% CI 3% 47% p = 0.02) ICU Mortality - Control 51.5% - Intervention 29%

Shiramizo et al. (2011) In-hospital Mortality -Control 54.0% -Intervention 41.1% from 5/06 to 12/06 39.3% in 2007 41.4% in 2008 16.2% in 2009

Memon et al. (2012) Hospital Mortality - Historical 31.3% - Intervention 21.1% (p = 0.05) ICU Mortality - Historical 27.3% - Intervention 19.6%

7.9 days Intervention 7.6 8.3 days (p = .53)

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Hospital LOS: Two of the four studies assessed hospital LOS. It is unclear if the 6 Hour Resuscitation sepsis protocol can be linked to reduction in hospital LOS

Protocol Compliance: Three studies found improved

compliance.
Shiramizo et al. (2011) 6 Hour Bundle Compliance - Control 6% - Intervention 8.2% from 5/06 to 12/06 9.3% in 2007 21.1% in 2008 13.7% in 2009 Complete Compliance 6Hour Bundle OR 0.54; CI95 0.300.96, (p = 0.033)

Shiramizo et al. (2011)

Control 51 122.6 Intervention 37 81.8

Memon et al. (2012)

Historical 21.1 19.6 Intervention 21.8 19.4 (p = .89)

MacRedmond et al. (2010) 6 Hour Bundle Compliance - Control 13.5% - Intervention 62.2% (p < 0.0001)

Memon et al. (2012) Complete Compliance for 6 Hour Bundle - Historical 5.1% - Intervention23.6% (p = 0.001)

To implement the 6 Hour Resuscitation sepsis protocol when managing septic patients. No firm recommendation regarding the affect the 6 Hour Resuscitation sepsis protocol has on ICU can be made at this time. Further research on the topic of ICU LOS is warranted. Due to lack of reliable and sufficient evidence, no firm recommendation as to the use of the 6 Hour Resuscitation sepsis protocol regarding hospital length of stay can be made at this time. Additional research on the connection between hospital length of stay and sepsis protocol is needed. There is support that the implementation of sepsis education programs for healthcare staff would be beneficial in improving the compliance.

The 6 Hour Resuscitation sepsis protocol compared to standard, non-protocolized care reduces patient mortality rates. Educational programs focusing on sepsis management for healthcare staff were found to significantly improve compliance. Improved sepsis protocol compliance was shown to have a direct correlation with reduction in mortality. In order to provide the most current, evidence-based care, the 6 Hour Resuscitation sepsis protocol should be utilized during the initial management of sepsis.

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Centers for Disease Control and Prevention. (2012). National vital statistics report. Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_06.pdf Chamberlain, D., Willis, E., &Bersten, A. (2011). The severe sepsis bundles as processes of care: A meta-analysis. Australian Critical Care, doi:10.1016/j.aucc.2011.01.003 Elixhauser, A., Friedman, B., &Stranges, E. (2011). Septicemia in U.S. hospitals, 2009. HCUP Statistical Brief #122. Retrieved from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb122.pdf Hall M. J., Williams, S. N., DeFrances C. J., & Golosinskiy, A. (2011).Inpatient care for septicemia or sepsis: A challenge for patients and hospitals. NCHS data brief, no 62. Hyattsville, MD: National Center for Health Statistics. MacRedmond, R., Hollohan, K., Stenstrom, R., Nebre, R., Jaswal, D., &Dodek, P. (2010). Introduction of a comprehensive management protocol for severe sepsis is associated with sustained improvements in timeliness of care and survival. Quality & Safety in Health Care, 19(5), e46.doi:http://dx.doi.org.ezproxy.lib.ucf.edu/10.1136/qshc.2009.033407 Melnyk, B. M. & Fineout-Overholt, E. (2010). Evidence-Based Practice in Nursing and ealthcare: A Guide to Best Practice (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Memon, J., Rehmani, R., Alaithan, A., Gammal, A., Lone, T., Ghorab, K., &Abdulbasir, A. (2012). Impact of 6-hour sepsis resuscitation bundle compliance on hospital mortality in a saudi hospital. Critical Care Research and Practice, vol. 2012, Article ID 273268, doi:10.1155/2012/273268 Quelly, S. B. (2007). The influence of breastfeeding on reducing risks for childhood obesity and overweight. Orlando, Florida, United States of America: Unpublished. Rivers, E. P., McIntyre, L., Morro, D. C., & Rivers, K. K. (2005). Early and innovative interventions for severe sepsis and septic shock: taking advantage of a window of opportunity. Canadian Medical Association Journal, 173(5), 1054-1065. Shiramizo, S., Marra, A. R., Duro, M. S., Paes, . T., Edmond, M. B., & Santos, O. (2011). Decreasing mortality in severe sepsis and septic shock patients by implementing a sepsis bundle in a hospital setting. Plos ONE, 6(11), 1-6. doi:10.1371/journal.pone.0026790