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The SSC Bundles and Outcome Results From The International Multicentre Prevalence Study On Sepsis IMPreSS Rhodes ICM 2015
The SSC Bundles and Outcome Results From The International Multicentre Prevalence Study On Sepsis IMPreSS Rhodes ICM 2015
The SSC Bundles and Outcome Results From The International Multicentre Prevalence Study On Sepsis IMPreSS Rhodes ICM 2015
Andrew Rhodes
Gary Phillips
The Surviving Sepsis Campaign bundles
Richard Beale and outcome: results from the International
Maurizio Cecconi
Jean Daniel Chiche Multicentre Prevalence Study on Sepsis
Daniel De Backer
Jigeeshu Divatia (the IMPreSS study)
Bin Du
Laura Evans
Ricard Ferrer
Massimo Girardis
Despoina Koulenti
Flavia Machado
Steven Q. Simpson
Cheng Cheng Tan
Xavier Wittebole
Mitchell Levy
D. De Backer D. Koulenti
Received: 28 March 2015 Department of Intensive Care, Erasme Burns, Trauma and Critical Care Research
Accepted: 28 May 2015
Published online: 25 June 2015 University Hospital, Université Libre de Centre, The University of Queensland,
Ó Springer-Verlag Berlin Heidelberg and Bruxelles, Brussels, Belgium Brisbane, Australia
ESICM 2015
J. Divatia F. Machado
Electronic supplementary material Department of Anaesthesia, Critical Care & Federal University of Sao Paulo, Sao Paulo,
The online version of this article Pain Tata Memorial Hospital, Mumbai Brazil
(doi:10.1007/s00134-015-3906-y) contains 400012, India
supplementary material, which is available S. Q. Simpson
to authorized users. B. Du MICU, MTICU, MSICU Division of
Medical ICU, Peking Union Medical Pulmonary and Critical Care, University of
College Hospital, 1 Shuai Fu Yuan, Beijing Kansas, 3901 Rainbow Blvd, Mail Stop
A. Rhodes ()) 100730, China #3007, Kansas City, KS 66160, USA
Department of Intensive Care Medicine,
St George’s University Hospitals NHS L. Evans C. C. Tan
Foundation Trust, London SW17 0QT, UK Critical Care Department, NYU School of ICU, Sultanah Aminah Hospital,
e-mail: andrewrhodes@nhs.net Medicine, Bellevue Hospital Center, Johor Baru, Johor, Malaysia
Tel.: ?44 208 725 5699 462 First Avenue NBV-7N24,
New York, NY 10016, USA X. Wittebole
G. Phillips Critical Care Department, Cliniques
The Ohio State University Center for R. Ferrer Universitaires St Luc, UCL, Brussels,
Biostatistics, Columbus, OH, USA Intensive Care Department, Hospital Belgium
Universitari Mútua Terrassa, Barcelona,
R. Beale Spain M. Levy
Department of Critical Care, King’s College Alpert Medical School at Brown University,
London, Guy’s and St Thomas’ Foundation R. Ferrer Rhode Island Hospital, Providence, RI,
Trust, Westminster Bridge Road, London CIBER Enfermedades Respiratorias, USA
SE1 7EH, UK Barcelona, Spain
Surviving Sepsis Campaign (SSC) than non-compliance (20 vs. 31 %, and 6-h bundle (OR = 0.71 (95 % CI
bundles are used in different geo- p \ 0.001). Overall compliance with 0.56-0.90), p = 0.005)). Discus-
graphic areas, and how this relates to all the 6-h bundle metrics was 36 %. sion: Compliance with all of the
outcome. Methods: This was a glo- This was associated with lower hos- evidence-based bundle metrics was
bal, prospective, observational, pital mortality than non-compliance not high. Patients whose care inclu-
quality improvement study of com- (22 vs. 32 %, p \ 0.001). After ded compliance with all of these
pliance with the SSC bundles in adjusting the crude mortality differ- metrics had a 40 % reduction in the
patients with either severe sepsis or ences for ICU admission, sepsis status odds of dying in hospital with the 3-h
septic shock. Results: A total of (severe sepsis or septic shock), loca- bundle and 36 % for the 6-h bundle.
1794 patients from 62 countries were tion of diagnosis, APACHE II score
enrolled in the study with either sev- and country, compliance remained Keywords Sepsis
ere sepsis or septic shock. Overall independently associated with Quality improvement
compliance with all the 3-h bundle improvements in hospital mortality Surviving Sepsis Campaign Bundle
metrics was 19 %. This was associ- for both the 3-h bundle (OR = 0.64
ated with lower hospital mortality (95 % CI 0.47-0.87), p = 0.004))
Detail Asia Oceania West Europe East Europe North Central/South Africa and
America America Middle East
Detail
Detail Asia Oceania West East North Central/South Africa and Middle East
Europe Europe America America
Table 4 Hospital mortality odds ratios based on general estimating equation (GEE) population-averaged logistic regression models
the difference did not remain after adjusting for baseline compensate for the known seasonal variations in inci-
confounding influences [17]. In this current study, the dence of the condition in the different regions of the
differences between West Europe and North America world. In addition we only followed our patients up until
were not significant after adjustments; however, we have hospital discharge; therefore, we have little understanding
been able to document significant differences between into what happened to the patients following discharge
North America and Central/South America and Eastern and to where the patients went. This is likely to be very
Europe. Other authors have described differences in the different between countries in the study.
provision of intensive care facilitates and treatments We have limited data describing other quality metrics
between and within continents [18–22], but this study of the participating institutions. It is possible that the
adds to this by extending the findings to a global scale. association we have found between bundle compliance
The strengths of this study include the defined data set, and outcome improvement may be nothing more than a
a web-based data entry portal, a website containing all surrogate of how well that institution performs. It would
relevant documents and training manuals and the partic- be unwise to infer causality from this relationship. Indeed
ipation from over 60 countries representing all parts of the results from several recent large randomized controlled
globe. We describe a cohort of patients with severe sepsis trials [13, 14, 26] have questioned the need for some of
and septic shock that could be identified in EDs and ICUs the elements that are included in the 6-h bundle. These
in each participating country. We have previously pub- new data are currently being assimilated into an update of
lished [7] and extensively marketed [23–25] the evidence- the evidence-based guidelines and the quality improve-
based bundle metrics so they were familiar to all partic- ment metrics will also change to reflect the new data, in
ipating sites. We were then able to collect data describing particular the emphasis placed on measurement of central
compliance with these metrics and also data describing venous oxygen saturations as part of the overall proto-
presentation patterns and severity of these patients, colized resuscitation strategy.
enabling us to correct bundle compliance and outcome Our study has confirmed the reports of others that
metrics for such differences. compliance with sepsis improvement metrics are not
Our study has some limitations. Our data set was a good, although when performed they are associated with
compromise between being an exhaustive list describing outcome improvements. This study is the first report of
all facets of a patient with sepsis and being small enough compliance with the 2012 SSC bundles [7] and as such
to encourage site participation and data reliability. We adds to the literature supporting this methodology for
enrolled relatively few patients per site on a single study quality improvement [4, 17, 27–29]. Our study confirms
day and for many countries only a few sites participated. previous reports that the rate of bundle compliance is
This reduces the external generalizability of our data set. different between regions [4, 17] and confirms the ability
This ‘point’ estimate reduces the external validity as there of sites in North America to perform the initial (3-h)
is likely to be significant variance in both admission resuscitation bundle elements better that other regions,
numbers of patients presenting to hospital and clinical but also suggests that Western Europe has higher com-
practice on a day to day basis and also does not pliance with the 6-h elements. In addition we have
1627
confirmed the reports that compliance with these tools Acknowledgments Eduardo Romay for providing help and assis-
improves outcome even when taking into account all tance with the E-CRF. The SSC, the ESICM and the SCCM
provided logistic support for mailings, the website, and meetings of
presenting differences [4, 17, 23, 25, 27, 28]. the steering committee. Centres did not receive any payment for
In conclusion we have observed in a large multina- recruiting patients.
tional observational study that compliance with evidence-
based bundle metrics designed to improve outcomes from Conflicts of interest AR, JDC, DdB, ML, LE and RF have all
held leadership positions in the Surviving Sepsis Campaign. No
septic shock remains low, varies significantly between other conflicts of interest have been declared as relevant to this
different geographical regions and when performed is paper.
associated with improvements in outcome.
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