Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality

Crit Care Med. 2007 Apr;35(4):1105-12. doi: 10.1097/01.CCM.0000259463.33848.3D.


Objective: The purpose of this study was to examine the outcome implications of implementing a severe sepsis bundle in an emergency department as a quality indicator set with feedback to modify physician behavior related to the early management of severe sepsis and septic shock.

Design: Two-year prospective observational cohort.

Setting: Academic tertiary care facility.

Patients: Patients were 330 patients presenting to the emergency department who met criteria for severe sepsis or septic shock.

Interventions: Five quality indicators comprised the bundle for severe sepsis management in the emergency department: a) initiate central venous pressure (CVP)/central venous oxygen saturation (Scvo2) monitoring within 2 hrs; b) give broad-spectrum antibiotics within 4 hrs; c) complete early goal-directed therapy at 6 hrs; d) give corticosteroid if the patient is on vasopressor or if adrenal insufficiency is suspected; and e) monitor for lactate clearance.

Measurements and main results: Patients had a mean age of 63.8 +/- 18.5 yrs, Acute Physiology and Chronic Health Evaluation II score 29.6 +/- 10.6, emergency department length of stay 8.5 +/- 4.4 hrs, hospital length of stay 11.3 +/- 12.9 days, and in-hospital mortality 35.2%. Bundle compliance increased from zero to 51.2% at the end of the study period. During the emergency department stay, patients with the bundle completed received more CVP/Scvo2 monitoring (100.0 vs. 64.8%, p < .01), more antibiotics (100.0 vs. 89.7%, p = .04), and more corticosteroid (29.9 vs. 16.2%, p = .01) compared with patients with the bundle not completed. In a multivariate regression analysis including the five quality indicators, completion of early goal-directed therapy was significantly associated with decreased mortality (odds ratio, 0.36; 95% confidence interval, 0.17-0.79; p = .01). In-hospital mortality was less in patients with the bundle completed compared with patients with the bundle not completed (20.8 vs. 39.5%, p < .01).

Conclusions: Implementation of a severe sepsis bundle using a quality improvement feedback to modify physician behavior in the emergency department setting was feasible and was associated with decreased in-hospital mortality.

MeSH terms

  • Aged
  • Clinical Protocols
  • Emergency Service, Hospital / organization & administration*
  • Female
  • Guideline Adherence
  • Hospital Mortality
  • Hospitals, University / organization & administration
  • Humans
  • Length of Stay
  • Male
  • Middle Aged
  • Prospective Studies
  • Quality Indicators, Health Care / organization & administration*
  • Sepsis / mortality*
  • Sepsis / therapy*
  • Severity of Illness Index
  • Shock, Septic / mortality
  • Shock, Septic / therapy
  • Treatment Outcome