Damian McNamara

October 16, 2013

SEATTLE — Patients with severe sepsis or septic shock triaged and managed using 4 clinical goals were significantly less likely to die in hospital than patients who did not meet all 4 objectives, a new prospective study shows.

The take-home message is "simple saves," said Jason D'Amore, MD, from North Shore University Hospital and Long Island Jewish Medical Center in Manhasset, New York.

He explained that the strategy his team developed is easier than targeting specific physiologic goals for patients with sepsis. The work, known as the Early Sepsis Prophylaxis Study, is in contrast to other efforts over the past decade, which manage sepsis using early physiologic-directed therapy.

Here at the American College of Emergency Physicians 2013 Scientific Assembly, Dr. D'Amore reported that his team evaluated all-cause in-hospital mortality using registry data from a healthcare system that include 11 acute care facilities, 3 tertiary centers, and 700,000 emergency department visits per year.

They assessed the impact of goal compliance in 5787 adults who either presented to the emergency department with severe sepsis or septic shock or developed these conditions during hospitalization.

Their sepsis bundle consists of 4 clinical goals:

  • blood cultures before antibiotics

  • lactate before 90 min

  • intravenous (IV) antibiotics before 180 min

  • 30 cc/kg of IV fluids before 180 min

In-hospital all-cause mortality was significantly lower when the goals were used than when they were not (22.6% vs 26.5%; P = .0005).

The strategy was fully implemented in January 2012. Mean in-hospital mortality for this patient population dropped from 30% in the first quarter of 2012 to 23% in the fourth quarter of 2012.

Table. Performance of the Sepsis Management Strategy

Measure First Quarter Last Quarter
Patients in full goal compliance (%) 32.4 57.1
Mean time    
   To antibiotic administration (min) 140 102
   To fluid bolus (min) 96 71
   From lactate order to result (min) 45 54


On multivariate regression analysis, complete compliance with the goals was associated with a survival odds ratio of 1.194 (1.04 - 1.37; P = .013), even after adjustment for factors such as age, admission to the intensive care unit, vasopressor initiation, central venous catheter insertion, and monitoring of central venous pressure and central venous oxygen saturation.

The overall absolute risk reduction for in-hospital mortality was 3.9% (1.7% - 6.0%).

We're not asking people to do anything other than take a good hard look at a patient, give timely antibiotics, timely fluids, and then remain vigilant.

On the basis of these figures, the team calculated the number of patients needed to treat to see a survival benefit. "Every 26 times we complete a bundle, we think we have an opportunity to save a life. That's meaningful," Dr. D'Amore said.

"We're not asking people to do anything other than take a good hard look at a patient, give timely antibiotics, timely fluids, and then remain vigilant about decompensation," he explained.

This study "certainly shows that the bundle improved care, relative to historic outcomes. We still don't know if there's an opportunity to improve this even more," said session moderator Alan Heffner, MD, from the Carolinas Healthcare System in Charlotte, North Carolina.

Future research could evaluate whether the strategy combined with physiologic parameters or goal-directed therapy improves outcomes in patient with severe sepsis, Dr. Heffner added.

Dr. D'Amore has disclosed no relevant financial relationships. Dr. Heffner reports being a speaker for Cook Critical Care and Edwards Lifesciences.

American College of Emergency Physicians (ACEP) 2013 Scientific Assembly: Abstract 7. Presented October 14, 2013.


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