Guideline Bundles Adherence and Mortality in Severe Sepsis and Septic Shock

Objective: Surviving Sepsis Campaign bundles have been associated with reduced mortality in severe sepsis and septic shock patients. Case-mix adjusted mortality evaluations have not been performed to compare hospitals participating in sepsis bundle programs with those not participating. We aimed to achieve an individual bundle target adherence more than 80% and a relative mortality reduction of at least 15% (absolute mortality reduction 5.2%) at the end of 2012. Design: Prospective multicenter cohort study in participating and nonparticipating centers. Setting: Eighty-two ICUs in The Netherlands. Patients: In total, 213,677 adult ICU patients admitted to all ICUs among which 8,387 severe sepsis patients at 52 participating ICUs and 8,031 severe sepsis patients at 30 nonparticipating ICUs. Interventions: A national program to screen patients for severe sepsis and septic shock and implement Surviving Sepsis Campaign bundles to complete within 6 and 24 hours after ICU admission. Measurements and Main Results: Bundle target adherence and case-mix adjusted in-hospital mortality were evaluated through odds ratios of time since program initiation by logistic generalized estimating equation analyses (July 2009 through January 2013). Outcomes were adjusted for age, gender, admission type, severity of illness, and sepsis diagnosis location. Participation duration was associated with improved bundle target adherence (adjusted odds ratio per month = 1.024 [1.016-1.031]) and decreased in-hospital mortality (adjusted odds ratio per month = 0.992 [0.986-0.997]) equivalent to 5.8% adjusted absolute mortality reduction over 3.5 years. Mortality reduced in screened patients with other diagnoses (1.9% over 3.5 yr, adjusted odds ratio per month = 0.995 [0.99060-0.9996]) and did not change in nonscreened patients in participating ICUs, nor in patients with sepsis or other diagnoses in nonparticipating ICUs. Conclusions: Implementation of a national sepsis program resulted in improved adherence to sepsis bundles in severe sepsis and septic shock patients and was associated with reduced adjusted in-hospital mortality only in participating ICUs, suggesting direct impact of sepsis screening and bundle application on in-hospital mortality.