Improving sepsis care: the road ahead.


IN RECENT YEARS THERE HAVE BEEN UNPRECEDENTED ADvances in the understanding of the epidemiology, pathophysiology, and treatment of sepsis syndrome. This work has culminated in several clinical trials demonstrating the efficacy of targeted interventions to improve sepsis-related outcomes. These interventions include not only novel therapeutic agents such as drotrecogin alfa but also treatments directed at improving the way more traditional therapy is delivered, such as early resuscitation and lowtidal volume ventilation for acute lung injury. Unfortunately the gaps between evidence and practice have long been huge. Indeed, most available data suggest that clinical trial and observational study results have not yet changed clinical practice in sepsis care. Few emergency departments have implemented protocols for early resuscitation of patients with severe sepsis, delayed and inappropriate antibiotic administration remains common, and many patients with acute lung injury receive mechanical ventilation with potentially injurious tidal volumes. Numerous obstacles get in the way of implementing clinical evidence. Clinicians may be unaware of published evidence, disagree with practice guidelines, or be unable to effect change due to environmental and structural barriers. These challenges are particularly salient in sepsis care, which requires dedicated efforts between multiple disciplines and coordination of care throughout the hospital, all in a setting in which time to treatment is central. Comprehensive strategies are needed to standardize practice, improve care processes, and optimize outcomes for this high-risk patient group. Recent evidence suggests that grouping care practices together into “bundles” may be an effective method to improve outcomes for complex diseases such as catheterrelated bloodstream infections, ventilator-associated pneumonia, and even sepsis. But it has proved extremely challenging to take complex care improvement programs and disseminate them broadly across a region, state, country, or across national boundaries. In this issueof JAMA,Ferrerandcolleagues report the findings of an ambitious, nationwide effort to improve the quality of care for patients with severe sepsis and septic shock. A total of 59 intensive care units (ICUs) participated in the program, representing 21% of all ICUs in Spain. Each hospital received aneducational interventionbasedontheSurvivingSepsisCampaign, an international program designed to increase sepsis awareness and develop and disseminate practice guidelines. The interventionconsistedof identifyinga local clinical champion,assemblingamultidisciplinaryteamwithbroadstakeholder involvement,abaselineperformanceaudit,educationallectures, andguidelinedisseminationtophysiciansandstaff intheemergency department, in hospital units, and in the ICU. In the period following the intervention, patients were more likely to receive early appropriate antibiotic therapy, adequate fluid resuscitation, and documented consideration of drotrecogin alfa and low-dose corticosteroids. Survival also improved, with statistically significant reductions in both hospital and 28-day mortality. Improvement in survival was greatest in hospitals with the poorest baseline performance. These performance gains provide an important process-outcome link in support of the sepsis guidelines because some of the elements of this campaign have not yet been strongly linked to outcome in patients with severe sepsis. The intervention was associated with important process and outcome improvements even though it was relatively simple. Didactic teaching and passive guideline dissemination are not the most effective methods of behavior change. The investigators did not include some of the more effective methods for implementing evidence-based practice, including academic detailing, computerized reminders, and repeated audit and feedback. Additionally, the intervention was homogeneous across sites, with no attempt to customize the program based on local cultures or specific organizational barriers. The fact that performance improved even after this type of intervention is probably due to poor compliance and high mortality at baseline.

DOI: 10.1001/jama.299.19.2322


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@article{Kahn2008ImprovingSC, title={Improving sepsis care: the road ahead.}, author={Jeremy M. Kahn and David W. Bates}, journal={JAMA}, year={2008}, volume={299 19}, pages={2322-3} }