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Multicenter Implementation of a Treatment Bundle for Sepsis Patients with Intermediate Lactate Values.
Am J Respir Crit Care Med. 2015 Dec 22;
Authors: Liu VX, Morehouse JW, Marelich GP, Soule J, Russell T, Skeath M, Adams C, Escobar GJ, Whippy A
Abstract
Rationale Treatments for sepsis patients with intermediate lactate values (≥2 and <4 mmol/L) are poorly defined. Objective Evaluate multicenter implementation of a treatment bundle (including timed intervals for antibiotics, repeat lactate testing, and intravenous fluids) for hemodynamically stable sepsis patients with intermediate lactate values in the emergency department. Methods and Measurements We evaluated patients in annual intervals before and after bundle implementation in March 2013. We evaluated bundle compliance and compared outcomes measures across groups with multivariable logistic regression. We also evaluated patients with a history of heart failure and/or chronic kidney disease because of their perceived risk for iatrogenic fluid overload. Main Results We identified 18,122 intermediate lactate sepsis patients, including 36.1% treated after implementation. Full bundle compliance increased from 32.2% in 2011 to 44.9% after bundle implementation (p<0.01). Hospital mortality was 8.8% in 2011, 9.3% in 2012, and 7.9% in 2013 (p=0.02). Treatment after bundle implementation was associated with an adjusted hospital mortality odds ratio of 0.81 (95% CI: 0.66-0.99; p=0.04). Decreased hospital mortality was observed primarily in patients with a heart failure/kidney disease history (p<0.01), rather than patients without this history (p>0.40). This corresponded with notable changes in the volume of fluid resuscitation in heart failure/kidney disease patients after implementation. Conclusions Multi-center implementation of a treatment bundle for sepsis patients with intermediate lactate values improved bundle compliance and was associated with decreased hospital mortality. These decreases were mediated by improved mortality and increased fluid administration among patients with a history of heart failure or chronic kidney disease.
PMID: 26695114 [PubMed - as supplied by publisher]