Implementation of early goal-directed therapy and the surviving sepsis campaign resuscitation bundle in Asia

Abstract

OBJECTIVE: To examine the impact of implementing sepsis bundle in multiple Asian countries, having 'team' vs. 'non-team' models of patient care.

DESIGN: Prospective cohort study.

SETTING: Eight urban hospitals, five countries in Asia.

PARTICIPANTS: Adult patients with severe sepsis or septic shock.

INTERVENTIONS: Implementation was divided into six quartiles: Baseline, Education and four Quality Improvement quartiles.

MAIN OUTCOME MEASURES: Quarterly bundle compliance and in-hospital mortality with respect to bundle completion and implementation model.

METHODS: In the team model, the implementation was championed by intensivists, where the bundle was completed in the intensive care unit. The non-team model led by emergency physicians completed the bundle in the emergency department as part of standard care.

RESULTS: Five hundred and fifty-six patients were enrolled. The overall in-hospital mortality rate was 29.9%, and 67.1% of the patients had septic shock. Compliance to the bundle was 13.3, 26.9, 37.5, 45.9, 48.8 and 54.5% over the six quartiles of implementation (P < 0.01). With team model, compliance increased from 37.5% baseline to 88.2% in the sixth quartile (P < 0.01), whereas hospitals with a non-team model increased compliance from 5.2 to 39.5% (P < 0.01). Crude in-hospital mortality was better in the patients who received the entire bundle (24.5 vs. 32.7%, P = 0.04). Bundle completion was associated with crude in-hospital mortality reduction (odds ratio 0.67, 95% confidence interval 0.45-0.99), but this survival benefit disappeared after adjustment for confounding variables.

CONCLUSIONS: Through education and quality improvement efforts, initially low sepsis bundle compliance was improved in Asia. A team model was more effective in achieving bundle compliance compared with a non-team model.