Survival Benefit and Cost Savings From Compliance With a Simplified 3-Hour Sepsis Bundle in a Series of Prospective, Multisite, Observational Cohorts
Survival Benefit and Cost Savings From Compliance With a Simplified 3-Hour Sepsis Bundle in a Series of Prospective, Multisite, Observational Cohorts
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DOI：
10.1097/ccm.0000000000002184
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发表时间：
2017-03-01
影响因子：
8.8
通讯作者：
D'Amore, Jason A.
中科院分区：
文献类型：
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作者：
Leisman, Daniel E.;Doerfler, Martin E.;D'Amore, Jason A.
目的：确定严重脓毒症和感染性休克患者坚持使用侵袭性的3小时脓毒症捆绑包与不遵守大于或等于一种捆绑包元素的死亡率和成本。设计：前瞻性、多点、观察性研究，跟踪三个连续的独立队列，来自单个美国卫生系统，通过他们的住院。设置：队列1：5个三级医院和6个社区医院。队列2：单一的三级学术医学中心。队列3：5家三级医院和4家社区医院。患者：所有严重败血症和感染性休克患者的连续样本(定义：感染，=2例全身炎症反应综合征和低灌流器官功能障碍)。暴露是完全3小时的捆绑依从性。捆绑元素如下：1)抗生素之前的血培养；2)从大于或等于两个全身性炎症反应综合征开始给予小于或等于180分钟的PAR肠内抗生素“和”乳酸盐订购，或从“时间零”起少于或等于60分钟：‘以较早发生者为准；3)乳酸盐结果小于或等于90分钟后；以及4)30 mU kg IV晶体丸剂从“时间零”开始小于或等于30分钟。主要结果是住院死亡率(所有队列)和总直接成本(队列2和队列3)。测量和主要结果：队列1：5819名患者；1050名(18.0%)捆绑治疗依从性。死亡率：604(22.6%)vs834(26.5%)；CI，0.9-7.1%；调整后的优势比，0.72；CI，0.61-0.86；p值小于0.001。队列2：1,697名患者；739名(43.5%)捆绑依从性。死亡率：99例(13.4%)vs171例(17.8%)，可信区间为1.0-7.9%；调整后优势比为0.6；可信区间为0.44-0.80；p值为0.001。平均成本：14,845美元对20,056美元；CI，4,798美元至-5,624美元；调整后的Beta版，2,851美元；CI，4,880美元至822美元；p值等于0.006。队列3：总共7,239名患者；2,115名(29.2%)捆绑依从性。死亡率：383(18.1%)对1,078(21.0%)；CI，0.9-4.9%；调整后的优势比，0.84；CI，0.73-0.96；p值等于0.013。平均成本：17,885美元与22,108美元；CI，2,783美元至5,663美元；调整后的Beta，1,423美元；CI，2,574美元至272美元；p值等于0.015。结论：在三个独立的队列中，3小时捆绑依从性与改善生存和节省成本有关。
Objectives: To determine mortality and costs associated with adherence to an aggressive, 3-hour sepsis bundle versus noncompliance with greater than or equal to one bundle element for severe sepsis and septic shock patients.Design: Prospective, multisite, observational study following three sequential, independent cohorts, from a single U.S. health system, through their hospitalization.Setting: Cohort 1: five tertiary and six community hospitals. Cohort 2: single tertiary, academic medical center. Cohort 3: five tertiary and four community hospitals.Patients: Consecutive sample of all severe sepsis and septic shock patients (defined: infection, >= 2 systemic inflammatory response syndrome, and hypoperfusive organ dysfunction) identified by a quality initiative. The exposure was full 3-hour bundle compliance. Bundle elements are as follows: 1) blood cultures before antibiotics; 2) par enteral antibiotics administered less than or equal to 180 minutes from greater than or equal to two systemic inflammatory response syndrome "and" lactate ordered, or less than or equal to 60 minutes from "time-zero:' whichever occurs earlier; 3) lactate result available less than or equal to 90 minutes postorder; and 4) 30 mUkg IV crystalloid bolus initiated less than or equal to 30 minutes from "time-zero!' Main outcomes were in-hospital mortality (all cohorts) and total direct costs (cohorts 2 and 3).Measurements and Main Results: Cohort 1: 5,819 total patients; 1,050 (18.0%) bundle compliant. Mortality: 604 (22.6%) versus 834 (26.5%); CI, 0.9-7.1%; adjusted odds ratio, 0.72; CI, 0.61-0.86; p value is less than 0.001. Cohort 2: 1,697 total patients; 739 (43.5%) bundle compliant. Mortality: 99 (13.4%) versus 171 (17.8%), CI, 1.0-7.9%; adjusted odds ratio, 0.60; CI, 0.44-0.80; p value is equal to 0.001. Mean costs: $14,845 versus $20,056; CI, $4,798 to -5,624; adjusted beta, $2,851; CI, $4,880 to 822; p value is equal to 0.006. Cohort 3: 7,239 total patients; 2,115 (29.2%) bundle compliant. Mortality: 383 (18.1%) versus 1,078 (21.0%); CI, 0.9-4.9%; adjusted odds ratio, 0.84; CI, 0.73-0.96; p value is equal to 0.013. Mean costs: $17,885 versus $22,108; CI, $2,783 to 5,663; adjusted beta, $1,423; CI, $2,574 to 272; p value is equal to 0.015.Conclusions: In three independent cohorts, 3-hour bundle compliance was associated with improved survival and cost savings.