Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain
Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain
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DOI：
10.1001/jama.299.19.2294
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发表时间：
2008-05-21
影响因子：
120.7
通讯作者：
de la Torre-Prados, Maria Victoria
中科院分区：
文献类型：
--
作者：
Ferrer, Ricard;Artigas, Antonio;de la Torre-Prados, Maria Victoria
上下文关注存在的严重脓毒症和脓毒性休克患者的护理目前的指导方针是遵循journal，可能是由于缺乏足够的education.Objective. Objective. Objective的基础上生存脓毒症运动指导方针的国家教育计划是否影响严重脓毒症的护理过程和医院死亡率。在西班牙各地的59个内科-外科重症监护室（ICU）中进行设计前后的患者。所有ICU患者每天接受筛查，如果符合严重脓毒症或脓毒性休克标准，则入选。在干预前阶段共招募了854名患者（2005年11月至12月），干预后期间有1465名患者（2006年3月至6月），1年后长期随访247例（2006年11月至12月）在23个ICU的子集中。干预教育计划包括对急诊科、病房和ICU的医生和护理人员进行定义培训，识别和治疗指南中概述的严重脓毒症和脓毒性休克。治疗分为2组：急救包（6项任务立即开始并在6小时内完成）和管理捆绑包（4项任务在24小时内完成）.主要结果测量住院死亡率，遵守捆绑护理过程变量的差异，ICU死亡率，28天死亡率，住院时间，结果干预前后患者的年龄、性别、急性生理学和慢性健康评估II评分均相似。在基线时，只有3个护理过程测量（抗生素治疗前的血培养，广谱抗生素的早期给药，以及具有足够吸气平台压的机械通气）的依从率高于50%。干预后队列患者的住院死亡风险较低（44.0% vs 39.7%; P = 0.04）。在脓毒症复苏包的干预后，对护理过程变量的依从性也得到了改善（5.3% [95%置信区间[CI]，4%-7%] vs 10.0% [95% CI，8%-12%]; P <0.001）和败血症管理组（10.9% [95% CI，9%-13%] vs 15.7% [95% CI，14%-18%]; P = 0.001）。干预后住院时间和ICU住院时间没有变化。在长期随访中，遵守脓毒症复苏束恢复到基线，但遵守脓毒症管理束和死亡率保持稳定，相对于postintervention period.Conclusions一个国家的教育努力，以促进严重脓毒症和脓毒性休克的护理束与改善的指导方针的遵守和降低住院死亡率。然而，依从率仍然很低，复苏束的改善延迟了1年。
Context Concern exists that current guidelines for care of patients with severe sepsis and septic shock are followed variably, possibly due to a lack of adequate education.Objective To determine whether a national educational program based on the Surviving Sepsis Campaign guidelines affected processes of care and hospital mortality for severe sepsis.Design, Setting, and Patients Before and after design in 59 medical-surgical intensive care units (ICUs) located throughout Spain. All ICU patients were screened daily and enrolled if they fulfilled severe sepsis or septic shock criteria. A total of 854 patients were enrolled in the preintervention period (November-December 2005), 1465 patients during the postintervention period (March-June 2006), and 247 patients during the long-term follow-up period 1 year later (November-December 2006) in a subset of 23 ICUs.Intervention The educational program consisted of training physicians and nursing staff from the emergency department, wards, and ICU in the definition, recognition, and treatment of severe sepsis and septic shock as outlined in the guidelines. Treatment was organized in 2 bundles: a resuscitation bundle (6 tasks to begin immediately and be accomplished within 6 hours) and a management bundle (4 tasks to be completed within 24 hours).Main Outcome Measures Hospital mortality, differences in adherence to the bundles' process-of-care variables, ICU mortality, 28-day mortality, hospital length of stay, and ICU length of stay.Results Patients included before and after the intervention were similar in terms of age, sex, and Acute Physiology and Chronic Health Evaluation II score. At baseline, only 3 process-of-care measurements (blood cultures before antibiotics, early administration of broad-spectrum antibiotics, and mechanical ventilation with adequate inspiratory plateau pressure) we had compliance rates higher than 50%. Patients in the postintervention cohort had a lower risk of hospital mortality (44.0% vs 39.7%; P =.04). The compliance with process-of-care variables also improved after the intervention in the sepsis resuscitation bundle (5.3% [95% confidence interval [CI], 4%-7%] vs 10.0% [95% CI, 8%-12%]; P < .001) and in the sepsis management bundle (10.9% [95% CI, 9%-13%] vs 15.7% [95% CI, 14%-18%]; P = .001). Hospital length of stay and ICU length of stay did not change after the intervention. During long-term follow-up, compliance with the sepsis resuscitation bundle returned to baseline but compliance with the sepsis management bundle and mortality remained stable with respect to the postintervention period.Conclusions A national educational effort to promote bundles of care for severe sepsis and septic shock was associated with improved guideline compliance and lower hospital mortality. However, compliance rates were still low, and the improvement in the resuscitation bundle lapsed by 1 year.