A Critical Review of the Government Mandated Cardiovascular Resuscitation Interventions for Sepsis (SEP-1)

国家质量论坛(NQF)和CMS已经制定了一种绩效衡量标准，适用于出现脓毒症的患者，称为严重脓毒症和感染性休克早期管理捆绑(SEP-1)。这项绩效评估的主要目的是降低与败血症、严重败血症和感染性休克相关的住院死亡率和护理成本。绩效测量包括与脓毒症患者血流动力学管理相关的五种干预措施(治疗和措施)：对于患有严重脓毒症的成年人，必须在出现初始乳酸水平后3小时内进行初始乳酸水平测量，如果初始乳酸水平升高，则必须在出现初始乳酸水平升高后6小时内进行重复乳酸水平测量。对于感染性休克的成人，必须在出现后3小时内用30ml/kg的晶体液体进行复苏。在感染性休克出现的6小时内，如果输液后持续低血压，成人必须接受血管升压剂治疗。此外，如果输液后低血压持续存在，或者如果初始乳酸水平为&gt；4 mmo1/L，则必须进行容量状态和组织灌注量评估。根据CMS性能测量，评估容量状态和组织灌注量需要有重点的体检(必须进行生命体征、心肺检查、毛细血管充盈评估、外周脉搏评估和皮肤检查)，或以下两项中的任何一项：测量CVP、测量ScvO2、床边心血管超声或被动腿部抬高或液体挑战。目前，CMS要求提供者报告其机构使用这一绩效衡量中的干预措施的情况。然而，随后，CMS将要求提供者完成所有干预。这一绩效衡量标准是复杂的，需要大量的医院资源才能实现合规。我们将进行一项系统的综述和荟萃分析，重点是支持使用每种血流动力学干预措施降低脓毒症死亡率的证据，以及住院时间、器官衰竭和护理成本。

The National Quality Forum (NQF) endorsed and CMS has instituted a performance measure to be applied to patients presenting with sepsis termed the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). The primary purpose of this performance measure is to decrease hospital mortality and costs of care related to sepsis, severe sepsis and septic shock. The performance measure includes five interventions (both treatments and measures) related to the hemodynamic management of patients with sepsis: In adults with severe sepsis, initial lactate level measurement must be performed within 3 hours of presentation, and repeat lactate level measurement must be performed within 6 hours of presentation, if initial lactate level is elevated. In adults with septic shock, resuscitation with 30ml/kg crystalloid fluids must be performed within 3 hours of presentation. Within 6 hours of presentation of septic shock, adults must receive vasopressors if hypotension persists after fluid administration. Also, if hypotension persists after fluid administration or if the initial lactate level is > 4 mmol/L, then a volume status and tissue perfusion assessment must be performed. According to the CMS performance measure, assessment of volume status and tissue perfusion requires either a focused physical exam (vital signs, cardiopulmonary exam, capillary refill evaluation, peripheral pulse assessment and skin examination all must be performed), or any two of the following: measure CVP, measure ScvO2, bedside cardiovascular ultrasound, or passive leg raise or fluid challenge. At present CMS requires that providers report on their institutions use of the interventions in this performance measure. Subsequently, however, CMS will require that providers complete all interventions. This performance measure is complex and requires substantial hospital resources to achieve compliance. We will perform a systematic review and meta-analysis that will focus on the evidence supporting the use of each of these hemodynamic interventions in decreasing mortality from sepsis, as well as the length of hospital stay, organ failure and cost of care.