McColl Tamara, Gatien Mathieu, Calder Lisa, Yadav Krishan, Tam Ryan, Ong Melody, Taljaard Monica, Stiell Ian
*Department of Emergency Medicine,University of Ottawa,Ottawa,ON.
Ottawa Hospital Research Institute,University of Ottawa,Ottawa,ON.
CJEM. 2017 Mar;19(2):112-121. doi: 10.1017/cem.2016.351. Epub 2016 Sep 9.
BACKGROUND: In 2008-2009, the Canadian Institute for Health Information reported over 30,000 cases of sepsis hospitalizations in Canada, an increase of almost 4,000 from 2005. Mortality rates from severe sepsis and septic shock continue to remain greater than 30% in Canada and are significantly higher than other critical conditions treated in the emergency department (ED). Our group formed a multidisciplinary sepsis committee, conducted an ED process of care analysis, and developed a quality improvement protocol. The objective of this study was to evaluate the effects of this sepsis management bundle on patient mortality. METHODS: This before and after study was conducted in two large Canadian tertiary care EDs and included adult patients with suspected severe infection that met at least two systemic inflammatory response syndrome (SIRS) criteria. We studied the implementation of a sepsis bundle including triage flagging, RN medical directive, education campaign, and a modified sepsis protocol. The primary outcomes were 30-day all-cause mortality and sepsis protocol use. RESULTS: We included a total of 167 and 185 patients in the pre- and post-intervention analysis, respectively. Compared to the pre-intervention group, mortality was significantly lower in the post-intervention group (30.7% versus 17.3%; absolute difference, 13.4%; 95% CI 9.8-17.0; p=0.006). There was also a higher rate of sepsis protocol use in the post-intervention group (20.3% versus 80.5%, absolute difference 60.2%; 95% CI 55.1-65.3; p<0.001). Additionally, we found shorter time-intervals from triage to MD assessment, fluid resuscitation, and antibiotic administration as well as lower rates of vasopressor requirements and ICU admission. Interpretation The implementation of our multidisciplinary ED sepsis bundle, including improved early identification and protocolized medical care, was associated with improved time to achieve key therapeutic interventions and a reduction in 30-day mortality. Similar low-cost initiatives could be implemented in other EDs to potentially improve outcomes for this high-risk group of patients.
背景：2008 - 2009年，加拿大卫生信息研究所报告称，加拿大有超过30000例败血症住院病例，比2005年增加了近4000例。在加拿大，严重败血症和感染性休克的死亡率仍超过30%，且显著高于急诊科（ED）治疗的其他危急病症。我们的团队成立了一个多学科败血症委员会，对急诊科的护理流程进行了分析，并制定了一项质量改进方案。本研究的目的是评估该败血症管理方案对患者死亡率的影响。 方法：这项前后对照研究在加拿大两家大型三级护理急诊科进行，纳入了至少符合两项全身炎症反应综合征（SIRS）标准的疑似严重感染的成年患者。我们研究了包括分诊标记、注册护士医疗指令、教育活动和改良败血症方案在内的败血症方案的实施情况。主要结局指标为30天全因死亡率和败血症方案的使用情况。 结果：干预前和干预后分析分别纳入了167例和185例患者。与干预前组相比，干预后组的死亡率显著降低（30.7%对17.3%；绝对差异13.4%；95%置信区间9.8 - 17.0；p = 0.006）。干预后组败血症方案的使用率也更高（20.3%对80.5%，绝对差异60.2%；95%置信区间55.1 - 65.3；p < 0.001）。此外，我们发现从分诊到医生评估、液体复苏和抗生素给药的时间间隔更短，血管活性药物需求率和重症监护病房（ICU）入住率更低。解读：我们多学科急诊科败血症方案的实施，包括改善早期识别和规范化医疗护理，与实现关键治疗干预的时间缩短以及30天死亡率降低相关。其他急诊科可以实施类似的低成本举措，以潜在地改善这一高危患者群体的治疗效果。
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