Department of Emergency Medicine, UMass Chan Medical School - Baystate, Springfield, MA, USA.
Department of Emergency Medicine, Yale New Haven Hospital, New Haven, CT, USA.
Am J Emerg Med. 2022 Dec;62:19-24. doi: 10.1016/j.ajem.2022.09.038. Epub 2022 Oct 1.
The Centers for Medicare and Medicaid Services introduced the Early Management Bundle, Severe Sepsis/Septic Shock (SEP-1) as a national quality measure in October 2015. The purpose of SEP-1 is to facilitate the efficient, effective, and timely delivery of high-quality care to patients presenting along the spectrum of sepsis severity.
The primary aim of this study was to investigate whether provider practice surrounding emergency department (ED) fluid management of suspected septic shock patients was impacted by SEP-1.
The study was a retrospective observational analysis of 470,558 patient encounters at an urban academic center over a five-year period. The sample of suspected septic shock patients was defined by the following: blood cultures collected, antibiotics administered, and vasopressors initiated. Participants were divided into two cohorts based on date of presentation (Pre-SEP-1: May 1, 2013, - August 30, 2015, and Post-SEP-1: November 1, 2015, - February 28, 2018). The primary outcome was classified as a dichotomous variable based on whether the total volume of fluids administered equaled or exceeded the calculated weight-based (≥30 cc/kg) goal. Segmented logistic regression analyses were used to assess the immediate impact of SEP-1 as well as to compare the long-term trend of fluid volume administered between Pre-SEP-1 and Post-SEP-1 cohorts.
A total of 413 and 482 septic shock patients were included in the Pre-SEP-1 and Post-SEP-1 cohorts, respectively. There was no statistically significant change in weight-based fluid management between the cohorts. The odds of compliance with the weight-based goal decreased 22% immediately following dissemination of SEP-1, however, this was not statistically significant (log-odds = -0.25, p = 0.41). A positive trend in compliance was observed during both the Pre-SEP-1 and Post-SEP-1 periods with odds ratios increasing 0.005 and 0.018 each month, respectively, however, these findings were not statistically significant (log-odds = 0.005, p = 0.736, and log-odds = 0.018, p = 0.10, respectively).
Overall, there were no clinically or statistically meaningful changes in fluid volume resuscitation strategies for suspected septic shock patients following SEP-1. Broad mandates may not be effective tools for promoting practice change in the ED setting. Further research investigating barrier to changes in practice patterns surrounding fluid administration and other SEP-1 bundle elements is warranted.
医疗保险和医疗补助服务中心于 2015 年 10 月推出了早期管理捆绑包，严重脓毒症/脓毒性休克（SEP-1）作为一项国家质量措施。SEP-1 的目的是促进沿着脓毒症严重程度范围的患者高效、有效和及时地提供高质量的护理。
本研究的主要目的是调查 SEP-1 是否影响了疑似脓毒性休克患者的急诊（ED）液体管理的提供者实践。
该研究是对一个城市学术中心五年内 470,558 名患者就诊情况的回顾性观察分析。疑似脓毒性休克患者的样本通过以下标准定义：采集血培养、给予抗生素和开始血管加压素。参与者根据就诊日期分为两个队列（SEP-1 前：2013 年 5 月 1 日至 2015 年 8 月 30 日和 SEP-1 后：2015 年 11 月 1 日至 2018 年 2 月 28 日）。主要结局是根据给予的液体总量是否等于或超过计算的体重基础（≥30 cc/kg）目标来分类的二项变量。使用分段逻辑回归分析评估 SEP-1 的即时影响，并比较 SEP-1 前和 SEP-1 后队列之间给予液体量的长期趋势。
SEP-1 前和 SEP-1 后队列分别纳入 413 名和 482 名脓毒性休克患者。两个队列之间的体重基础液体管理没有统计学上的显著变化。SEP-1 发布后，符合体重基础目标的可能性降低了 22%，但这没有统计学意义（对数几率=-0.25，p=0.41）。在 SEP-1 前和 SEP-1 后期间均观察到符合率呈正趋势，每月分别增加 0.005 和 0.018，但这些发现没有统计学意义（对数几率=0.005，p=0.736，和对数几率=0.018，p=0.10）。
总体而言，SEP-1 后，疑似脓毒性休克患者的液体复苏策略在容量上没有临床或统计学上的显著变化。广泛的授权可能不是促进 ED 环境实践改变的有效工具。需要进一步研究围绕液体给药和其他 SEP-1 捆绑包元素的实践模式改变的障碍。
