Journal of the Formosan Medical Association
Volume 108, Issue 10 , Pages 778-787, October 2009

Key Process Indicators of Mortality in the Implementation of Protocol-driven Therapy for Severe Sepsis

  • Jiun-Long Wang

      Affiliations

    • Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
    • Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan
    • ,
  • Chun-Shih Chin

      Affiliations

    • Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
    • ,
  • Ming-Chen Chang

      Affiliations

    • Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
    • ,
  • Chi-Yuan Yi

      Affiliations

    • Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
    • ,
  • Sou-Jen Shih

      Affiliations

    • Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
    • ,
  • Jeng-Yuan Hsu

      Affiliations

    • Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
    • Institute of Medicine, Chung-Shan Medical University, Taichung, Taiwan
    • ,
  • Chieh-Liang Wu

      Affiliations

    • Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
    • Department of Life Science, National Chung-Hsing University, Taichung, Taiwan
    • School of Medicine, China Medical University, Taichung, Taiwan
    • Corresponding Author InformationCorrespondence to: Dr Chieh-Liang Wu, Department of Internal Medicine, Taichung Veterans General Hospital, 160, Section 3, Chung-Kang Road, Taichung 407, Taiwan

Received 14 November 2008; received in revised form 5 January 2009; accepted 4 February 2009.

Article Outline

Background/Purpose

Severe sepsis and septic shock are life-threatening disorders. Integrating treatments into a bundle strategy has been proposed to facilitate timely resuscitation, but is difficult to implement. We implemented protocol-driven therapy for severe sepsis, and analyzed retrospectively the key process indicators of mortality in managing sepsis.

Methods

Continuous quality improvement was begun to implement a tailored protocol-driven therapy for sepsis in a 24-bed respiratory intensive care unit (RICU) of Taichung Veterans General Hospital from January 2007 to February 2008. Patients, who were admitted to the RICU directly, or within 24 hours, were enrolled if they met the criteria for severe sepsis and septic shock. Disease severity [Acute Physiology and Chronic Health Evaluation (APACHE) II and lactate level], causes of sepsis, comorbidity and site of sepsis onset were recorded. Process-of-care indicators included resuscitation time (Tr-s), RICU bed availability (Ti-s) and the ratio of completing the elements of the protocol at 1, 2, 4 and 6 hours. The structure and process-of-care indicators related to mortality at 7 days after RICU admission and at RICU discharge were identified retrospectively.

Results

Eighty-six patients (mean age, 71 ± 14 years; 72 men, 14 women; APACHE II, 25.0 ± 7.0) were enrolled. APACHE II scores and lactate levels were higher for mortality than survival at 7 days after RICU admission (p < 0.01). For the process-of-care indicators, Ti-s (562.2 ± 483.3 vs.1017.3 ± 557.8 minutes, p = 0.03) and Tr-s (60.7 ± 207.8 vs. 248.5 ± 453.1 minutes, p = 0.07) were shorter for survival than mortality at 7 days after RICU admission. The logistic regression study showed that Tr-s was an important indicator. The ratio of completing the elements of protocols at 1, 2, 4 and 6 hours ranged from 70% to 90% and was not related to mortality.

Conclusion

Protocol-driven therapy for sepsis was put into clinical practice. Early resuscitation and ICU bed availability were key process indicators in managing sepsis, to reduce mortality.

Key Words:  compliance , indicator , protocol implementation , quality improvement , severe sepsis

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PII: S0929-6646(09)60405-8

doi:10.1016/S0929-6646(09)60405-8

Journal of the Formosan Medical Association
Volume 108, Issue 10 , Pages 778-787, October 2009

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