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Wiener klinische Wochenschrift

, Volume 124, Issue 19–20, pp 692–698 | Cite as

Do clinical guidelines improve management of sepsis in critically ill elderly patients? A before-and-after study of the implementation of a sepsis protocol

  • Hans Juergen HeppnerEmail author
  • Katrin Singler
  • Anja Kwetkat
  • Steffen Popp
  • Adelheid Susanne Esslinger
  • Philipp Bahrmann
  • Matthias Kaiser
  • Thomas Bertsch
  • Cornel Christian Sieber
  • Michael Christ
original article

Summary

Aim

Guidelines for the management of sepsis have been published but not validated for elderly patients, though a prompt work-up and initiation of appropriate therapy are crucial. This study assesses the impact of a sepsis protocol on timelines for therapy and mortality in standardized management.

Methods

Consecutive patients aged 70 years and older who were diagnosed with sepsis and admitted during the observation periods were included in this before-and-after study at a medical intensive care unit (ICU). Age, sex, and process-of-care variables including timely administration of antibiotics, obtaining blood cultures before the start of antibiotics, documenting central venous pressure, evaluation of central venous blood oxygen saturation, fluid resuscitation, and patient outcome were recorded.

Results

A total of 122 patients were included. Sepsis was diagnosed in 22.9 % of patients prior to the introduction of the protocol and 57.4 % after introduction. Volume therapy was conducted in 63.9 % of the patients (11.5 % preprotocol). Blood culture samples were taken prior to the administration of antibiotics in 67.2 % of patients (4.9 % preprotocol), and antibiotics were applied early in 72.1 % of patients (32.8 % preprotocol). Lactate was set in 77.0 % of patients (11.5 % preprotocol). A central venous catheter was inserted in 88.5 % of patients (68.9 % preprotocol), and the target central venous pressure was achieved in 64.3 % of patients (47.2 % preprotocol). ICU mortality was reduced by 5.2 % and hospital mortality by 6.4 %.

Conclusions

The use of standardized order sets for the management of sepsis in elderly patients should be strongly recommended for better performance in treatment. Compliance with the protocol was associated with reduced length of stay, reduced mortality, and improved initial appropriate therapy.

Keywords

Sepsis Protocol Standardized order Outcome Intensive care medicine Geriatric patients 

Verbessern innerklinische Handlungsanweisungen die Versorgung kritisch kranker älterer Sepsispatienten? Eine vorher-nachher Betrachtung der Einführung eines standardisierten Sepsisprotokolls

Zusammenfassung

Ziel

Leitlinien für die Behandlung der Sepsis sind gut publiziert, aber bisher noch nicht für die alten Patienten speziell betrachtet worden, wenngleich ein rascher Therapiebeginn in dieser Patientengruppe sehr wichtig ist. Die Studie überprüft den Einfluss eines standardisierten Behandlungsablaufes auf eine zeitnahe Therapie und auf die Mortalität.

Methodik

Alle Patienten, 70 Jahre und älter, mit der Diagnose Sepsis, die während des Beobachtungszeitraumes zur intensivmedizinischen Aufnahme kamen, wurden in die vorher-nachher-Studie eingeschlossen. Alter, Geschlecht und Qualitätsmerkmale der Therapie wie zeitnahe antiinfektive Behandlung, Entnahme von Blutkulturen vor der Antibiotikaerstgabe, Messung des zentralen Venendruckes, Messung der zentralvenösen Sättigung, Volumenmanagement und Patientenoutcome wurden evaluiert.

Ergebnisse

Einhundertzweiundzwanzig Patienten konnten in die Studie eingeschlossen werden. Eine Sepsis wurde in 22,9 % der Fälle vor der Einführung des Protokolls und in 57,4 % nach der Einführung dokumentiert. Eine adäqute Volumentherapie wurde bei 63,9 % der Patienten durchgeführt (11,5 % vor Protokolleinführung). Blutkulturen wurden bei 67,2 % der Patienten (4,9 % vor Protokolleinführung) vor der Erstgabe des Antibiotikums abgenommen, und eine zeitnahe Gabe des Antibitokums erfolgte bei 72,1 % der Patienten (32,8 % vor Protokolleinführung). Die Laktatbestimmung erfolgte bei 77,0 % der Patienten (11,5 % vor Protokolleinführung). Ein zentraler Venenkatheter wurde bei 88,5 % der Patienten (68,9 % vor Protokolleinführung) angelegt, und der vorgegebene zentralvenöse Druck wurde zu 64,3 % (47,2 % vor Protokolleinführung) erreicht. Die Intensivsterblichkeit konnte um 5,2 % und die Krankenhausterblichkeit um 6,4 % gesenkt werden.

Schlussfolgerungen

Die Verwendung von standardisierten Konzepten bei der Therapie der Sepsis beim älteren Patienten ist unbedingt zu empfehlen, um bessere Behandlungserfolge zu erzielen. Die konsequente Einhaltung des Protokolls führte zu einer reduzierten Intensivverweildauer, einer reduzierten Sterblichkeit und einer Verbesserung der Initialtherapie.

Schlüsselwörter

Sepsis Protokoll Behandlungsstandard Outcome Intensivmedizin Geriatrische Patienten 

Notes

Conflict of interest

The authors affirm that no conflict of interest exist to be declared regarding the content of this article. Hans Jürgen Heppner and Philipp Bahrmann are research fellows of the “ForschungskollegGeriatrie” Robert-Bosch-Foundation, Stuttgart, Germany.

References

  1. 1.
    El Solh AA, Akinnusi ME, Alsawalha LN, et al. Outcome of septic shock in older adults after implementation of the sepsis “bundle”. J Am Geriatr Soc. 2008;56:272–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence outcome and associated costs of care. Crit Care Med. 2001;29:1303–10.PubMedCrossRefGoogle Scholar
  3. 3.
    Martin GS, Mannino DM, Eaton S, et al. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003;348:1546–54.PubMedCrossRefGoogle Scholar
  4. 4.
    Kollef MH, Micek ST. Using protocols to improve patient outcomes in the intensive care unit: focus on mechanical ventilation and sepsis. Semin Respir Crit Care Med. 2010;31:19–30.PubMedCrossRefGoogle Scholar
  5. 5.
    Toussaint S, Gerlach H. Sepsis-klinischer Stellenwert der Sepsisbündel und Möglichkeiten der Implementierung. Anästheol Intensivmed Notfallmed Schmetrzther. 2010;45:566–71.CrossRefGoogle Scholar
  6. 6.
    Karbach U, Schubert I, Hagemeister J, et al. Physicians’ knowledge of and compliance with guidelines: an exploratory study in cardiovascular diseases. Dtsch Arzteblatt. 2011;108(5):61–9.Google Scholar
  7. 7.
    Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368–77.PubMedCrossRefGoogle Scholar
  8. 8.
    Beal Al, Cerra FB. Multiple organ failure syndrome in the 1990s: systemic inflammatory response and organ dysfunction. JAMA. 1994;271:226–33.PubMedCrossRefGoogle Scholar
  9. 9.
    Barochia AV, Cui X, Vitberg D, et al. Bundled care for septic shock: an analysis of clinical trials. Crit Care Med. 2010;38:668–78.PubMedCrossRefGoogle Scholar
  10. 10.
    Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med. 2008;36:296–327.PubMedCrossRefGoogle Scholar
  11. 11.
    Brunkhorst FM, Gastmeier P, Kern W, et al. Prevention and follow-up care of sepsis. 1st revision of S2k guidelines of the German Sepsis Society. Internist. 2001;51:925–32.CrossRefGoogle Scholar
  12. 12.
    Schmidt GA. Counterpoint: adherence to early goal-directed therapy: does it really matter? No. Both risks and benefits require further study.Chest. 2010;138:480–3.PubMedCrossRefGoogle Scholar
  13. 13.
    Reade MC, Huang DT, Bell D, et al. Variability in management of early severe sepsis. Emerg J Med. 2010;27:110–5.CrossRefGoogle Scholar
  14. 14.
    Jones AE, Kline JA. Use of goal-directed therapy for severe sepsis and septic shock in academic emergency departments. Crit Care Med. 2005;33:1888–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Levey MM, Dellinger RP, Townsend SR, et al. The surviving sepsis campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med. 2010;36:222–31.CrossRefGoogle Scholar
  16. 16.
    Esslinger AS, Meier F, Roller-Wirnsberger R, et al. Attitudes towards age-related rationing of medical supply: results of a cross-national analysis in Germany and Austria. Wien Klin Wochenschr. 2011;123:422–31.PubMedCrossRefGoogle Scholar
  17. 17.
    Donnino MW, Clardy P, Talmor D. A central venous pressure goal of 8–12 mmHg for all patients in septic shock. Crit Care Med. 2007;35:1441.PubMedCrossRefGoogle Scholar
  18. 18.
    Prasad M, Christie JD, Bellamy SL, et al. The availability of clinical protocols in US teaching intensive care units. J Crit Care. 2010;4:610–9.CrossRefGoogle Scholar
  19. 19.
    Wright SW, Trott A, et al. Creating a system to facilitate translation of evidence into standardized clinical practice: a preliminary report. Ann Emerg Med. 2008;51:80–6.PubMedCrossRefGoogle Scholar
  20. 20.
    Trzeciak S, Dellinger RP, Abate NL, et al. Translating research to clinical practice. A 1-year experience with implementing early-goal-directed therapy for septic shock in the emergency department. Chest. 2006,129;225–32.PubMedCrossRefGoogle Scholar
  21. 21.
    Gao F, Melody T, Daniels D, et al. The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study. Crit Care. 2005;9:R764–70.PubMedCrossRefGoogle Scholar
  22. 22.
    Shapiro NI, Howell MD, Talmor D, et al. Implementation and outcomes of the Multiple Urgent Sepsis Therapies (MUST) protocol. Crit Care Med. 2006;34:1025–32.PubMedCrossRefGoogle Scholar
  23. 23.
    Kollef MH. Inadequate antimicrobial treatment: an important determinant of outcome for hospitalized patients. Clin Infect Dis. 2000;31:S131–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Ibrahim EH, Sherman G, Ward S, et al. The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest. 2000;118:146–55.PubMedCrossRefGoogle Scholar
  25. 25.
    Kollef MH, Sherman G, Ward S, et al. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest. 1999;115:462–74.PubMedCrossRefGoogle Scholar
  26. 26.
    Capelastegui A, Espana PP, Quintana JM, et al. Improvement of process-of-care and outcomes after implementing a guideline fort he management of community-acquired-pneumonia: a controlled before-and-after design study. Clin Infect Dis. 2004; 39:955–63.PubMedCrossRefGoogle Scholar
  27. 27.
    Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med. 1996;335:1864–9.PubMedCrossRefGoogle Scholar
  28. 28.
    Brook AD, Ahrens TS, Schaiff R, et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med. 1999;27:2609–15.PubMedCrossRefGoogle Scholar
  29. 29.
    Ibrahim EH, Ward S, Sherman G, et al. Experience with a clinical guideline for the treatment of ventilator-associated pneumonia. Crit Care Med. 2001;29:1109–15.PubMedCrossRefGoogle Scholar
  30. 30.
    Martinez R, Reyes S, Lorenzo MJ, et al. Impact of guidelines on outcome: the evidence. Semin Respir Crit Care Med. 2009;30:172–8.PubMedCrossRefGoogle Scholar
  31. 31.
    Ferrer R, Artigas A, Suarez D, et al. Effectiveness of treatments for severe sepsis: a prospective, multicenter, observational study. Am J Resp Crit Care. 2009;180:861–6.CrossRefGoogle Scholar
  32. 32.
    Micek ST, Roubinian N, Heuring T, et al. Before–after study of a standardized hospital order set for the management of septic shock. Crit Care Med. 2006;34(11):2707–13.PubMedCrossRefGoogle Scholar
  33. 33.
    Kortgen A, Niederprüm P, Bauer M. Implementation of an evidence-based “standard operating procedure” and outcome in septic shock. Crit Care Med. 2006;34:943–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34:1589–96.PubMedCrossRefGoogle Scholar
  35. 35.
    Otero RM, Nguyen HB, Huang DT, et al. Early goal-directed therapy in severe sepsis and septic shock revisitted. Concepts, controversies, and contempary findings. Chest. 2006;130:1579–95.PubMedCrossRefGoogle Scholar
  36. 36.
    Berwick DM. Disseminating innovations in health care. JAMA. 2003;289:1969–75.PubMedCrossRefGoogle Scholar
  37. 37.
    Levey MM, Pronovost PJ, Dellinger RP, et al. Sepsis change bundles: converting guidelines into meaningful change in behavior and clinical outcome. Crit Care Med. 2004;32:S595–7.CrossRefGoogle Scholar
  38. 38.
    Phua J, Koh Y, Du B, et al. Management of severe sepsis in patients admitted to Asian intensive care units: prospective cohort study. BMJ. 2011;342:d3245.PubMedCrossRefGoogle Scholar
  39. 39.
    Foy R, Walker A, Ramsay C, et al. Theory-based identification of barriers to quality-improvement: induced abortion care. Int J Qual Health Care. 2005;17:147–55.PubMedCrossRefGoogle Scholar
  40. 40.
    Cabanna MD Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines.JAMA. 1999;282:1458–65.CrossRefGoogle Scholar
  41. 41.
    Berenholtz S, et al. Barriers to translating evidence into practice. Curr Opin Crit Care. 2003;4:321–5.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Wien 2012

Authors and Affiliations

  • Hans Juergen Heppner
    • 1
    • 2
  • Katrin Singler
    • 2
    • 3
  • Anja Kwetkat
    • 4
  • Steffen Popp
    • 1
  • Adelheid Susanne Esslinger
    • 5
  • Philipp Bahrmann
    • 2
    • 3
  • Matthias Kaiser
    • 2
    • 3
  • Thomas Bertsch
    • 6
  • Cornel Christian Sieber
    • 2
    • 3
  • Michael Christ
    • 1
  1. 1.Department of Emergency and Intensive Care MedicineKlinikum NurembergNurembergGermany
  2. 2.Institut for Biomedicine of AgingFriedrich-Alexander-University Erlangen-NurembergNurembergGermany
  3. 3.Department of Acute Geriatric MedicineKlinikum NurembergNurembergGermany
  4. 4.Department of Geriatric MedicineFriedrich-Schiller-University JenaJenaGermany
  5. 5.Health economics and Business AdministrationUniversity AalenAalenGermany
  6. 6.Department of Clinical Chemistry, Laboratory and Transfusion MedicineKlinikum NurembergNurembergGermany

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