• Christian S Scheer, Christian Fuchs, Sven-Olaf Kuhn, Marcus Vollmer, Sebastian Rehberg, Sigrun Friesecke, Peter Abel, Veronika Balau, Christoph Bandt, Konrad Meissner, Klaus Hahnenkamp, and Matthias Gründling.
• 1Department of Anesthesiology, University Hospital of Greifswald, Greifswald, Germany. 2Department of Mathematics and Computer Science, University of Greifswald, Greifswald, Germany. 3Department of Internal Medicine, University Hospital of Greifswald, Greifswald, Germany. 4Department of Microbiology, University Hospital of Greifswald, Greifswald, Germany.
• Crit. Care Med. 2017 Feb 1; 45 (2): 241-252.

ObjectiveTo investigate the impact of a quality improvement initiative for severe sepsis and septic shock focused on the resuscitation bundle on 90-day mortality. Furthermore, effects on compliance rates for antiinfective therapy within the recommended 1-hour interval are evaluated.DesignProspective observational before-after cohort study.SettingTertiary university hospital in Germany.PatientsAll adult medical and surgical ICU patients with severe sepsis and septic shock.InterventionImplementation of a quality improvement program over 7.5 years.MeasurementsThe primary endpoint was 90-day mortality. Secondary endpoints included ICU and hospital mortality rates and length of stay, time to broad-spectrum antiinfective therapy, and compliance with resuscitation bundle elements.Main ResultsA total of 14,115 patients were screened. The incidence of severe sepsis and septic shock was 9.7%. Ninety-day mortality decreased from 64.2% to 45.0% (p < 0.001). Hospital length of stay decreased from 44 to 36 days (p < 0.05). Compliance with resuscitation bundle elements was significantly improved. Antibiotic therapy within the first hour after sepsis onset increased from 48.5% to 74.3% (p < 0.001). Multivariate analysis revealed blood cultures before antibiotic therapy (hazard ratio, 0.60-0.84; p < 0.001), adequate calculated antibiotic therapy (hazard ratio, 0.53-0.75; p < 0.001), 1-2 L crystalloids within the first 6 hours (hazard ratio 0.67-0.97; p = 0.025), and greater than or equal to 6 L during the first 24 hours (hazard ratio, 0.64-0.95; p = 0.012) as predictors for improved survival.ConclusionsThe continuous quality improvement initiative focused on the resuscitation bundle was associated with increased compliance and a persistent reduction in 90-day mortality over a 7.5-year period. Based on the observational study design, a causal relationship cannot be proven, and respective limitations need to be considered.

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