12: Implementation of Early Goal-Directed Therapy and the Surviving Sepsis Campaign Resuscitation Bundle In Asia Is Associated With Decreased Mortality: Analysis of a Team Versus Non-Team Model of Care for the ATLAS Investigators

Abstract

Evidence from America and Europe suggests that successful implementation of the Surving Sepsis Campaign severe sepsis resuscitation bundle including early goal-directed therapy is associated with significant outcome benefit. This study examines the impact of implementing such bundle in multiple Asian countries having team versus non-team models of care. The study is a multi-national, prospective interventional cohort of adult severe sepsis or septic shock patients presenting to the emergency department (ED) of 8 hospitals in Korea, Singapore, India, Taiwan, and China. Implementation of the bundle was divided into six quartiles from July 1, 2008 to December 31, 2009: Baseline, Education, and four Quality Improvement quartiles. Components of the bundle included: 1) lactate measured; 2) blood cultures prior to antibiotics; 3) fluid bolus given; 4) antibiotics by 3 hours; 5) achieve CVP > 8 mm Hg by 6 hours; and 6) achieve ScvO2 > 70% by 6 hours. Three hospitals with team model were championed by intensive care medicine, with initiation of the bundle in the ED and completion in the ICU setting by a focused multi-disciplinary team. Five hospitals with non-team model were championed by emergency medicine, with completion of the bundle in the ED as part of standard care. Five-hundred and fifty-seven patients were enrolled with age 61+/-18 yrs, APACHE II 22+/-8, lactate 4.7+/-3.2 mmol/L, 72% septic shock, 50% mechanical ventilation, and 31% Inhospital mortality. ED length of stay was 13+/-32 hours and hospital length of stay 13+/-14 days. Compliance to all items of the bundle was 13, 27, 38, 46, 49, and 55% (p=0.01) over the six quartiles of implementation. Comparing compliance in the first quartile to 6th quartile, hospitals with team increased from 38 to 76%, whereas hospitals with non-team increased from 3 to 29% (p<0.001). Throughout the study period, patients who received the entire bundle had mortality of 25%, compared to 34% mortality in patients who only received some components of the bundle (p=0.03). Baseline compliance to the severe sepsis resuscitation bundle is low in Asia and similar to other published data in Europe and America. Through education and quality improvement efforts, improved compliance and outcome benefit was achieved. A team model was more effective compared to a non-team model of implementation in achieving compliance.