Surviving sepsis bundle compliance: getting the time of the day it deserves

Abstract

We appreciate the efforts of Almeida and colleagues to establish differences in compliance to the Surviving Sepsis Campaign (SSC) bundle for patients with community-acquired severe sepsis, but we have some concerns [1]. The study is similar to other studies noting a difference in delivered care based on time [2]. Parikh and colleagues showed improvement in quality measures with the use of bundles and implementing the Leapfrog Intensive Physician Staffing Standard [3]. Almeida and colleagues showed only a 2% overall compliance rate with the entire 6-hour bundle, which is too small to draw conclusions. The difference between the compliance rate of the SSC bundle for day versus night was not statistically significant. The authors agree and state that the outcomes in community-acquired severe sepsis improve when all components of the SSC bundle are executed together [4]. However, the authors derive conclusions based on the compliance of individual components. Time zero was defined as the hospital entrance time. However, community-acquired severe sepsis was defined as the onset of infection before hospital admission or infection becoming evident in the first 48 hours. The patient presenting after 6 hours but before 48 hours would by default fail the compliance of the SSC bundle. Patient time groups (day and night) were different from nurse shifts (three shifts in a 24-hour period). The study did not take into account the possibility of handoff errors from nursing shift changes. Also the time between some patients’ hospital entrance and the completion of bundle components could have overlapped the cutoff time for two patient groups.