A Standardized Order Set for Sepsis Management - Journal Watch Infectious Diseases 4/13/09 10:25 PM

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Infectious Diseases (Link to: http://infectious-diseases.jwatch.org) >Summary and Comment
A Standardized Order Set for Sepsis Management
Implementation of an order set brought significant improvements in patient care and survival rates.

Severe sepsis and septic shock are associated with a mortality rate >30% in the U.S. Early, goal-directed cardiovascular
resuscitation and rapid initiation of adequate antibiotic therapy have proved beneficial for patients with sepsis and have
become essential elements of sepsis treatment guidelines. However, clinicians often do not follow such guidelines in
daily practice.

To improve sepsis outcome at a St. Louis hospital, a standardized order set for treating severe sepsis and septic shock,
based on recommendations from the Surviving Sepsis Campaign, was implemented hospital-wide in June 2005. Now,
in a retrospective study involving 400 patients with sepsis, researchers have compared patient care and outcomes
between the 18 months before order-set implementation and the 18 months afterward (December 2003–May 2005 vs.
June 2005–December 2006).

Compared with patients in the "before" group, those in the "after" group received more intravenous fluids during the
first 12 hours (mean, 1627 vs. 2054 mL; P<0.04), received appropriate initial antibiotic treatment more often (53.0%
vs. 65.5%; P<0.01), and received appropriate antibiotic treatment earlier (mean, 995 vs. 737 minutes; P=0.04).
Documented compliance with blood pressure goals for hemodynamic resuscitation was similar between groups, but
patients in the after group showed significant reductions in need for vasopressors, incidence of organ failure, mean
length of hospital stay, and in-hospital mortality rate (39.5% vs. 55.0%). Treatment before order-set implementation
and higher APACHE II scores were independently associated with in-hospital mortality. Sepsis patients treated in the
ICU showed a greater reduction in in-hospital mortality than those treated on the wards.

Comment: Because of the retrospective study design, we cannot determine how much of this success is due to the
standardized order set. Promotion of the program could have improved treatment by increasing clinicians’ awareness of
sepsis and of the critical timing of specific treatments. Nevertheless, this program could serve as a model for other
hospitals.

— Thomas Glück, MD (Link to: http://infectious-

diseases.jwatch.org/misc/board_about.dtl#aGluck)
Published in Journal Watch Infectious Diseases April 1, 2009

Citation(s):
Thiel SW et al. Hospital-wide impact of a standardized order set for the management of bacteremic severe sepsis. Crit
Care Med 2009 Mar; 37:819.

Medline abstract (Link to: /cgi/external_ref?access_num=19237883&link_type=MED) (Free)

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