Association Between Implementation of the Severe Sepsis and Septic Shock Early Management Bundle Performance Measure and Outcomes in Patients With Suspected Sepsis in US Hospitals

Objective: Sepsis is a common cause of death in hospitalized patients. The Centers for Medicare & Medicaid Service (CMS) Severe Sepsis and Septic Shock Bundle (SEP-1) is an evidence-based early management bundle focused on improving sepsis outcomes. It is unknown which quality improvement (QI) practices are associated with SEP-1 compliance and if those practices reduce sepsis mortality. The objectives of this study were to compare sepsis QI practices in SEP-1 reporting and non-reporting hospitals and to measure the association between specific elements of sepsis QI processes and SEP-1 performance and hospital-specific risk-adjusted sepsis mortality. Design, Setting, and Patients: This mixed methods study linked telephone survey data on QI practices from Iowa hospitals to SEP-1 performance data and risk-adjusted mortality from statewide all-payer administrative claims database. The survey assessed sepsis QI practices in eight categories. Characteristics of hospitals and sepsis QI practices were compared by SEP-1 reporting status. Univariable and multivariable logistic and linear regression estimated the association of QI practices with hospital SEP-1 performance and observed-to-expected sepsis mortality ratios. Interventions: None Measurements and Main Results: All 118 Iowa hospitals completed the survey (100% response rate). SEP-1 reporting hospitals were more likely to have sepsis QI practices, including reporting sepsis quality to providers (64% vs. 38%, p = 0.026) and using the case review process to develop sepsis care plans (87% vs. 64%, p = 0.013). Sepsis QI practices were not associated with increased SEP-1 scores. Two were associated with reduced mortality: having a sepsis committee B= -0.11, p = 0.036) and using case review results for sepsis care plans (B= -0.10, p = 0.049). Conclusions: Hospitals reporting SEP-1 compliance to CMS conduct more sepsis QI practices. Most QI practices are not associated with increased SEP-1 performance or decreased sepsis mortality. Future work could explore how to implement these performance improvement practices in hospitals not reporting SEP-1 compliance.

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Infectious Diseases Society of America Position Paper: Recommended Revisions to the National Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) Sepsis Quality Measure

Clinical Infectious Diseases ◽

10.1093/cid/ciaa059 ◽

2020 ◽

Cited By ~ 3

Author(s):

Chanu Rhee ◽

Kathleen Chiotos ◽

Sara E Cosgrove ◽

Emily L Heil ◽

Sameer S Kadri ◽

...

Keyword(s):

Septic Shock ◽

Severe Sepsis ◽

Infectious Diseases ◽

Unintended Consequences ◽

Position Paper ◽

Antibiotic Prescribing ◽

Evidence Based ◽

Early Management ◽

Treatment Standard ◽

Sepsis And Septic Shock

Abstract The Centers for Medicare & Medicaid Services’ Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) measure has appropriately established sepsis as a national priority. However, the Infectious Diseases Society of America (IDSA and five additional endorsing societies) is concerned about SEP-1’s potential to drive antibiotic overuse because it does not account for the high rate of sepsis overdiagnosis and encourages aggressive antibiotics for all patients with possible sepsis, regardless of the certainty of diagnosis or severity of illness. IDSA is also concerned that SEP-1’s complex “time zero” definition is not evidence-based and is prone to inter-observer variation. In this position paper, IDSA outlines several recommendations aimed at reducing the risk of unintended consequences of SEP-1 while maintaining focus on its evidence-based elements. IDSA’s core recommendation is to limit SEP-1 to septic shock, for which the evidence supporting the benefit of immediate antibiotics is greatest. Prompt empiric antibiotics are often appropriate for suspected sepsis without shock, but IDSA believes there is too much heterogeneity and difficulty defining this population, uncertainty about the presence of infection, and insufficient data on the necessity of immediate antibiotics to support a mandatory treatment standard for all patients in this category. IDSA believes guidance on managing possible sepsis without shock is more appropriate for guidelines that can delineate the strengths and limitations of supporting evidence and allow clinicians discretion in applying specific recommendations to individual patients. Removing sepsis without shock from SEP-1 will mitigate the risk of unnecessary antibiotic prescribing for noninfectious syndromes, simplify data abstraction, increase measure reliability, and focus attention on the population most likely to benefit from immediate empiric broad-spectrum antibiotics.

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