Research Activities, January 2014
Deaths from septic shock decline when guidelines followed
Patient Safety and Quality of Care
Severe sepsis and septic shock claim one-third of patients hospitalized for these conditions. For many years, there were few new therapies that improved mortality outcomes. However, in 2001, it was discovered that early resuscitation within 6 hours using a central venous catheter (CVC) could measure and improve physiologic parameters. Called early goal-directed therapy, the process was incorporated into clinical practice guidelines developed by the multidisciplinary Surviving Sepsis Campaign (SCC).
In a recent commentary on a newly published study, researchers point out that mortality from septic shock is declining, which is most likely due to SCC guideline adherence. The key to reducing mortality is early placement of the CVC.
In the new study, in-hospital mortality was compared for early (day 0) CVC placement versus no or late (after day 0) CVC placement. During the period from 1998 to 2009, the researchers found that early CVC placement tripled but was still at a disappointing rate of 19 percent. Nevertheless, in-hospital mortality decreased from 40 percent to 31 percent. Declines in mortality were even greater in patients who received an early CVC.
According to the commentators, there may be several reasons why the early placement rate of a CVC is a mere 19 percent. There is modest sensitivity of ICD-9-CM diagnostic coding for CVC placement. Other reasons may include timing ambiguities, contraindications to placement, and patient improvement with just initial fluid administration. Since the rate of early CVC placement is still less than ideal for goal-directed treatment, more improvements are needed.
The researchers believe more educational initiatives would further encourage adherence to the SCC guidelines and result in additional survival gains. The commentary was supported by AHRQ (HS20672).
See "Trends in mortality and early central line placement in septic shock: True, true, and related?" by Hallie C. Prescott, M.D., and Collin R. Cooke, M.D., M.Sc., M.S., in the June 2013 Critical Care Medicine 41(6), pp. 1577-1578.