Mortality associated with severe sepsis remains high at 30 to 50% and rises to 50 to 60% when shock is present. The Surviving Sepsis Campaign (SSC) recommends two bundles for severe sepsis management to achieve 25% reduction in mortality; the Initial Resuscitation Bundle (within the first 6 hours) and the Management Bundle (within 24 hours). West Middlesex University Hospital set up a severe sepsis management protocol based on the SSC initial resuscitation and management bundles. It is a 350-bed hospital with an emergency department. Five hundred patients (medical and surgical) are admitted to the critical care unit per year.
To assess the early recognition of sepsis and the application of the initial resuscitation bundle according to SSC guidelines at West Middlesex University Hospital.
Retrospective data collection of all patients with severe sepsis or septic shock who were admitted to the ITU over 3 months (December 2008, January and February 2009). All patients who developed sepsis before admission to the ITU/HDU were included.
Thirty-three patients were admitted to the ITU at West Middlesex Hospital with either severe sepsis or septic shock. Median age was 72 years. The overall mortality rate was 50%. Patients with septic shock had a mortality rate of 52%. The results of the initial resuscitation of the patients are summarized in Table 1. In septic shock patients, only 35% had ITU intervention within 6 hours (had CVP insertion and/or started on vasopressor and/or inotropic support). Central venous oxygen saturation or mixed venous oxygen saturation was not measured for these patients.
Table 1. Breakdown of tasks of the initial resuscitation bundle achieved within 6 hours
Early recognition and the initial resuscitation of sepsis at this District General Hospital were assessed for the first time. Patients with severe sepsis or septic shock were not resuscitated appropriately and the SSC guidelines were not implemented, resulting in a high mortality rate. The results showed that there is a delay in recognizing sepsis at early stages resulting in inadequate management of patients. In septic shock patients, this resulted in delayed CVP measurement and administration of vasopressors and/or inotropic support. Therefore, we have suggested an educational programme running throughout the year to educate medical and nursing teams about the early recognition and management of sepsis, with emphasis on the strict implementation of all tasks of sepsis protocol according to SSC guidelines to reduce the mortality rate by 25%. We also suggest setting up critical care beds on each ward that will be supported by ITU outreach for CVP insertion and level 1 monitoring.