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Do clinical guidelines improve management of sepsis in critically ill elderly patients? A before-and-after study of the implementation of a sepsis protocol

Verbessern innerklinische Handlungsanweisungen die Versorgung kritisch kranker älterer Sepsispatienten? Eine vorher-nachher Betrachtung der Einführung eines standardisierten Sepsisprotokolls

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Summary

Aim

Guidelines for the management of sepsis have been published but not validated for elderly patients, though a prompt work-up and initiation of appropriate therapy are crucial. This study assesses the impact of a sepsis protocol on timelines for therapy and mortality in standardized management.

Methods

Consecutive patients aged 70 years and older who were diagnosed with sepsis and admitted during the observation periods were included in this before-and-after study at a medical intensive care unit (ICU). Age, sex, and process-of-care variables including timely administration of antibiotics, obtaining blood cultures before the start of antibiotics, documenting central venous pressure, evaluation of central venous blood oxygen saturation, fluid resuscitation, and patient outcome were recorded.

Results

A total of 122 patients were included. Sepsis was diagnosed in 22.9 % of patients prior to the introduction of the protocol and 57.4 % after introduction. Volume therapy was conducted in 63.9 % of the patients (11.5 % preprotocol). Blood culture samples were taken prior to the administration of antibiotics in 67.2 % of patients (4.9 % preprotocol), and antibiotics were applied early in 72.1 % of patients (32.8 % preprotocol). Lactate was set in 77.0 % of patients (11.5 % preprotocol). A central venous catheter was inserted in 88.5 % of patients (68.9 % preprotocol), and the target central venous pressure was achieved in 64.3 % of patients (47.2 % preprotocol). ICU mortality was reduced by 5.2 % and hospital mortality by 6.4 %.

Conclusions

The use of standardized order sets for the management of sepsis in elderly patients should be strongly recommended for better performance in treatment. Compliance with the protocol was associated with reduced length of stay, reduced mortality, and improved initial appropriate therapy.

Zusammenfassung

Ziel

Leitlinien für die Behandlung der Sepsis sind gut publiziert, aber bisher noch nicht für die alten Patienten speziell betrachtet worden, wenngleich ein rascher Therapiebeginn in dieser Patientengruppe sehr wichtig ist. Die Studie überprüft den Einfluss eines standardisierten Behandlungsablaufes auf eine zeitnahe Therapie und auf die Mortalität.

Methodik

Alle Patienten, 70 Jahre und älter, mit der Diagnose Sepsis, die während des Beobachtungszeitraumes zur intensivmedizinischen Aufnahme kamen, wurden in die vorher-nachher-Studie eingeschlossen. Alter, Geschlecht und Qualitätsmerkmale der Therapie wie zeitnahe antiinfektive Behandlung, Entnahme von Blutkulturen vor der Antibiotikaerstgabe, Messung des zentralen Venendruckes, Messung der zentralvenösen Sättigung, Volumenmanagement und Patientenoutcome wurden evaluiert.

Ergebnisse

Einhundertzweiundzwanzig Patienten konnten in die Studie eingeschlossen werden. Eine Sepsis wurde in 22,9 % der Fälle vor der Einführung des Protokolls und in 57,4 % nach der Einführung dokumentiert. Eine adäqute Volumentherapie wurde bei 63,9 % der Patienten durchgeführt (11,5 % vor Protokolleinführung). Blutkulturen wurden bei 67,2 % der Patienten (4,9 % vor Protokolleinführung) vor der Erstgabe des Antibiotikums abgenommen, und eine zeitnahe Gabe des Antibitokums erfolgte bei 72,1 % der Patienten (32,8 % vor Protokolleinführung). Die Laktatbestimmung erfolgte bei 77,0 % der Patienten (11,5 % vor Protokolleinführung). Ein zentraler Venenkatheter wurde bei 88,5 % der Patienten (68,9 % vor Protokolleinführung) angelegt, und der vorgegebene zentralvenöse Druck wurde zu 64,3 % (47,2 % vor Protokolleinführung) erreicht. Die Intensivsterblichkeit konnte um 5,2 % und die Krankenhausterblichkeit um 6,4 % gesenkt werden.

Schlussfolgerungen

Die Verwendung von standardisierten Konzepten bei der Therapie der Sepsis beim älteren Patienten ist unbedingt zu empfehlen, um bessere Behandlungserfolge zu erzielen. Die konsequente Einhaltung des Protokolls führte zu einer reduzierten Intensivverweildauer, einer reduzierten Sterblichkeit und einer Verbesserung der Initialtherapie.

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Conflict of interest

The authors affirm that no conflict of interest exist to be declared regarding the content of this article. Hans Jürgen Heppner and Philipp Bahrmann are research fellows of the “ForschungskollegGeriatrie” Robert-Bosch-Foundation, Stuttgart, Germany.

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Authors and Affiliations

  1. Department of Emergency and Intensive Care Medicine, Klinikum Nuremberg, Prof.-E.-Nathan-Str. 1, 90419, Nuremberg, Germany

    Hans Juergen Heppner MD, Steffen Popp MD & Michael Christ MD

  2. Institut for Biomedicine of Aging, Friedrich-Alexander-University Erlangen-Nuremberg, Heimerichstr. 58, 90419, Nuremberg, Germany

    Hans Juergen Heppner MD, Katrin Singler MD, Philipp Bahrmann MD, Matthias Kaiser MD & Cornel Christian Sieber MD

  3. Department of Acute Geriatric Medicine, Klinikum Nuremberg, Prof.-E.-Nathan-Str. 1, 90419, Nuremberg, Germany

    Katrin Singler MD, Philipp Bahrmann MD, Matthias Kaiser MD & Cornel Christian Sieber MD

  4. Department of Geriatric Medicine, Friedrich-Schiller-University Jena, Bachstrasse 18, 07743, Jena, Germany

    Anja Kwetkat MD

  5. Health economics and Business Administration, University Aalen, Beethovenstrasse 1, 73430, Aalen, Germany

    Adelheid Susanne Esslinger PhD

  6. Department of Clinical Chemistry, Laboratory and Transfusion Medicine, Klinikum Nuremberg, Prof.-E.-Nathan-Str. 1, 90419, Nuremberg, Germany

    Thomas Bertsch MD

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  1. Hans Juergen Heppner MD
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  2. Katrin Singler MD
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  10. Michael Christ MD
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Corresponding author

Correspondence to Hans Juergen Heppner MD.

Additional information

Hans Jüergen Heppner and Katrin Singler contributed equally to this manuscript.

This paper was presented in abstract form at the Weimar Sepsis Update 2011 [Heppner HJ, et al. Sepsis in geriatric patients: Process oriented knowledge management. Infection. 2011;39:S127–8] and the 7th Congress of the European Geriatric Medicine Society, Malaga 2011 [Heppner HJ, et al. Sepsis in geriatric patients. Eur Geriatr Med. 2011; 2S:S105–6].

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Heppner, H., Singler, K., Kwetkat, A. et al. Do clinical guidelines improve management of sepsis in critically ill elderly patients? A before-and-after study of the implementation of a sepsis protocol. Wien Klin Wochenschr 124, 692–698 (2012). https://doi.org/10.1007/s00508-012-0229-7

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