Analysis of Factors Influencing 3-and 6-h Compliance with the Surviving Sepsis Campaign Guidelines Based on Medical-Quality Intensive Care Unit Data from China
Sepsis remains a significant global health challenge, with an estimated 31.5 million cases worldwide and 5.3 million deaths annually. The Surviving Sepsis Campaign (SSC) guidelines have been proven to reduce mortality when adhered to effectively. Compliance with these guidelines, however, is heavily dependent on the execution by the medical team, particularly within the intensive care unit (ICU). This study aimed to investigate the relationship between the quality of ICU care (QICU) and compliance with the SSC guidelines (Cssc) in China, focusing on 3- and 6-hour compliance metrics.
The study was conducted using data from the China National Critical Care Quality Control Center (China-NCCQC), which included 7,525 secondary and tertiary hospitals in 2018. Hospitals with fewer than 20 septic shock patients admitted to ICUs annually or incomplete data were excluded, resulting in 1,854 hospitals being analyzed. Data were collected from January 1, 2018, to December 31, 2018. The quality indicators of ICUs included deep vein thrombosis (DVT) prophylaxis rate, unplanned extubation rate, reintubation rate within 48 hours, rate of unplanned ICU admission, and return rate within 48 hours. Each indicator was divided into four grades based on implementation, with scores ranging from 0 to 3 points, and categorized into the lowest, lower, higher, and highest groups.
The endpoints of the study were the 3- and 6-hour Cssc. The 3-hour Cssc monitoring indicators included completion of lactate concentration determination, appropriate routine microbiologic cultures obtained before starting antimicrobial therapy, empiric broad-spectrum therapy, and resuscitation with 30 mL/kg crystalloid fluid. The 6-hour Cssc monitoring indicators included repeated measurement of lactate levels in patients with initial hyperlactatemia, resuscitation with vasopressors in patients with mean arterial pressure (MAP) ≤65 mmHg after fluid resuscitation, and measurement of central venous pressure (CVP) and central venous oxygen saturation (ScvO2) in patients with lactate ≥4 mmol/L.
Statistical analysis was performed using SPSS software, version 16.0. The Kolmogorov-Smirnov test was used to check for normal distribution of data, which was described as mean ± standard deviation. Comparisons between multiple groups were analyzed using one-way analysis of variance (ANOVA), with pairwise comparisons conducted using the Tukey multiple comparisons test. A P-value <0.05 was considered statistically significant.
The study found that the completion of 3-hour Cssc was generally higher than the 6-hour Cssc. The primary constraint on 6-hour Cssc was the measurement of CVP and ScvO2 in patients with lactate ≥4 mmol/L. In the lower, higher, and highest groups of the DVT prophylaxis rate, the 6-hour Cssc, the sub-indicators of 3-hour Cssc, and the sub-indicators of 6-hour Cssc were significantly higher than those in the lowest group (P < 0.05). Similarly, in the higher and highest groups of the DVT prophylaxis rate, the sub-indicators of 6-hour Cssc were significantly higher than those in the lower group (P < 0.05).
In the lower, higher, and highest groups of the unplanned extubation rate, the 6-hour Cssc, the sub-indicators of 3-hour Cssc, and the sub-indicators of 6-hour Cssc were significantly higher than those in the lowest group (P < 0.05). The same pattern was observed for the reintubation rate within 48 hours, with the 6-hour Cssc, the sub-indicators of 3-hour Cssc, and the sub-indicators of 6-hour Cssc being significantly higher in the lower, higher, and highest groups compared to the lowest group (P < 0.05). In the highest group of the reintubation rate within 48 hours, the sub-indicators of 6-hour Cssc were significantly higher than those in the higher group (P < 0.05).
For the rate of unplanned ICU admission, the 6-hour Cssc and the sub-indicators of 3-hour Cssc were significantly higher in the lower, higher, and highest groups compared to the lowest group (P < 0.05). Additionally, the completion of repeated measurement of lactate levels in patients with initial hyperlactatemia and resuscitation with vasopressors in patients with MAP ≤65 mmHg after fluid resuscitation were significantly higher in the lower, higher, and highest groups compared to the lowest group (P < 0.05).
The relationship between Cssc and the return rate within 48 hours was uncertain. In the lower and higher groups of the return rate within 48 hours, the 6-hour Cssc was significantly higher than in the lowest group of ICU readmission rates within 48 hours (P < 0.05). However, this phenomenon was not observed for the 3-hour Cssc.
The study concluded that factors related to 3- and 6-hour Cssc include DVT prophylaxis rate, unplanned extubation rate, reintubation rate within 48 hours, and rate of unplanned ICU admission. The relationship between Cssc and the return rate within 48 hours remains unclear. The intrinsic risk of ICU patients, combined with the extrinsic risk created by the process of care, underscores the importance of improving ICU care quality. The China-NCCQC has been instrumental in promoting quality improvement in critical care medicine, with this study being part of the Quality Improvement of Critical Care Program initiated in 2015.
The study has some limitations, including the inclusion of only one year of data, which prevents continuous and dynamic analysis of the relationship between QICU and 3- and 6-hour Cssc. Additionally, further research is needed to determine whether differences in sepsis mortality might emerge with follow-up beyond one year.
In summary, this study highlights the critical role of QICU in achieving compliance with the SSC guidelines. The findings suggest that improving specific quality indicators, such as DVT prophylaxis rate, unplanned extubation rate, reintubation rate within 48 hours, and rate of unplanned ICU admission, can significantly enhance 3- and 6-hour Cssc. Strengthening the construction of QICU in hospitals where sepsis treatment is not yet standardized remains of great importance.
doi.org/10.1097/CM9.0000000000001362
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