Effect of Delaying Each Element of the Bundle

11/1/18 8:00 AM

Sepsis, a severe and quickly deteriorating medical condition, affects millions of Americans every year with an estimated mortality rate ranging from 28-50%. The 3-hour bundle, has been implemented across hospitals in the US. In this bundle, it is recommended that physicians measure lactate levels, administer antibiotics upon drawing cultures, and administer 30 mL/kg Crystalloid for hypotension or lactate levels greater than or equal to 4 mmol/L within three hours of sepsis diagnosis.

Recently, a study published in Critical Care Medicine examined the timing component of the three hour bundle to ascertain whether three hours is a good benchmark for completion of treatment administration. This was a retrospective study that included 5,374 patients from six hospitals from 2011 to 2014. Sepsis was identified based on meeting “at least two of the following criteria: MAP less than 65, heart rate (HR) greater than 100, RR greater than 20, temperature less than 95 or greater than 100.94, WBC count less than 4 or greater than 12, and lactate greater than 2.0”. Further, this study used the variable “delay,” defined as t minutes to complete each bundle element. In particular the study focused on t values that ranged from 15 to 360 minutes and average treatment effect (ATT). The primary outcome was in-hospital mortality.

The study found that 27.8% of patients died in the hospital and that most of the patients completed the 3-hour bundle within 3 hours. Amongst patients who didn’t receive any bundle elements within 3 hours, 41.1% died. t appears that 3 hours is a reasonable benchmark, but not  absolute since, “delays in administering all four guideline recommendations, even when they did not exceed 3 hours, were associated with a significant increase in in-hospital mortality.”

There were a few limitations with this study such as reusing EHR data from one source and only including in-hospital mortality. However, the findings suggest that every delay in treatment administration makes a difference and that efforts should be directed towards recognizing and treating sepsis early.

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