Adherence to sepsis treatment standard did not reduce mortality

Short-term sepsis and septic shock mortality rates did not improve after implementation of a Centers for Medicare & Medicaid Services (CMS) required sepsis management performance indicator, in a study covering 114 hospitals in various locations in the United States.

The CMS has required hospitals to begin reporting their adherence to the Early Management of Severe Sepsis and Septic Shock (MS-1) package in October 2015, to improve treatment of this leading cause of death, disability and health care costs, according to Chanu Rhee, MD, MPH, Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, and colleagues.

“MS-1 has catalyzed widespread efforts to improve the quality of sepsis, but concerns have been raised about its potential unintended consequences, including the increasing inappropriate use of broad-spectrum antibiotics, over-resuscitation with intravenous fluids and diagnostic misdirection by over-emphasizing sepsis to the exclusion of other serious diagnoses,” Rhee and colleagues noted.

To assess the effectiveness of SEP-1, investigators reviewed medical records for 2 years before and after implementation at participating hospitals. hospice). Secondary outcomes included lactate test and administration of antibiotics indicated for methicillin-resistant patients. Staphylococcus aureuss (MRSA) or β-lactam antipseudomonas antibiotics within 24 hours of hospital admission.

The methodology of their retrospective cohort study was notable for accessing detailed electronic clinical data to identify cases based on symptoms and course, rather than relying on the inclusion of a diagnosis code. Similarly, these records helped determine lactate testing, antibiotic use, and outcomes for people with suspected sepsis. Investigators applied interrupted time series analysis and logistic regression models to compare management and outcomes in the periods before and after the implementation of SEP-1.

Rhee and colleagues found that lactate test rates increased from 55.1% in the fourth quarter (Q4) of 2013 to 76.7% in Q4 of 2017. The increase was strongly associated with the implementation of SEP-1 (odds ratio [OR] 1.35; 95% CI, 1.04-1.74). There were also increases in the use of anti-MRSA and anti-pseudomonas antibiotics, but the researchers noted that these trends preceded and continued after MS-1. Unadjusted short-term mortality rates were similar in the pre-MS-1 period (2013 Q4 to 2015 Q3) compared to the post-MS-1 period (2016 Q1 to 2017 Q4).

“These results suggest that MS-1 was not associated with improved sepsis outcomes and that alternative approaches to prevent sepsis deaths in hospitals are needed,” Rhee and colleagues report.

In a guest comment, Foster Gesten, MD, formerly of the New York State Department of Health, and Laura Evans, MD, MSc, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, endorsed the assessment that SEP-1 did not achieve the necessary improvements and acknowledged the difficulty of designing a better approach needed.

“A national consortium of interested, respected, and influential organizations, perhaps with support from relevant federal agencies — CMS, the Centers for Disease Control and Prevention, and the National Institutes of Health — could spearhead such an effort,” Gesten suggested. and Evans. “We can do more than SEP-1, and we can do better.”