Grand Rounds

Do Mandated Sepsis Procedures Reduce Sepsis-Related Deaths?

BACKGROUND AND PURPOSE:

In 2013 New York State mandated that hospitals implement evidence-based sepsis protocols including the following elements
- Antibiotics within 3 hours
- IV resuscitation within 6 hours for those with hypoperfusion
- Staff training
- Track and report data to the state government
Kahn et al. (JAMA, 2019) evaluated whether mandating sepsis procedures improves and the outcomes

Retrospective cohort study
Participants with sepsis diagnosis
- Hospitalized patients in New York State
- Control populations from 4 control states (Florida, Maryland, Massachusetts, and New Jersey)
Data collection
- All-payer hospital discharge data (2011 to 2015) and a comparative interrupted time series analytic approach
- Adjustments were made for patient demographics, hospital characteristics, temporal trends and seasonal changes
Exposures
- Pre-protocol implementation time period: Hospitalization for sepsis prior to January 1, 2011-March 31, 2013
- Post-protocol implementation time period: Hospitalization for sepsis from April 1, 2013-September 30, 2015
Primary outcome
- 30-day in-hospital mortality
Secondary outcomes
- ICU admission rates
- Central venous catheter use
- Clostridium difficile infection rates
- Hospital length of stay

1,012,410 sepsis admissions | 509 hospitals
Mean age (SD): 69.5 (16.4) years | 47.9% were female
Sepsis admissions
- New York State
  - Before regulation: 139,019 patients
  - After regulation: 186,767 patients
- Control states
  - Before regulation: 289,255 patients
  - After regulation: 397,399 patients
Unadjusted 30-day in-hospital mortality
- New York State
  - Before regulation: 26.3%
  - After regulation: 22.0%
- Control States
  - Before regulation: 22.0%
  - After regulation: 19.1%
Adjusted 30-day mortality rate
- Mortality was significantly reduced following sepsis protocol implementation in New York State (P=.02)
Adjusted absolute mortality (in the last quarter covered by the study)
- 3.2% lower than expected in the New York vs control states (95% CI, 1.0% to 5.4; P = .004)
Regulations were significantly associated with the following
- Relative decrease in hospital length of stay (P = .04)
- Relative decrease in the C difficile infection rate (P < .001)
- Relative increase in central venous catheter use (P = .02)
No significant difference was seen in ICU admission rates (P = .09)

The authors acknowledge that results may not be generalizable to other states
However, implementation of an evidence-based sepsis-protocol was associated with reduced sepsis related deaths

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