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DNP Scholarly Projects School of Nursing

4-15-2019

Mortality Influenced by Sepsis Bundle Complianceand Initial Lactic Acid in Severe Sepsis and SepticShockEvelyn GeorgeBelmont University

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Recommended CitationGeorge, Evelyn, "Mortality Influenced by Sepsis Bundle Compliance and Initial Lactic Acid in Severe Sepsis and Septic Shock" (2019).DNP Scholarly Projects. 15.https://repository.belmont.edu/dnpscholarlyprojects/15

Running head: SEPSIS BUNDLE AND LACTIC ACID 1

Mortality Influenced by Sepsis Bundle Compliance and Initial Lactic Acid in Severe Sepsis and

Septic Shock

Evelyn George

Scholarly Project Advisor: Dr. Linda Wofford

Scholarly Project Team Members: Dr. Erin Shankel, Dr. David Phillippi

Date of Submission: April 15, 2019

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Table of Contents

Abstract 4

Introduction and Background 5

Problem Statement 6

Purpose 7

Review of Evidence 7

Defining Sepsis, Severe Sepsis, Septic Shock 7

Sepsis Bundle 8

Sepsis Bundle Compliance Related to Mortality Rates 9

Lactic Acid Related to Mortality Rates 9

Age and Sepsis Bundle 11

Theoretical Model 12

Structure 12

Process 13

Outcomes 13

Application 13

Project Design 14

Clinical Setting 14

Project Population 16

Sources of Data 16

Data Collection Process 17

Statistical Analysis 18

Results 18

Sample Characteristics 18

Overall Sepsis Bundle Compliance and Mortality 19

Lactic Acid and Mortality 19

Older Individuals and Mortality 19

Discussion 20

Conclusion 24

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References 25

Appendix 34

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Abstract

Sepsis, a life-threatening infection killing 270,000 yearly, is a concern to health care providers,

policy makers, and patients due to its high volume and increasing cost. Patients older than 64

years have a higher occurrence of sepsis and greater mortality risk. The Surviving Sepsis

Guidelines (SSG) recommends the use of the three-hour bundle that standardizes care to

decrease cost, morbidity, and mortality. The three-hour bundle includes two treatments,

intravenous fluids and antibiotics, and two tests, blood cultures and lactic acid level. One bundle

element, lactic acid level, is associated with higher mortality rates, although only a few studies

exist. The project purpose was to compare the influence of the three-hour sepsis bundle

completion and the initial lactic acid level on mortality rates in adults in an emergency

department over a two-year period. The Donabedian quality of care framework guided the

project related to structure, process, and outcome. Analysis of data from a retrospective chart

review of 341 charts determined the association between three-hour sepsis bundle compliance

and mortality rates. Individuals who received the three-hour bundle elements had lowered

mortality rates and those with higher lactic acid had increased odds of mortality. There was no

significance between mortality rates of older individuals who received the three-hour bundle

elements and those who did not. The findings of this project confirm completing the three-hour

bundle and improving current processes in a specific emergency room positively impact

mortality rate.

Keywords: three-hour sepsis bundle, lactic acid, mortality rate, emergency department

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Introduction and Background

According to Centers for Disease Control and Prevention (2018), sepsis affects 1.7

million adults annually in the United States and 270,000 die as a result of sepsis each year.

Sepsis is defined as the body’s reaction to an infection. Sepsis can progress into organ

dysfunction with a high risk of mortality leading to severe sepsis and septic shock (Rhodes et al.,

2017; Shah, Sterk, & Rech, 2018). Although the immune system is equipped to fight infection in

healthy individuals, treatments such as administration of intravenous fluids, antibiotics, and tests

such as blood cultures and lactic acid levels, can improve survival rates.

Sepsis is a concern for health care providers, policy makers, and patients due to the high

volume of cases and high cost. Sepsis prevalence is expected to increase in the coming years,

with a projected incidence of 1 million cases by year 2020 (Bang & Doty, 2009). According to

Agency for Healthcare Research and Quality (AHRQ), septicemia is the sixth most common

reason for hospitalization in the United States, affecting one of every 23 hospitalized patients

(AHRQ, 2012). Between 2005 and 2010, patients with a primary diagnosis of septicemia

contributed to a 71% increase in hospitalizations (Sutton & Friedman, 2013). Because longer

hospitalizations means higher cost, the projected cost of septicemia in the U.S healthcare system

was $20.3 billion in 2011 and increased to $24.3 billion in 2013 in the most recently published

data, which makes it the most expensive condition treated in the U.S hospitals (Torio &

Andrews, 2013; Torio & Moore, 2016)

Sepsis mortality is a serious concern in addition to high volume and increasing cost.

From 2009 to 2014, sepsis accounted for 6% of hospitalization, but 15% of hospital deaths (Rhee

et al., 2017). A 2014 study, including 2.9 million patients from 409 hospitals diagnosed with

sepsis, reported that 1.7 million hospitalizations in the U.S occurred due to sepsis with 270,000

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sepsis related deaths (Rhee et al., 2017). Medicare patients and patients older than 65 diagnosed

with sepsis have not only higher incidence, but also higher mortality risk when compared to a

younger population (Starr & Saito, 2014; Sutton & Friedman, 2013). In order to decrease sepsis

mortality, the Surviving Sepsis Campaign established Surviving Sepsis Guidelines (SSG)

recommending the use of a three-hour bundle which includes two treatments, intravenous fluids

and antibiotics, and two tests, blood cultures and lactic acid level (Rhodes et al., 2017; Society of

Critical Care Medicine, 2015). Additionally, as a quality process measure to address sepsis cost,

morbidity and mortality. The SSG facilitated timely standardized responses to sepsis patients to

decrease cost, decrease morbidity, and decrease mortality through the use of sepsis bundle.

One of the bundle elements, lactic acid level, is related to higher mortality rates in

patients admitted for sepsis and other critical illness (Park et al, 2018). Sinkovic, Markota,

Fluher, and Rehar (2013) performed a retrospective cohort analysis of 102 patients admitted with

sepsis and septic shock in medical ICU from 2008 – 2010 in which, increased levels of lactic

acid reliably predicted patients at higher risk of dying from sepsis and septic shock. However,

according to Liu et al (2013), sepsis patients with intermediate lactate values (less than four

mmol/L) had increased hospital admissions and higher 30-day mortality. Although the three-hour

sepsis bundle does have criteria to assess lactic acid level, the predictability of lactic acid level

on mortality rate needs further study.

Problem Statement

Sepsis is an alarming issue for the healthcare community because of high volume, cost,

morbidity, and mortality. Sepsis mortality rate can be positively influenced through compliance

of the sepsis bundle. Meanwhile, there is a literature gap in the study of mortality rate when

comparing three-hour sepsis bundle compliance and initial lactic acid level in sepsis patients.

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Purpose

The purpose of this quality improvement project was to compare if the three-hour sepsis

bundle compliance and initial lactic acid level influence mortality rate in adults diagnosed with

severe sepsis and septic shock in one ED over a two-year period. Through this project, the results

may reinforce the importance of sepsis bundle compliance in the ED and may highlight the

significance of the initial lactic acid measurement. The project may support the need for

standardized treatment in order to increase survival rates. The project findings will be

generalizable to patients diagnosed with sepsis who arrive to an ED. The author hypothesizes:

(a) Individuals who receive the three-hour bundle elements will have lower rates of

mortality compared to individuals who did not receive the three-hour bundle elements.

(b) Individuals with higher initial lactic acid level for diagnosis will have higher rates of

mortality compared to individuals who have decreased initial lactic acid.

(c) Older individuals who receive all the three-hour elements will have lower mortality

rates compared to who did not receive all of the three-hour bundle elements.

Review of Evidence

Defining Sepsis, Severe Sepsis, Septic Shock

Bone et al., (1992) conducted a landmark study that classified sepsis as the manifestation

of the body’s response to an infection or lack of infection and named it systemic inflammatory

response syndrome (SIRS). SIRS symptoms include temperature (greater than 38° Celsius or

100.4° Fahrenheit or less than 36° degrees Celsius 96.8° Fahrenheit), tachycardia (greater than

90 beats per minute), tachypnea, (greater than 20 breaths per minute), a change in white blood

cell count (greater than 12,000/cu mm) and a neutrophil count (less than 4,000/cu mm or 10%

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immature neutrophils). Any two SIRS symptoms in a patient result in a diagnosis of sepsis (Bone

et al, 1992; Cawcutt & Peters, 2014).

Sepsis can progress into severe sepsis and septic shock. “Severe sepsis” is defined as an

organ dysfunction and “septic shock” is defined as persistent induced hypotension despite fluid

resuscitation (Dellinger et al., 2013; Rhodes et al., 2017; Singer et al., 2016). This definition had

remained unchanged over two decades, until recently. In 2016, The Society of Critical Care

Medicine (SSCM) and the European Society of Intensive Care Medicine (ESICM) revised

definitions through supporting evidence and recommended elimination of the term “severe

sepsis” (Singer et al., 2016). For the purposes of this project and due to prior literature that was

published using prior definitions, “severe sepsis” and “septic shock” will be the terms used.

Sepsis Bundle

In 2002, the SSCM and the ESICM launched goals to increase septic awareness, improve

diagnosis and treatment, educate health care providers, and develop management guidelines to

reduce sepsis mortality (Makic & Bridges, 2018). In 2004, SSC partnered with the Institute of

Healthcare Improvement (IHI) along with panel experts, to develop two practice bundles that

included interventions in the first six hours, the resuscitation bundle, and, within 24 hours, the

management bundle (Marshall, Dellinger & Levy, 2010). After 2004, the resuscitation bundle

was renamed the three-hour bundle and the management bundle as the six-hour bundle (Society

of Critical Care Medicine, 2015). The SSC guidelines are revised every four years and the latest

revision was accomplished in 2016 (Makic & Bridges, 2018; Rhodes et al., 2017).

This project focused on the three-hour bundle elements. The three-hour bundle consists

of two tests, a lactic acid level and blood cultures prior to administration of antibiotics, and two

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treatments, administration of broad-spectrum antibiotics and intravenous fluids (Society of

Critical Care Medicine, 2015).

Sepsis Bundle Compliance Related to Mortality Rates

Sepsis bundle compliance improves patient outcomes (Dellinger et al., 2013; Rhodes et

al., 2017; Seymour et al., 2017). An all-or-none phenomenon is applied to the sepsis bundle

which requires all elements of the bundle to be accomplished in order to achieve bundle

compliance (Marshall et al., 2010). The largest study following the 2004 SSC guidelines

examined the relationship between sepsis bundle compliance and mortality. Levy et al (2015)

conducted a 7.5 year study with 29,470 patients from 218 hospitals in the United States, Europe,

and South America who met the criteria for severe sepsis and septic shock to determine the

association between sepsis bundle compliance and mortality. Overall mortality was lowered at

highly compliant sites (29.0%) compared to low compliance sites (38.6%); Overall hospital

mortality rate dropped 0.7% for every three month participation (p <0.001) (Levy et al., 2015).

Rhodes et al (2015) also conducted another global study with 618 hospitals from 62 countries

with patients presenting with severe sepsis and septic shock. The overall three-hour compliance

was associated with lower hospital mortality than non-compliance along with 40% reduction in

dying at the hospital when compliant with either three or six-hour bundle (Rhodes et al., 2015).

Bundle compliance changes patients’ outcomes globally in populations from ED, medical

surgical wards, and intensive care units (ICU) (Levy et al., 2015; Nguyen et al., 2011; Rhodes et

al., 2015).

Lactic Acid Related to Mortality Rates

Measuring lactic acid levels is one of the four elements of the three-hour sepsis bundle.

Lactic acid accumulates in the body due to an increase of lactic production, diminished use, and

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clearance of lactic or both which is a common cause for hyperlactemia in sepsis (Suetrong &

Walley, 2016). Hyperlactemia, elevated lactic acid, four mmol/L or higher is one criterion to

diagnose severe sepsis (Dellinger et al., 2013). Two-thirds of patients with severe sepsis or shock

had elevated lactate concentrations from the findings of Surviving Sepsis Campaign Database

(Casserly et al., 2015). There are ways to decrease initial lactic acid to decrease morality. In

septic patients decreasing initial lactic acid with hemodynamic resuscitation strategies such as

fluid administration is a successful strategy to impact mortality (Liu et al., 2013, Suetrong &

Walley, 2016).

Mikkelsen et al. (2009) evaluated the association between initial serum lactate level and

mortality rate in patients presenting to the ED with severe sepsis through a retrospective cohort

of patients from January 2005 to December 2006. The study confirmed that lactic acid level is

associated with mortality independent of organ dysfunction and shock in patients admitted to the

ED (Mikkelsen et al., 2009). However, since this study was published, SSG has updated

guidelines multiple times. The authors only focused on initial lactic acid levels and mortality

rates and neglected compliance of sepsis bundle along with this finding. Though studies establish

lactic acid levels and persistent hyperlactemia are associated with adverse outcomes in sepsis,

evidence has failed to compare noncompliance sepsis bundle and lactic acid levels (Khosravani

et al., 2009, Liu et al., 2013, Nguyen et al., 2011, Puskkarich, Illich, & Jones, 2014, Puskkarich

et al., 2013, Song et al., 2012, Toraman et al., 2004). With updated guidelines, new studies need

to compare the impact of three-hour sepsis bundle compliance and initial lactic acid levels on

mortality.

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Age and Sepsis Bundle

The aging population plays a significant role in the increasing rates of sepsis. In the last

10 years in the United States, the population aged 65 years and older increased from 37.2 million

in 2006 to 49.2 million in 2016 (33% increase) and is anticipated to almost double to 98 million

in 2060 (Administration of Aging, 2018). With increased age, the body’s immune response to

infection is reduced and puts older individuals at higher risk for developing infection (Rowe &

McKoy, 2017). Stoller et al. (2015) found sepsis prevalence increased from 346 per 100,000

persons in 2008 to 436 per 100,000 persons in 2012. The mean age of the patients was 69 years

in 2008 and 68 years in 2012 (Stoller et al., 2015).

Older adults have increased risk factors for deterioration from sepsis than younger

patients due to decrease in organ function, immune function, and other comorbidities (Girard,

Opal & Ely, 2005). Over the past several decades, the sepsis bundle has provided standardized

care in both young adults and elderly patients (Makic & Bridges, 2018; Rhodes et al., 2015;

Rhodes et al., 2017). Negret-Delgado et al. (2016) determined the adherence of the sepsis bundle

comparing groups over and under 65 years of age; the study learned decreased sepsis bundle

compliance occurred in the group over 65 years of age compared to the other group which

resulted in more negative patient outcomes. However, other studies report older individuals

diagnosed with sepsis had lower mortality rate when treated with all of elements of sepsis bundle

(El Solh, Akinnusi, Alsawalha & Pineda, 2008; Heppner et al., 2012; Nasa, Juneja & Singh,

2012). Although treating infection in adults older than 65 years is challenging, sepsis bundle

compliance is an evidence-based strategy to mitigate the higher risk of sepsis mortality in the

older population.

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Theoretical Model

For the purposes of this project, the Donabedian quality of care framework was used to

guide the scholarly project. Avedis Donabedian, a physician and professor of medical care

organization, was commissioned by the Health Services Research Section of the U.S Public

Health Service to evaluate research on quality assessment (Ayanian & Markel, 2016). From his

findings, he developed a framework to evaluate quality (Donabedian, 1966; Hickey & Brosnan,

2017).

The three concepts of the Donabedian model are structure, process, and outcomes

(Ayanian & Markel, 2016; Donabedian 1966; Hickey & Brosnan, 2017). This framework has

been used in multiple settings to evaluate quality such as implementation of nurse led triage, an

integrated trauma system, and providing care for pediatric patients in an ED (Abdelwahab, Yang,

& Teka 2017; Moore, Lavoie, Bourgeois, Lapointe, 2015; Ohns, Oliver-McNeil, Nantais-Smith,

& George, 2016). The important assumptions related to this model are that structure, processes,

and outcomes are all related and the relationships between all three concepts are unidirectional

(Donabedian, 1966). Figure 1 illustrates the organization of the specific scholarly project

elements into the Donabedian framework.

Structure

Structure refers to the administrative support needed for quality care and the environment

in which the health care occurs (Donabedian 1966; Hickey & Brosnan, 2017). The number of

available supplies and health care providers, and types of equipment are examples of structural

components (Donabedian 1966; Hickey & Brosnan, 2017). The structural components in the

scholarly project include the emergency department, the electronic health record (EHR) and the

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Sepsis Committee. The feature most important to the scholarly project was the retrieval of data

from the EHR.

Process

Process consists of provider and patient relationship and the ability of the provider to

develop therapeutic relationships with patients. The diagnostic tests, differential diagnoses,

interpretation of the results, and prescribed treatments are all process components (Donabedian

1966; Hickey & Brosnan, 2017). The current practices include the provider use of sepsis bundle,

the initial lactic acid level, and patients receiving the bundle elements. The data collection

facilitated understanding of current process and practices of an emergency department (ED). The

Sepsis Committee identified and shared barriers in the current process through an interview with

the scholarly project leader.

Outcomes

Outcomes are measurable change seen in health status because of the delivered health

care (Donabedian 1966; Hickey & Brosnan, 2017). Outcomes can be seen by both providers and

patients and are standard across all settings (Hickey & Brosnan, 2017). Outcomes such as

mortality and life expectancy reflect culture and values of family while specific disease

outcomes are a better indicator of provided health care quality (Hickey & Brosnan, 2017). The

mortality rate was the outcome measured in the scholarly project.

Application

The structure, process, and outcomes elements of the Donabedian quality of care

framework constructed the underpinning and support of this project. These three elements are

key factors in understanding this quality improvement project that assessed the association of the

three-hour sepsis bundle compliance and initial lactic acid level on mortality rate in adults

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diagnosed with sepsis in the ED. Donabedian (1966) reported that structure, process, and

outcomes provide unique information individually, but together facilitate an improved

understanding of the medical care process.

Project Design

The scholarly project used a retrospective chart review designed to evaluate the

association of three-hour sepsis bundle compliance and initial lactic acid level on mortality rate

in adults diagnosed with sepsis in the ED. The retrospective chart review obtained data about

patients diagnosed with severe sepsis and septic shock in an ED located in the southern region of

United States. The retrospective chart review captured data from January 1, 2016 to December

31, 2017. The scholarly project protocol, data collection, and design were approved by the

Belmont University Institutional Review Board. Additionally, through the collaboration, the

project was supported by the facility who granted access to the retrospective data.

Clinical Setting

Accessing the electronic health record (EHR) was accomplished at this facility. This

facility has 657 beds with 27 beds dedicated to the 24 hour adult emergency department. The

care of sepsis patients is a priority for this organization. The facility includes, Sepsis Committee,

which meets monthly to address issues related to sepsis care. This committee consists of chief

nursing officer (CNO), medical directors of ED and ICU, director of hospitalist service, sepsis

coordinator, nursing director, manager of ED, nurse manager of medical intensive care unit

(MICU), and a nurse from cardiovascular intensive care unit (CVICU). The committee reviews

sepsis cases by analyzing the successes and failures of each case, as well as continuously seeks

strategies to improve the process and outcome of caring for sepsis patients. This quality

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improvement project analyzed data, provided findings, and recommended interventions to the

committee that may help decrease sepsis mortality.

The facility’s mortality target goals in 2016 were to lower severe sepsis mortality by 10%

and lower septic shock mortality by 20%. The mortality target goals for 2017 for severe sepsis

were to lower sepsis mortality by 10% and to lower septic shock mortality by 30%. In relation to

sepsis diagnosis, providers, nurses, and paramedic technicians in the ED are aware of the

importance of early diagnosis and treatment of patients who might present with sepsis. The triage

process is crucial in alerting staff about possible sepsis patients.

When a patient arrives to the ED, a registered nurse (RN) or a paramedic triages the

patient. If a patient meets SIRS criteria for sepsis, a provider is notified. Immediately after the

patient is brought to an available room and a thorough history and physical obtained by the

provider and/or nurse, the sepsis order set is initiated that contains the three-hour sepsis bundle

elements. The RN completes the sepsis order set in a timely manner with the priority to obtain

initial lactic acid level, obtain two sets of blood culture from two different sites, administer

antibiotics after collecting two sets of blood cultures, and administering intravenous fluids. The

provider and the RN communicate about any abnormal changes throughout patient’s care in the

ED. Through the diagnostic testing, treatment, and evaluation of the patient’s overall response to

the treatment, the provider determines if the patient is admitted to the hospital for further

treatment or discharged home after ED treatment completion. Through the sepsis bundle

initiation, the patient receives standard of care and their mortality rate risk can be reduced. The

patient treatment and response data was captured from the EHR to analyze the processes and

outcomes of patients diagnosed with sepsis.

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Project Population

The project population consisted of cases identified through the retrospective chart

review of the EHR. A purposive sample was used through the use of ICD-10 and MS-DRG

codes. The inclusion criteria included patients age 18 and older, present on arrival (POA) with a

diagnosis of severe sepsis and septic shock in the ED, an ICD-10 diagnosis code R65.2 (severe

sepsis), R65.21 (septic shock) and MS-DRG code 871 (severe sepsis without mechanical

ventilation), and who met SIRS criteria during triage. The sample criteria were chosen because

the specific ED treats a high volume of sepsis patients aged 18 and older and the criteria match

the published evidence (Gaieski, Edwards, Kallan, & Carr, 2013; Seymour et al., 2017). Through

this project design and data collection, the project leader did not engage with patients directly.

Sources of Data

The retrospective chart review analyzed cases from January 1, 2016 through December

31, 2017. Data was retrieved from the facility EHR system applying the established inclusion

criteria. The independent variables are the three-hour sepsis bundle compliance and initial lactic

acid measurement. The data acquired included patient demographic characteristics: such as, age

and gender. Age was measured as a discrete ratio variable and gender measured as a

dichotomous variable. Ages 65 and greater were considered older individuals. The three-hour

sepsis bundle consists of four elements that included obtaining lactic acid level, obtaining blood

cultures prior to administration of antibiotics, administering broad spectrum antibiotics, and

administering intravenous fluids.

Lactic acid. When a patient meets SIRS criteria, lactic acid level is obtained. The normal

value for lactic acid ranges from 0-1.9 mmol/L. A lactic acid level 2.0 mmol/L or greater is

considered abnormal. In this project, the action of obtaining a lactic acid level was measured as a

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dichotomous variable and the actual numerical measurement of lactic acid level was measured as

a continuous ratio variable.

Blood cultures. Blood cultures were defined when one set of aerobic and one set of

anaerobic cultures were obtained. In this project, two sets of blood cultures received by the

laboratory prior to antibiotic administration were measured as a dichotomous variable.

Antibiotics. The administration of broad spectrum antibiotic therapy of one or more

drugs to have activity against all organisms is part of the three-hour sepsis bundle. In this project,

the administration of antibiotics was measured as a dichotomous variable.

Fluid therapy. The administration of 30ml/kg of crystalloid fluids in patients who

presented with hypotension or blood lactate concentration 4 mmol/L or greater was part of the

three-hour sepsis bundle. In this project, the administration of fluid therapy was considered a

dichotomous variable.

The dependent variable was mortality rate. Mortality was defined as a patient’s death in

the hospital. Mortality was measured as a dichotomous variable in this project. The Sepsis

Committee was also asked open ended questions concerning the barriers to sepsis bundle

implementation and ideas or changes that have been implemented to help decrease sepsis

mortality rates.

Data Collection Process

The data collection process started in August 2018 at the facility. Cases that met the

inclusion criteria were captured through the EHR and given to the project leader. The project

leader went to the facility twice a week to transcribe data using the facility’s computer in a

private office. The review of cases included ED providers’ notes, nurses’ notes, laboratory

results, medication orders and administration logs, case managements’ notes, hospitalists’ notes

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and discharge notes. Each case was searched by the medical record number (MRN) through the

EHR and results of each variable were transcribed on the Microsoft Excel sheet. The project

adhered to the regulations of the Health Insurance Portability and Protection Act (HIPPA) to

protect the confidentiality and anonymity of all cases. Each case was de-identified, assigned a

unique number, and recorded on the Excel sheet. Every 19th case, one case was chosen randomly

to double check results of the variables transcribed on the Excel sheet. If during the double

checking errors were found, every 5th case was randomly chosen to be double checked.

Statistical Analysis

Data was analyzed using IBM Statistical Package for Social Sciences (SPSS) 25.0 for

Windows. The demographic characteristics such as age and gender of the participants were

analyzed using descriptive statistics by using the mean and standard deviation. The first

hypothesis used Pearson chi-square test to compare mortality rates in individuals who did and

who did not receive three hour bundle elements. The second hypothesis used logistic regression

model to compare mortality rates and lactic acid levels. The third hypothesis used Pearson chi-

square test to compare mortality rates in older individuals who did and did not receive three hour

bundle elements. A p-value of 0.05 was employed with a 95% confidence interval.

Results

A total of 350 charts were collected through the retrospective chart review process. Nine

charts were not included because they failed to meet the SIRS criteria during triage process, one

of the inclusion criteria.

Sample Characteristics

A total sample of 341 charts was used for data analysis. Table 1 summarizes the age,

gender, and mortality rate characteristics. The individuals’ age ranged from 18 to 97 years old

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with an average age of 64.8 years (SD = 15.3) and a median age of 66 years. Forty seven percent

were female (n = 163) and 52.2% were male (n = 178). In 2016, the mortality rate was 25% (n =

124) and in 2017, the mortality rate was 14.3% (n = 217).

Overall Sepsis Bundle Compliance and Mortality

Of 341 charts, 340 charts were analyzed for the first hypothesis and one chart was

excluded due to missing data. Eighty one percent (n = 277) received three-hour bundle elements

compared to 18.5% (n = 63) who did not receive the three-hour bundle elements. A chi-square

test of independence (see Table 2) determined the relationships between individuals who

received and did not receive the three-hour bundle elements and mortality rates were statistically

significant ( χ2 = 3.93; p = 0.04). Individuals who received the three-hour bundle elements had

lower rates of mortality compared to individuals who did not receive the three-hour bundle

elements.

Lactic Acid and Mortality

Of 341 charts, 317 charts were analyzed for the second hypothesis and 24 charts were

excluded due to missing data. Lactic acid levels ranged from 0.3mmol/L to 18.0mmol/L with an

average lactic acid level of 3.8mmol/L (SD = 2.9) and a median level of 2.9mmol/L. A logistic

regression (see Table 3) was calculated to predict mortality rates based on lactic acid levels.

Higher lactic acid was associated with increased odds of mortality rates (adjusted odds ratio,

0.84; 95% confidence interval [CI], 0.77 to 0.92). Results indicated that the variables were

statistically significant (p < 0.01).

Older Individuals and Mortality

187 charts (N = 341) were individuals who were 65 years old and above. The mean age of

the sub-group was 76.0 (SD = 7.6) and median age was 75 years old. A chi-square test of

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independence (Table 4) determined the relationships between older individuals who received the

three-hour bundle and mortality rates were not statistically significant, ( χ2= 0.32, p = 0.56). No

statistically significant evidence was produced that older individuals who received all the three-

hour elements had lower mortality rates compared to those who did not receive all the three-hour

bundle elements.

Discussion

In this retrospective chart review, the Donabedian quality of care framework guided the

scholarly project through the concepts structure, process, and outcomes. The most important

structural feature of this study was the data collection obtained through EHR of individuals who

presented through the ED. The process and the outcomes components were studied through the

three hypotheses and their results.

Process and Outcomes

The use of sepsis bundle through the sepsis order set, the initial lactic acid level, patients

receiving the bundle elements, and the Sepsis Committee are the process components of this

project. The mortality rate was a measured outcome in all three hypotheses. The mortality rates

decreased by 10.7% from 2016 to 2017. The change in mortality rates could be attributed to staff

awareness about sepsis, educational programs by Sepsis Committee and possible updated

changes in the EHR.

The results confirm the first hypothesis. Individuals who received the three-hour bundle

elements did have lower rates of mortality compared to individuals who did not receive the

three-hour bundle elements. Previous research has shown the effectiveness of the three-hour

bundle compliance in increasing survival rates (Leisman et al., 2017; Lynn et al., 2018). The

results show that at this facility, the current process use of sepsis order set initiated the three-hour

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bundle elements to be carried out by staff which in turn facilitated lower mortality rates in the

ED. Further research can be useful in comparing provider’s use of sepsis order set with staff

driven sepsis protocols at other facilities.

The results for second hypothesis confirmed that individuals with higher initial lactic acid

level had higher rates of mortality compared to individuals who had decreased initial lactic acid

level. Gribben et al., (2016) conducted a study that showed that higher lactic acid in sepsis

patients did have higher mortality rates. Moreover, Filho et al., (2016) studied 443 patients with

severe sepsis and septic shock; patients with initial lactic acid levels greater than 2.5mmol/L had

a mortality rate more than 3.2 times higher than patients with lower or equal to 2.5mmol/L.

Further research can be useful in evaluating lactic acid level measurement as a sensitive marker

for sepsis patients.

The third hypothesis was not supported by the results. No relationship was demonstrated

between older individuals who received all the three-hour elements having lower mortality rates

compared to older individuals who did not. Prior research did report an association between

older adults and mortality rate when bundle compliant (El Solh, Akinnusi, Alsawalha & Pineda,

2008; Heppner et al., 2012; Nasa, Juneja & Singh, 2012). However, Rowe et al., (2016)

conducted a study which compared adults greater than 60 years old admitted to ICU with an

higher mortality when compared to those who did not receive all three-hour elements. This study

did not study the association of mortality with three-hour bundle compliance but suggested that

early use of antimicrobials and vasopressors may be associated with lowered in sepsis mortality

(Rowe et al., 2016). It can be challenging to identify sepsis in older adults because temperature,

heart rate, and white blood cell count may be diminished in older adults compared to younger

adults (Umberger, Callen & Brown, 2015). Since the current population contains a large

SEPSIS BUNDLE AND LACTIC

ACID 22

proportion of older adults, early identification and prompt treatment is crucial in improving

mortality rates. Further research is warranted in evaluating different ways sepsis can be identified

in the older population.

The goal of the Sepsis Committee is to bring awareness to the hospital about sepsis,

improve the treatment of sepsis patients, and decrease sepsis mortality rates. The Sepsis

Committee identified the most important barrier of the current process in the ED and proposed an

idea that can be implemented to help with decreasing mortality rates through bundle compliance.

Most of the committee members agreed that a “check” box mentality can occur when the

provider orders the sepsis bundle, staff administers the ordered tests and treatment, but the

provider does not continue to monitor and treat the individual. An idea proposed by the project

leader and Sepsis Committee to overcome this barrier is to incorporate educational programs

every three months to increase provider and staff awareness of sepsis and to share results of

sepsis bundle compliance efforts.

This quality improvement project’s findings support that sepsis bundle compliance leads

to lower mortality rates. The project also supported that measurement of lactic acid is a vital part

of the bundle and helps providers gauge sepsis severity. To further improve outcomes, the

current processes can be improved. The project leader recommends education and training about

sepsis for the ED staff every three months and as needed. Online modules that include a pretest,

the clinical information, and a post test can be an effective approach. Sepsis reference pocket

cards given to staff and posters about the three-hour bundle can be placed in the department to

assist with staff awareness. Substantial evidence demonstrates the positive impact of sepsis

educational programs (Delaney et al., 2015; Ferrer et al., 2008; Herran-Monge et al., 2016).

SEPSIS BUNDLE AND LACTIC

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Implications for Practice

Since the initiation of the scholarly project started, there has been updates to the SSC

guidelines. The new SSC guidelines were revised with a major change to combine the three-hour

bundle and six-hour bundle into a single one-hour bundle (Levy, Evans, & Rhodes, 2018). This

major change communicates a sense of urgency to providers that resuscitation and management

of sepsis patients can be started immediately (Levy, Evans, & Rhodes, 2018). Early recognition

and prompt resuscitation are important especially in the ED, but also in other settings. This

should be addressed and studied in future projects to address the global burden of sepsis

mortality.

The findings from this project support the importance of three-hour sepsis bundle

compliance, initial lactic acid measurement and its relation to mortality rates. This scholarly

project confirms the importance of using evidence-based guidelines such as the three-hour

bundle to guide practice with sepsis patients. The project also highlights the value of the lactic

acid level for sepsis patients and aggressive treatment in the early hours. Continued

improvements in processes of care that enhance early recognition are necessary to further

improve outcomes of sepsis.

Strengths and Limitations

This project had limitations. Firstly, this was not a randomized trial, so results may be

biased by confounding factors. Secondly, although the data was from a single facility and, was

collected over two years from a large study population, the results may have limited external

validity. Thirdly, the project leader did not include any other variables in the logistic regression

model other than lactic acid levels. As research has shown, many factors influence mortality

rates (Rhee et al., 2019; Sanderson et al., 2018; Shen et al., 2012).

SEPSIS BUNDLE AND LACTIC

ACID 24

Conclusion

The ED has a responsibility to provide the best overall care because it is the primary

gateway for many sepsis patients. While sepsis is recognized as hard to identify, the three-hour

bundle can improve sepsis mortality rates. The study did not find a relationship between older

individuals who received the three-hour elements and mortality rates. However, this project’s

results support that three-hour sepsis bundle compliance is associated with lowered mortality

rates and higher lactic acid level can assist in gauging risk of mortality.

SEPSIS BUNDLE AND LACTIC

ACID 25

References

Abdelwahab, R., Yang, H., & Teka, H. G. (2017). A quality improvement study of the

emergency centre triage in a tertiary teaching hospital in northern Ethiopia. African Journal

of Emergency Medicine, 7(4), 160-166. doi:10.1016/j.afjem.2017.05.009

Administration of Aging. (2018). 2017 Profile of older Americans. Retrieved from

https://acl.gov/sites/default/files/Aging and Disability in

America/2017OlderAmericansProfile.pdf

Agency for Healthcare Research and Quality. (2012). Healthcare cost and utilization projection.

Septicemia in U.S. hospital, 2009. Retrieved from

http://www.hcupus.ahrq.gov/reports/statbriefs/sb161.pdf

Ayanian, J., & Markel, H. (2016). Donabedian's lasting framework for health care quality. The

New England Journal of Medicine, 375(3), 205-7.

Bang, E., & Doty, C. I. (2009). Sepsis treatment in the emergency department: An evidence-

based review. Medscape Emergency Medicine. Retrieved from

https://www.medscape.org/viewarticle/587247

Bone, R. C., Balk, R. A., Cerra, F. B., Dellinger, R. P., Fein, A. M., Knaus, W. A., ... & Sibbald,

W. J. (1992). Definitions for sepsis and organ failure and guidelines for the use of

innovative therapies in sepsis. Chest, 101(6), 1644-1655.

Casserly, B. S., Phillips, G. P., Schorr, C. R., Dellinger, R. M., Townsend, S., Osborn, T., . . .

Levy, M. (2015). Lactate measurements in sepsis-induced tissue hypoperfusion: Results

from the surviving sepsis campaign database. Critical Care Medicine, 43(3), 567-573.

SEPSIS BUNDLE AND LACTIC

ACID 26

Cawcutt, K. A., & Peters, S. G. (2014). Severe sepsis and septic shock: Clinical overview and

update on management. Mayo Clinic Proceedings, 89(11), 1572-1578.

doi:10.1016/j.mayocp.2014.07.009

Centers for Disease Control and Prevention. (2018). Sepsis. Retrieved from

https://www.cdc.gov/sepsis/datareports/index.html

Delaney, M. M., Friedman, M. I., Dolansky, M. A., & Fitzpatrick, J. J. (2015). Impact of a sepsis

educational program on nurse competence. The Journal of Continuing Education in

Nursing, 46(4), 179-186.

Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S. M., ... & Osborn, T.

M. (2013). Surviving sepsis campaign: International guidelines for management of severe

sepsis and septic shock, 2012. Intensive care medicine, 39(2), 165-228.

Donabedian, A. (1966). Evaluating the quality of medical care. The Milbank Memorial Fund

Quarterly, 44(3), 166-206. doi:10.2307/3348969

El Solh, A. A., Akinnusi, M. E., Alsawalha, L. N., & Pineda, L. A. (2008). Outcome of septic

shock in older adults after implementation of the sepsis “bundle”. Journal of the American

Geriatrics Society, 56(2), 272-278.

Ferrer, Ricard, Artigas, Antonio, Levy, Mitchell M., Blanco, Jesus, Gonzalez-Diaz, Gumersindo,

Ibanez, Jordi, . . . De la Torre-Prados, Maria Victoria. (2008). Improvement in process of

care and outcome after a multicenter severe sepsis educational program in Spain. The

Journal of the American Medical Association, 299(19), 2294-2303.

Filho, R. R., Rocha, L. L., Corrêa, T. D., Pessoa, C. M., Colombo, G., & Assuncao, M. S.

(2016). Blood lactate levels cutoff and mortality prediction in sepsis - time for a

SEPSIS BUNDLE AND LACTIC

ACID 27

reappraisal? a retrospective cohort study. Shock, 46(5), 480-485.

doi:10.1097/shk.0000000000000667

Gaieski, D. F., Edwards, J. M., Kallan, M. J., & Carr, B. G. (2013). Benchmarking the incidence

and mortality of severe sepsis in the United States. Critical Care Medicine, 41(5), 1167-

1174.

Girard, T. D., Opal, S. M., & Ely, E. W. (2005). Insights into severe sepsis in older patients:

From epidemiology to evidence-based management. Clinical Infectious Diseases, 40(5),

719-727.

Gribben, J., Bianculli, A., Van de Rijn, J., Akerman, M., Hamilton, E., Klein, Z., . . . Leisman,

D. (2016). Three-hour bundle compliance may confer greater mortality benefit for sepsis

patients presenting with less severe hyperlactemia. Annals of Emergency Medicine, 68(4),

S28.

Heppner, H. J., Singler, K., Kwetkat, A., Popp, S., Esslinger, A. S., Bahrmann, P., ... & Christ,

M. (2012). Do clinical guidelines improve management of sepsis in critically ill elderly

patients? A before-and-after study of the implementation of a sepsis protocol. Wiener

klinische Wochenschrift, 124(19-20), 692-698.

Herrán-Monge, R., Muriel-Bombín, A., García-García, M. M., Merino-García, P. A., Cítores-

González, R., Fernández-Ratero, J. A., . . . Blanco, J. (2016). Mortality reduction and long-

term compliance with surviving sepsis campaign. Shock, 45(6), 598-606.

doi:10.1097/shk.0000000000000555

Hickey, J. V. & Brosnan, C. A. (2017). Evaluation of health care quality in advanced practice

nursing. New York: Springer Publishing Co

SEPSIS BUNDLE AND LACTIC

ACID 28

Khosravani, H., Shahpori, R., Stelfox, H. T., Kirkpatrick, A. W., & Laupland, K. B. (2009).

Occurrence and adverse effect on outcome of hyperlactatemia in the critically ill. Critical

Care, 13(3), R90.

Leisman, D. E., Doerfler, M. F., Ward, M. D., Masick, K. J., Wie, B. L., Gribben, J. R., . . .

D’Amore, J. (2017). Survival benefit and cost savings from compliance with a simplified

3-hour sepsis bundle in a series of prospective, multisite, observational cohorts. Critical

Care Medicine, 45(3), 395-406.

Levy, M. M., Rhodes, A. S., Phillips, G. R., Townsend, S. A., Schorr, C. P., Beale, R., . . .

Dellinger, R. (2015). Surviving sepsis campaign: Association between performance metrics

and outcomes in a 7.5-year study. Critical Care Medicine, 43(1), 3-12

Levy, M. M., Evans, L. E., & Rhodes, A. (2018). The surviving sepsis campaign Bundle: 2018

update. Critical Care Medicine, 46(6), 997-1000.

Liu, V., Morehouse, J. W., Soule, J., Whippy, A., & Escobar, G. J. (2013). Fluid volume, lactate

values, and mortality in sepsis patients with intermediate lactate values. Annals of the

American Thoracic Society, 10(5), 466-473. doi:10.1513/annalsats.201304-099oc

Lynn, N. B., Gupta, C., Vaaler, M., Held, J., & Leon, L. (2018). Severe sepsis 3-hour bundle

compliance and mortality. American Journal of Infection Control, 46(11), 1299-1300.

doi:10.1016/j.ajic.2018.04.228

Makic, M. F., & Bridges, E. (2018). CE: Managing sepsis and septic shock: Current guidelines

and definitions. American Journal of Nursing, 118(2), 34-39

Marshall, J., Dellinger, R., & Levy, M. (2010). The surviving sepsis campaign: A history and a

perspective. Surgical Infections, 11(3), 275-281. doi:10.1089/sur.2010.024

SEPSIS BUNDLE AND LACTIC

ACID 29

Mikkelsen, M. E., Miltiades, A. N., Gaieski, D. F., Goyal, M. D., Fuchs, B. V., Shah, C. L., . . .

Christie, J. (2009). Serum lactate is associated with mortality in severe sepsis independent

of organ failure and shock. Critical Care Medicine, 37(5), 1670-1677

Moore, L., Lavoie, A., Bourgeois, G., & Lapointe, J. (2015). Donabedian's structure-process-

outcome quality of care model: Validation in an integrated trauma system. Journal of

Trauma & Acute Care Surgery, 78(6), 1168-1175. doi:10.1097/TA.0000000000000663

Nasa, P., Juneja, D., & Singh, O. (2012). Severe sepsis and septic shock in the elderly: An

overview. World Journal of Critical Care Medicine, 1(1), 23.

Negret-Delgado, Puentes-Corredor, Oliveros, Poveda-Henao, Pareja-Navarro, & Boada-Becerra.

(2016). Adherence to the guidelines for the management of severe sepsis and septic shock

in patients over 65 years of age admitted to the ICU. Colombian Journal of

Anesthesiology, 44(4), 299-304

Nguyen, H. B., Kuan, W. S., Batech, M., Shrikhande, P., Mahadevan, M., Li, C. H., ... & Dengel,

A. (2011). Outcome effectiveness of the severe sepsis resuscitation bundle with addition of

lactate clearance as a bundle item: a multi-national evaluation. Critical Care, 15(5), R229.

doi: 10.1186/cc10469

Park, Y. J., Kim, D. H., Kim, S. C., Kim, T. Y., Kang, C., Lee, S. H., & ... Lim, D. (2018).

Serum lactate upon emergency department arrival as a predictor of 30-day in-hospital

mortality in an unselected population. Plos One, 13(1), e0190519.

doi:10.1371/journal.pone.0190519

Ohns, M. J., Oliver-McNeil, S., Nantais-Smith, L. M., & George, N. M. (2016). Nonurgent use

of the emergency department by pediatric patients: A theory-guided approach for primary

SEPSIS BUNDLE AND LACTIC

ACID 30

and acute care pediatric nurse practitioners. Journal of Pediatric Healthcare, 30(4), 339-

346. doi:10.1016/j.pedhc.2015.09.003

Puskarich, M. A., Illich, B. M., & Jones, A. E. (2014). Prognosis of emergency department

patients with suspected infection and intermediate lactate levels: A systematic

review. Journal of critical care, 29(3), 334-339.

Puskarich, M. A., Trzeciak, S., Shapiro, N. I., Albers, A. B., Heffner, A. C., Kline, J. A., &

Jones, A. E. (2013). Whole blood lactate kinetics in patients undergoing quantitative

resuscitation for severe sepsis and septic shock. Chest, 143(6), 1548-1553.

Raschke, R. A., Groves, R. H., Khurana, H. S., Nikhanj, N., Utter, E., Hartling, D., ... & Calleja,

M. (2017). A quality improvement project to improve the Medicare and Medicaid Services

(CMS) sepsis bundle compliance rate in a large healthcare system. BMJ Open Qual, 6(2),

e000080

Rhee, C., Dantes, R., Epstein, L., Murphy, D., Seymour, C., Iwashyna, T., . . . Klompas, M.

(2017). Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009-

2014. JAMA, 318(13), 1241-1249

Rhee, C., Jones, T. M., Hamad, Y., Pande, A., Varon, J., O’Brien, C., ... & Klompas, M. (2019).

Prevalence, underlying causes, and preventability of sepsis-associated mortality in US

acute care hospitals. JAMA 2(2), e187571-e187571.

Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., & ... De

Backer, D. P. (2017). Surviving sepsis campaign: International guidelines for management

of sepsis and septic shock: 2016. Critical Care Medicine, 45(3), 486-552.

doi:10.1097/CCM.0000000000002255

SEPSIS BUNDLE AND LACTIC

ACID 31

Rhodes, A., Phillips, G., Beale, R., Cecconi, M., Chiche, J., Backer, D., . . . Levy, X. (2015). The

surviving sepsis campaign bundles and outcome: Results from the international multicentre

prevalence study on sepsis (the IMPreSS study). Intensive Care Medicine, 41(9), 1620-

1628

Rowe, T., Araujo, K., Van Ness, P., Pisani, M., & Juthani-Mehta, M. (2016). Outcomes of older

adults with sepsis at admission to an intensive care unit. Open Forum Infectious

Diseases, 3(1), 1-10

Rowe, T. A., & McKoy, J. M. (2017). Sepsis in older adults. Infectious Disease Clinics, 31(4),

731-742.

Sanderson, M., Chikhani, M., Blyth, E., Wood, S., Moppett, I., Mckeever, T., & Simmonds, M.

(2018). Predicting 30-day mortality in patients with sepsis: An exploratory analysis of

process of care and patient characteristics. Journal of the Intensive Care Society, 19(4),

299-304.

Seymour, C., Gesten, F., Prescott, H., Friedrich, M., Iwashyna, T., Phillips, G., . . . Levy, M.

(2017). Time to treatment and mortality during mandated emergency care for sepsis. The

New England Journal of Medicine, 376(23), 2235-2244

Shah, T., Sterk, E., & Rech, M. A. (2018). Emergency department sepsis screening tool

decreases time to antibiotics in patients with sepsis. The American Journal of Emergency

Medicine, 300 (20) 786-798 doi:10.1016/j.ajem.2018.01.060

Shen, H. N., Lu, C. L., & Li, C. Y. (2012). Dementia increases the risks of acute organ

dysfunction, severe sepsis and mortality in hospitalized older patients: a national

population-based study. PloS one, 7(8), e42751.

SEPSIS BUNDLE AND LACTIC

ACID 32

Singer, M., Deutschman, C., Seymour, C., Shankar-Hari, M., Annane, D., Bauer, M., . . . Angus,

D. (2016). The third international consensus definitions for sepsis and septic shock (Sepsis-

3). JAMA, 315(8), 801-10

Sinkovic, A., Markota, J., Fluher, D., & Rehar, A. (2013). Predictors of 30-day mortality in

medical patients with severe sepsis and septic shock. Intensive Care Medicine, 39, S410-

S411.

Society of Critical Care Medicine (2015). Surviving sepsis campaign. Retrieved from

http://www.survivingsepsis.org/Bundles/Pages/default.aspx

Song, Y. H., Shin, T. G., Kang, M. J., Sim, M. S., Jo, I. J., Song, K. J., & Jeong, Y. K. (2012).

Predicting factors associated with clinical deterioration of sepsis patients with

intermediate levels of serum lactate. Shock, 38(3), 249-254.

Starr, M. E., & Saito, H. (2014). Sepsis in old age: Review of human and animal studies. Aging

and disease, 5(2), 126.

Stoller, J. L., Halpin, L., Aplin, B., Weis, M. J., Georgescu, C., & Nazzal, M. M. (2015).

Epidemiology of severe sepsis: 2008-2012. Journal of the American College of

Surgeons, 221(4), S42.

Suetrong, B., & Walley, K. R. (2016). Lactic acidosis in sepsis: It’s not all anaerobic. Chest,

149(1), 252-261. doi:10.1378/chest.15-1703

Sutton, J. P., & Friedman, B. (2013). Trends in septicemia hospitalizations and readmissions in

selected HCUP states, 2005 and 2010: Statistical brief# 161. Retrieved from

https://www.hcup-us.ahrq.gov/reports/statbriefs/sb161.pdf

SEPSIS BUNDLE AND LACTIC

ACID 33

Toraman, F., Evrenkaya, S., Yuce, M., Aksoy, N., Karabulut, H., Bozkulak, Y., & Alhan, C.

(2004). Lactic acidosis after cardiac surgery is associated with adverse outcome. Heart

Surg Forum 7(2), 155-159.

Torio, C. M., & Andrews, R. M. (2013). National inpatient hospital costs: The most expensive

conditions by payer, 2011: Statistical brief # 160. Retrieved from https://www.hcup-

us.ahrq.gov/reports/statbriefs/sb160.pdf

Torio, C. M., & Moore, B. J. (2016). National inpatient hospital costs: The most expensive

conditions by payer, 2013: Statistical brief # 204. Retrieved from https://www.hcup-

us.ahrq.gov/reports/statbriefs/sb204-Most-Expensive-Hospital-Conditions.pdf

Umberger, R., Callen, B. & Brown, M. L. (2015). Severe sepsis in older Adults. Critical Care

Nursing Quarterly, 38(3), 259–270. doi: 10.1097/CNQ.0000000000000078.

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Appendix

Figure 1 – Donabedian Quality of Care Framework. The red colored blocks are the specific

elements applied to the framework

SEPSIS BUNDLE AND LACTIC

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Table 1

Age, Gender, and Mortality Characteristics

Age in years (N = 341)

Mean (SD) 64.89 (15.34)

Median 66

Range 18 - 97

Gender (N = 341)

Female (%) 163 (47.8%)

Male (%) 178 (52.2%)

Mortality Rate in 2016 (n = 124)

Lived (%) 93 (75%)

Died (%) 31 (25%)

Mortality Rate in 2017 ( n = 217)

Lived (%) 186 (85.7%)

Died (%) 31 (14.3%)

Table 2

Chi Square Test for Overall Sepsis Bundle Compliance and Mortality

Overall Sepsis Bundle Compliance and Mortality

Compliance

Total N Y

Mortality D Count 6 56 62

L Count 57 221 278

Pearson Chi-Square

Value df p value

Pearson Chi-

Square

3.936a 1 0.047

Note. df = degrees of freedom a 0 cells have expected count less than 5. The minimum expected count is 11.49

Table 3

Logistic Regression for Lactic Acid and Mortality

B S.E. Wald df p Adjusted Odds Ratio 95% C.I.for EXP(B)

Lactic acid -0.17 0.04 14.63 1 <0.01 0.84 [0.77, 0.92]

SEPSIS BUNDLE AND LACTIC

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Note. CI = confidence interval df = degrees of freedom SE = standard error

Table 4

Chi Square test for Older Adults and Mortality

Mortality

Total D L

Compliance N 5 27 32

Y 31 124 155

Pearson Chi-square

Value df p

Pearson Chi-

Square

.327a 1 0.568

a 0 cells have expected count less than 5. The minimum expected count is 6.16