BMJ Quality Improvement Reports 2015; u207871.w4032 doi: 10.1136/bmjquality.u207871.

w4032

Improving the management of sepsis in a district general hospital by

implementing the 'Sepsis Six' recommendations
Prashant Kumar, Mark Jordan, Jenny Caesar, Sarah Miller
South Canterbury DHB, New Zealand

Abstract

Sepsis is a common condition with a major global impact on healthcare resources and expenditure. The Surviving Sepsis Campaign has been
vigorous in promoting internationally recognised pathways to improve the management of septic patients and decrease mortality. However,
translating recommendations into practice is a challenging and complex task that requires a multi-faceted approach with sustained
engagement from local stakeholders.

Whilst working at a district general hospital in New Zealand, we were concerned by the seemingly inconsistent management of septic patients,
often leading to long delays in the initiation of life-saving measures such as antibiotic, fluid, and oxygen administration. In our hospital there
were no clear systems, protocols or guidelines in place for identifying and managing septic patients.

We therefore launched the Sepsis Six resuscitation bundle of care in our hospital in an attempt to raise awareness amongst staff and improve
the management of septic patients. We introduced a number of simple low-cost interventions that included educational sessions for junior
doctors and nursing staff, as well as posters and modifications to phlebotomy trolleys that acted as visual reminders to implement the Sepsis
Six bundle.

Overall, we found there to a be a steady improvement in the delivery of the Sepsis Six bundle in septic patients with 63% of patients receiving
appropriate care within one hour, compared to 29% prior to our interventions. However this did not translate to an improvement in patient
mortality.

This project forms part of an on going process to instigate a fundamental culture change among local healthcare professionals regarding the
management of sepsis. Whilst we have demonstrated improved implementation of the Sepsis Six bundle, the key challenge remains to ensure
that momentum of this project continues and forms a platform for sustainable clinical improvement in the long term.

Furthermore, the assessment of end-organ perfusion with relevant

Problem
blood tests, including lactate, to help determine the severity of
sepsis and requirement for escalation of care to high dependency
Whilst working at a 130-bed district general hospital in New
or intensive care units (ICU) was not performed well. One
Zealand, we noted a high incidence of sepsis amongst patients both
contributing factor to this phenomenon was the lack of a readily
in the emergency department (ED) and general hospital wards. We
accessible time critical resuscitation bundle. Another was a lack of
were concerned by the seemingly inconsistent management of
awareness amongst junior doctors regarding the necessary blood
these patients, often leading to long delays in the initiation of life-
tests. This meant antibiotics were frequently delayed, sometimes for
saving measures such as antibiotic, fluid, and oxygen
many hours, with blood cultures often acquired following
administration. As part of a global effect to reduce mortality from
administration of antibiotics.
sepsis, New Zealand endorses the Surviving Sepsis Campaign
International Guidelines for the management of sepsis.[1] However,
in our hospital there was no clear system in place for identifying Background
septic patients and triggering a co-ordinated clinician response.
Furthermore there were no local protocols or guidelines in place to Sepsis is a common condition with a major global impact on
aid in the delivery of optimal management for septic patients and healthcare resources and expenditure.[2] It is defined as the
subsequently the administration of antibiotics, intravenous fluids, presence (probable or documented) of infection together with
and oxygen within one hour was poorly executed. evidence of associated systemic manifestations, also known as
systemic inflammatory response syndrome (SIRS).[1] Severe
On further inspection, we felt that there were a number of factors sepsis is defined as sepsis combined with sepsis-induced organ
that contribute to suboptimal implementation of international sepsis dysfunction or tissue hypoperfusion, whilst septic shock is defined
guidelines.[1] One was the lack of awareness and understanding as continued sepsis-induced hypotension despite adequate fluid
amongst nurses and junior doctors that time-critical interventions resuscitation.[1] Data from studies conducted in mainly developed
significantly improves survival rates in septic patients.[1-5] countries suggests that in adults, the incidence of severe sepsis is

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up to 300 cases per 100,000 population, and rising.[6-8] Reported Reliable, timely delivery of more complex life-saving tasks, such as
in-hospital mortality for patients with severe sepsis or septic shock EGDT, demands greater awareness, faster recognition and
ranges between 20% and 50%.[7,9-12] Meanwhile, data specific for initiation of basic care, and more effective collaboration between
Australasia demonstrates 23% in-hospital mortality rates for clinicians and nurses involved in the initial assessment of the septic
patients with severe sepsis or septic shock.[10] There are few patient. As a life threatening condition associated with a high rate of
disease processes with such a high mortality, with patients admitted mortality, quality care of patients with sepsis is paramount. Due to
with severe sepsis having a 6-10 fold higher mortality risk than if concerns regarding early assessment and initiation of appropriate
they presented with an acute myocardial infarction and a 4-5 times therapy previously identified, we set about introducing the Sepsis
greater risk than if they had suffered an acute stroke.[2] Six resuscitation bundle into our hospital in an attempt to deliver
appropriate care in a timely manner to septic patients and thereby
The fundamental approach to the management of sepsis includes improve their outcomes.
early recognition, appropriate, and timely delivery of antibiotics,
controlling the source of infection and adequate resuscitation with
Baseline measurement
intravenous fluids and possibly vasoactive drugs.[10] Mortality has
been shown to increase by 7.6% for every hour of delay in starting
Data was retrospectively collected over a six-month period for all
antibiotic therapy.[13] Unfortunately however, due to a variety of
hospitalised adult (over 18-years old) patients with confirmed
reasons including indecision by junior staff, availability of senior
sepsis. Initially, case notes were obtained via the medical records
review and lack of awareness of the problem on general wards,
department, using a list of coded diagnoses that included infection,
there are frequently long delays between medical review and
sepsis, pneumonia, lower and upper respiratory infection,
antibiotic administration.[5,19] Meanwhile, whilst early goal-directed
urosepsis, urinary tract infection, pyrexia of unknown origin,
therapy (EGDT) has previously been associated with a 34% relative
meningitis, abdominal sepsis, biliary sepsis, bacteraemia,
risk reduction in mortality, and was subsequently endorsed as a key
septicaemia, endocarditis, pyelonephritis, septic arthritis, and
strategy to reduce mortality from sepsis by the Surviving Sepsis
cellulitis. 138 sets of notes were then scrutinised to identify patients
Campaign, more recent studies have not shown any benefit in
that satisfied sepsis or severe sepsis criteria as defined by the
terms of all-cause mortality in patients with early septic
international sepsis guidelines shown below.[1]
shock.[1,3,10]

Sepsis- clinical evidence of infection and any two of the following

The Surviving Sepsis Campaign is a joint collaboration of the
present;
Society of Critical Care Medicine and the European Society of
Intensive Care Medicine committed to reducing mortality from
1. Temperature <36°C or >38°C
sepsis worldwide.[1] This campaign included recommendations
2. Respiratory rate >20/min or pCO2 < 4.3 kPa (<32mmHg)
concerning the implementation of a core set of evidence-based
3. White cell count <4 x10^9/L or > 12 x10^9/L
interventions, otherwise known as ‘resuscitation bundles’.[1] Use of
4. Heart rate >90bpm
such bundles has been associated with a decrease in mortality.[15]
One such bundle is 'Sepsis Six' which was specifically designed to
Severe sepsis- patients with sepsis plus and any one of the
facilitate early intervention in busy hospital and pre-hospital
following present:
settings.[5,16] Delivery of the Sepsis Six resuscitation bundle is
associated with a 55% relative risk reduction in mortality.[17]
1. Systolic BP <90mmHg
Previous quality improvement projects reported in this journal, have
2. Mean arterial pressure <65mmHg
demonstrated implementation of the Sepsis Six bundle through a
3. Lactate >2mmol/L
variety of different interventions within different hospital settings, to
4. Other evidence of organ dysfunction: (creatinine >177
varying degrees of success.[18-20] What is consistent throughout
umol/L, bilirubin >34 umol/L, platelets <100 x10^9/L, INR
these projects however, is the recognition that successfully
>1.5, urine output <0.5mL/kg/hr, SpO2 <90%)
implementing the bundle is a challenging and complex task that
requires a multi-faceted approach with consistent engagement from
Those who met the criteria for sepsis or severe sepsis were
local stakeholders.[18-20]
subsequently included in the data collection. Our primary outcome
measure was administration of antibiotics, intravenous fluids, and
The Sepsis Six is comprised of three diagnostic and monitoring
oxygen if appropriate within one hour of initial assessment.
steps and three therapeutic interventions:
Secondary outcome measures focused on fulfilling the Sepsis Six
bundle that included obtaining blood cultures prior to antibiotic
1. Deliver high-flow oxygen
administration, lactate levels, and documentation of urine output
2. Take blood cultures prior to antibiotics but do not delay
monitoring either via indwelling catheter or fluid balance chart.
treatment
Furthermore we analysed data regarding time taken from initial
3. Administer empirical intravenous antibiotics
nursing assessment to clinician review and all-cause in-hospital
4. Measure serum lactate
mortality.
5. Start intravenous fluid resuscitation with crystalloids
6. Commence urine output monitoring via either a catheter or
A total of 55 patients (26 males, 29 females) were included in the
chart[5]
baseline measurement. 22 patients met the criteria for severe

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sepsis. 16 out of 55 patients (29%) had appropriate management Finally, we designated a number of ‘sepsis assistants’ throughout
with antibiotics, intravenous fluids +/- oxygen commenced within 1 the general wards and ED to ensure that education regarding the
hour. Only 10 out of 55 patients (18%) had lactate measured. 18 management of sepsis was reinforced on a day-to-day basis, and
(33%) had blood cultures taken and of this group 14 (78%) were that the momentum of our project was sustained. These ‘assistants’
taken prior to antibiotic administration. 15 out of 55 patients (27%) were able to aid staff and advise on appropriate initiation and
had urine output monitoring via either an indwelling catheter or escalation of treatment, finding equipment and requesting
designated fluid input/output chart. After initial assessment by appropriate investigations.
nursing staff, the mean waiting time to clinician review was 47
minutes (range 0-270). One patient, who did not fit criteria for As noted previously, sustainability of such projects is a difficult
severe sepsis at initial assessment, died whilst in hospital (2%). challenge, often due to the high turn around of staff, especially
junior doctors who consistently rotate through different jobs in
Overall, the numbers of patients receiving the equivalent of a sepsis different hospitals.[18-19] We were especially keen to ensure that
bundle were as follows: improvements we made in our hospital were sustainable in the long
term. We therefore recruited junior doctors to the sepsis-
Six parts: 2 (4%) management quality improvement team, who we knew would be
working in the hospital for the next two years. This was to ensure
Five parts: 6 (11%) that the momentum of the project was sustained, even once some
members of the team moved on to different jobs. Recruitment of
Four parts: 11 (20%) future members of the team will follow a similar practice to ensure
that progress is continued.
Three parts: 11 (20%)

Strategy
Two parts: 13 (24%)

PDSA cycle 1: Meetings were held by the sepsis-management

One part: 10 (18%)
quality improvement team to review national and international
sepsis guidelines and evaluate how they could be implemented
Zero parts: 2 (4%)
within our hospital. A sepsis recognition and management pathway
was then developed. Our aim was that this pathway, based on the
Design Sepsis Six,[5] could be used to prompt the consideration of sepsis
in unwell patients and to guide the user through the diagnostic and
When considering the underlying causes of the problem, it became therapeutic steps required in the management of the septic patient
obvious that a multi-faceted set of interventions were necessary to (intravenous fluids, blood cultures, antibiotics, lactate, oxygen,
improve the management of sepsis in our hospital. Firstly, since monitor urine output).
there was no readily available and accessible sepsis resuscitation
bundle in place, we introduced a Sepsis Six resuscitation bundle PDSA cycle 2: To raise awareness of sepsis diagnostic criteria and
algorithm which was reproduced in poster format and displayed in the Sepsis Six pathway, we designed sepsis recognition and
relevant areas of the hospital such as the ED, general ward care management algorithm posters for display in the ED and all ward-
stations and doctors’ offices. They were intended to act as a visual based doctors’ offices and nursing care stations. A first draft was
reminder to staff to implement the six appropriate diagnostic and displayed in the ED and received positive feedback from staff
therapeutic steps of the algorithm, ideally within one hour of initial detailing that it was easy to understand and clearly highlighted the
assessment. Sepsis Six resuscitation bundle. The design was bold and colourful
with an easy-to-read font. After minor layout adjustments, the poster
Secondly, we set out to engage key stakeholders to improve was distributed to the wards and received promising feedback from
awareness of the implications of poor management of sepsis and stakeholders.
the strategies we could employ to improve the situation. This was
achieved through a variety of presentations, workshops, and PDSA cycle 3: We held an educational awareness workshop on
informal discussions with both junior and senior medical and sepsis with all ED staff and all hospital junior doctors invited to
nursing staff. These were conducted over a two-week period and attend. 75% of ED staff and 30% of junior doctors attended the
focused on ED and general ward staff. We presented the Sepsis session. The session focused on the early recognition and
Six resuscitation bundle and used data from our baseline management of sepsis and was designed to emphasise the
measurement as a rationale for adopting these modifications to importance of recognising sepsis and the timely initiation of the
practice, thereby attempting to foster a fundamental culture change Sepsis Six bundle to improve patient outcomes. Examples of
from the hospital staff who, up until this point, were not familiar with clinical scenarios were used to give realistic representations of
using resuscitation bundles as tools to improve the management of septic patients and help contextualize background theory into
septic patients. These sessions focused on the recognition, clinical practice. Feedback from the session demonstrated that
investigation, monitoring, and management of septic patients and junior nurses and doctors, in particular, found the workshop
the importance of Sepsis Six implementation in improving patient extremely useful. We therefore repeated the workshop at one of the
outcomes and reducing mortality. weekly junior doctor teaching sessions. This was attended by just

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over 65% of junior doctors. We also held workshops in each of the 3 months post baseline measurement: A total of 71 patients (34
general wards, although only 30% of nurses were able to attend males, 37 females) were included in the data collection. 22 patients
due to clinical duties. We therefore designated a number of ‘sepsis met the criteria for severe sepsis. 37 out of 71 patients (52%) had
assistants’ throughout the general wards and the ED to ensure that appropriate management with antibiotics, intravenous fluids +/-
sepsis education could be continued and reinforced on a day-to-day oxygen commenced within 1 hour. Only 7 out of 71 patients (10%)
basis in a more informal environment. had lactate measured. 37 (52%) had blood cultures taken and of
this group all 37 (100%) were taken prior to antibiotic
PDSA cycle 4: Three months following implementation of these administration. 26 out of 71 patients (37%) had urine output
interventions, we conducted a re-audit. Whilst the results were monitoring via either an indwelling catheter or designated fluid
promising, further improvements could still be made. We noted that input/output chart. After initial assessment by nursing staff, the
the vast majority of patients with sepsis presented to the ED, with mean waiting time to clinician review was 48 minutes (range 0-345).
the number of ward-based patients that become septic 9 out of 71 patients (13%) died whilst in hospital, with 5 out of these
comparatively low. We therefore focussed our next set of 9 patients fitting criteria for severe sepsis at initial assessment.
interventions in the ED and sought feedback from ED staff as to
how to improve implementation of the Sepsis Six bundle. Nursing Overall, the numbers of patients receiving the equivalent of a sepsis
staff commented how they would often forget to take lactate and bundle were as follows:
blood cultures from patients who whilst tachypnoeic and
tachycardic, were afebrile during the initial assessments. We Six parts: 6 (8%)
therefore tied a laminated photo of a set of blood cultures, a lactate
tube, nasal prongs, a 500ml bag of normal saline, a catheter, and Five parts: 15 (21%)
vial of antibiotic on each phlebotomy trolley in the department.
Feedback from the nurses was extremely positive, remarking that Four parts: 14 (20%)
this photo reminded them to draw the relevant blood samples and
consider escalating management of possibly septic patients by Three parts: 17 (24%)
triaging them higher for a more urgent clinician review.
Two parts: 13 (18%)
PDSA cycle 5: We noted that there was no change in mean waiting
time to clinician review from initial nursing assessment. ED nursing One part: 6 (8%)
staff reported that even if patients were tachypnoeic, tachycardic,
and febrile, and therefore categorised as a higher triage priority, Zero parts: 0 (0%)
due to staff shortages in the ED, there were still delays in clinician
reviews. This was highlighted as a critical incident, and brought up 6 months post baseline measurement: A total of 40 patients (23
in a series of departmental meetings. As a consequence, another males, 17 females) were included in the data collection. 17 patients
full-time consultant is being recruited to the ED, to help improve met the criteria for severe sepsis. 25 out of 40 patients (63%) had
timely reviews of all patients, including those who may be septic. appropriate management with antibiotics, intravenous fluids +/-
oxygen commenced within 1 hour. Only 10 out of 40 patients (25%)
PDSA cycle 6: Following another three months, a re-audit had lactate measured. 25 (63%) had blood cultures taken and of
demonstrated further significant improvements in the this group 24 (96%) were taken prior to antibiotic administration. 17
implementation of the Sepsis Six bundle. These results are due to out of 40 patients (43%) had urine output monitoring via either an
be presented at a hospital managers meeting, to gain formal indwelling catheter or designated fluid input/output chart. After initial
approval for the integration of the Sepsis Six bundle into hospital assessment by nursing staff, the mean waiting time to clinician
guidelines. These will be placed on the trust intranet and be readily review was 44 minutes (range 0-205). 4 out of 40 patients (10%)
accessible to any healthcare professional in the hospital. died whilst in hospital, with all 4 patients fitting criteria for severe
Furthermore, we are extending the sepsis management quality sepsis at initial assessment.
improvement team to incorporate a wider range of stakeholders
including the antimicrobial pharmacist, the resident microbiologist Overall, the numbers of patients receiving the equivalent of a sepsis
and the ED clinical nurse manager. We are also working on bundle were as follows:
introducing ‘sepsis boxes’ in the general wards to centralise the
equipment needed to adequately manage septic patients. This has Six parts: 5 (13%)
previously been shown to improve implementation of the Sepsis Six
bundle.[18] Finally, we are incorporating sepsis management Five parts: 10 (25%)
education sessions into the induction programme for newly
appointed doctors. Further re-audit will be completed in three Four parts: 11 (28%)
months time to re-evaluate our practice, following which the sepsis
management quality improvement team will meet once more to Three parts: 7 (18%)
discuss the future direction of the project.
Two parts: 4 (10%)
Results

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One part: 1 (4%) group that have not previously been considered.

Zero parts: 2 (8%) Another key limitation of this study is that it does not examine the
costs associated with managing sepsis according to the Sepsis Six
Overall, we saw a significant improvement in the implementation of bundle. Nor does it explore any savings that may occur by reducing
the Sepsis Six bundle, with 66% of patients receiving 4-6 parts the incidence of septic patients becoming more unwell. Whilst this
compared to 35% at baseline. However these improvements did not would be difficult to incorporate into the study, it will be discussed at
translate to better patient outcomes, and indeed we noted future meetings.
worsening in-hospital mortality since the start of our project, from
2% to 10%. This may reflect the fact that our re-audits were Finally, the lack of outcome measures in our data analysis is
completed during the winter when patients are generally more another limitation of this study. For example, we did not analyse
unwell. To further evaluate these trends we will need to compare ICU admission rates, use of vasoactive drugs, appropriate antibiotic
future data sets from comparable times of the year. Furthermore, stewardship, length of stay in hospital, or post-discharge morbidity
there was no significant decrease in time taken from initial nursing and mortality. By increasing the stakeholders involved in the
assessment to clinician review, and this may be partly explained by project, we hope to increase the content of the data we can collect
the fact that the new ED consultant post has not been filled as yet. which will provide us with more information to guide future practice.

See supplementary file: ds6046.doc - “Sepsis Six Data”

Conclusion

Lessons and limitations As noted previously, sepsis is a serious condition with high
mortality. The international community has been vigorous in
We have learnt a number of important lessons during this project, promoting internationally recognised pathways to improve the
none more so than the importance of a multi-faceted approach to management of septic patients in an attempt to improve their
tackling an inherently complex problem. Certainly there is no magic outcomes. However, translating recommendations into practice is a
answer to improving the management of sepsis in busy clinical challenging and complex task that requires a multi-faceted
environments. It requires a co-ordinated effort from a dedicated approach with sustained engagement from local stakeholders. We
team to instigate changes, and even then, progress may prove to have implemented a number of simple, low-cost interventions that
be slow. However, small changes can lead to improvements in have improved the implementation of the Sepsis Six resuscitation
practice, and this project highlights the need for healthcare bundle in our hospital. However, this has not translated into better
professionals to be continually motivated to achieve such patient outcomes in terms of mortality. Whilst this quality
improvements. improvement project has helped instigate a fundamental culture
change among local healthcare professionals, there is more work to
Another key lesson is that a singular approach does not necessarily be done to improve the management of sepsis at our hospital. The
work in different situations or departments, and therefore flexibility key challenge remains to ensure that momentum of this project
is vital to achieving success. For example, we broached the idea of continues and forms a platform for sustainable clinical improvement
introducing a ‘sepsis box’ or ‘sepsis trolley’ into the ED. These have in the long term.
been successfully trialled in previous quality improvement
projects.[18-20] However, due to limited space, this idea was
References
thought to be impractical by department managers and we modified
our intervention accordingly. The original concept however, may still
1. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis
help in managing septic patients on the general wards, and we are
campaign: International guidelines for the management of
therefore implementing this idea during the next cycle of
severe sepsis and septic shock: 2012. Crit Care Med
interventions.
2013;41(2):580-637
2. Daniels, R. Surviving the first hours in sepsis: getting the
Admittedly there are a number of limitations to this project. Firstly
basics right (an intensivist's perspective). J Antimicrob
this study was conducted over a six-month period, and as such its
Chemother. 2011;66(suppl 2):ii11-23
sustainability is, as yet, untested. Therefore, the key challenge is to
3. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed
ensure the sustainability of this project for the future. To accomplish
therapy in the treatment of severe sepsis and septic shock.
this, we needed to extend the number of stakeholders involved in
N Engl J Med 2001;345:1368–77.
the team. Initially this was a junior doctor-led initiative, as it was felt
4. Baxter S, Hutchings S, & Barnes T. Timeliness of antibiotic
that to kick-start the project it would be better to have a smaller but
administration in septic shock. In: Colvin JR, & Pedan CJ.
highly motivated and dedicated team. Now the project is up and
[3rd ed.] Raising the standard: a compendium of audit
running and there is greater awareness across the hospital, we
recipes for continuous quality improvement in anaesthesia.
hope that with more of a multidisciplinary approach the
London: Royal College of anaesthetists; 2012. Available
improvements that we have made so far can be consolidated and
from
further improved upon, and that these may in turn lead to better
www.rcoa.ac.uk/system/files/CSQ-ARB2012-PRELIM.pdf
outcomes for our patients. Additionally, involvement of the other
5. Robson WP, & Daniels R. The Sepsis Six: helping patients
members of the multidisciplinary team may bring new ideas to the

Page 5 of 6

© 2015, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
 to survive sepsis. Br J Nurs 2008;17:16-21
Declaration of interests
6. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G,
Carcillo J, & Pinsky MR. Epidemiology of severe sepsis in
Nothing to declare
the United States: analysis of incidence, outcome, and
associated costs of care. Crit Care Med 2001;29:1303-10
7. Gaieski DF, Edwards JM, Kallan MJ, & Carr BG. Acknowledgements
Benchmarking the incidence and mortality of severe sepsis
in the United States. Crit Care Med 2013;41:1167-74 Elaine Clark
8. Jawad I, Luksic I, & Rafnsson SB. Assessing available
information on the burden of sepsis: global estimates of Rachel Mills
incidence, prevalence and mortality. J Glob Health
2012;2(1):010404 Raewyn Brown
9. Australasian Resuscitation in Sepsis Evaluation (ARISE)
Investigators and the Australian and New Zealand Intensive
Ethical approval
Care Society (ANZICS) Adult Patient Database (APD)
Management Committee. The outcome of patients with
Local policy did not require ethical approval to be sought for this
sepsis and septic shock presenting to emergency
project
departments in Australia and New Zealand. Crit Care
Resusc 2007;9:8-18.
10. Peake SL, Delaney A, Bailey M, et al. Goal-directed
resuscitation for patients with early septic shock. N Engl J
Med 2014;371:1496-1506
11. Quenot JP, Binquet C, Kara F, et al. The epidemiology of
septic shock in French intensive care units: the prospective
multicentre cohort EPISS study. Crit Care 2013;17:R65
12. Yealy DM, Kellum JA, Huang DT, et al. A randomized trial
of protocol-based care for early septic shock. N Engl J Med
2014;370:1683-1693
13. Kumar A, Roberts D, Wood KE, et al. Duration of
hypotension before initiation of effective antimicrobial
therapy is the critical determinant of survival in human septic
shock. Critical Care Medicine 2006; 34:1589-1596.
14. Marwick CA, Guthrie B, Pringle JE, et al. A Multifaceted
intervention to improve sepsis management in general
hospital wards with evaluation using segmented regression
of interrupted time series. British Medical Journal 2013;0:1-8
15. Levy MM, Dellinger RP, Townsend SR, et al. The Surviving
Sepsis Campaign: results of an international guideline-
based performance improvement programme targeting
severe sepsis. Crit Care Med 2010;38:1–8
16. Robson W, Nutbeam T, & Daniels R. Sepsis- a need for pre-
hospital intervention? Emerg Med J 2009;26:535-5388.
17. Daniels R, Nutbeam T, McNamara G, Galvin C. The sepsis
six and the severe sepsis resuscitation bundle: a
prospective observational cohort study. EMJ
2011;28(6):507-12
18. Kafle S, & Nath N. Improving management of severe sepsis
and uptake of sepsis resuscitation bundle in an acute
setting. BMJ Qual Improv Report 2014;u204152.w1807 doi:
10.1136/bmjquality.u204152.w1807
19. Adcroft L. Improving sepsis management in the acute
admissions unit. BMJ Qual Improv Report
2014;u204974.w2091 doi:
10.1136/bmjquality.u204974.w2091
20. McGregor C. Improving time to antibiotics and
implementing the “Sepsis 6”. BMJ Qual Improv Report
2014;u202548.w1443 doi:
10.1136/bmjquality.u202548.w1443

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