Original article
A multicenter, prospective evaluation of quality of care and mortality in Japan based on the Surviving Sepsis Campaign guidelines

https://doi.org/10.1016/j.jiac.2013.09.003Get rights and content

Abstract

To elucidate the standard Surviving Sepsis Campaign (SSC) guidelines-based quality of care and mortality related to severe sepsis in Japan, we conducted a multicenter, prospective, observational study using a new web-based database between June 1, 2010, and December 31, 2011. A total of 1104 patients with severe sepsis were enrolled from 39 Japanese emergency and critical care centers. All-cause hospital mortality was 29.3% in patients with severe sepsis and 40.7% in patients with septic shock. Pulmonary, renal, hepatic, and hematological dysfunctions were associated with significantly higher mortality, and hematological dysfunction, especially coagulopathy, was associated with the highest odds ratio for mortality. Compliance with severe sepsis bundles in our study was generally low compared with that in a previous international sepsis registry study, and glycemic control was associated with lowest odds ratio for mortality. Despite higher complication rates of multiple organ dysfunction syndrome and low compliance with severe sepsis bundles on the whole, mortality in our study was similar to that in the international sepsis registry study. From these results, we concluded that our prospective multicenter study was successful in evaluating SSC guidelines-based standard quality of care and mortality related to severe sepsis in Japan. Although mortality in Japan was equivalent to that reported worldwide in the above-mentioned international sepsis registry study, compliance with severe sepsis bundles was low. Thus, there is scope for improvement in the initial treatment of severe sepsis and septic shock in Japanese emergency and critical care centers.

Introduction

Sepsis is prevalent among hospitalized patients worldwide. In fact, severe sepsis and septic shock are the major cause of admission and mortality in intensive care units (ICUs). However, mortality rates vary among countries and regions, depending on medical resources available. Japan has government health insurance and emergency medical systems but is also at the forefront of countries with an aging population; therefore, morbidity and mortality statistics may not be comparable with those of other countries in which sepsis epidemiology has been demonstrated on a multicenter basis. A Japanese retrospective study examined incidence in a single emergency room and found that 4.5% of patients met the criteria for sepsis, 2.5% for severe sepsis, and 2.1% for septic shock [1]. In another retrospective study using Japan Nosocomial Infection Surveillances (JANIS), the incidence of sepsis was reported to be 2.1% among patients admitted to ICUs [2]; however, this value is very low compared with that observed in previous multicenter cohort studies, and it does not appear to be generalizable to nationwide ICUs accepting patients from emergency rooms, including our facilities. Prospective, multicenter-based, epidemiological studies of sepsis should have been conducted in Japan in order to advance the development of institutional and governmental strategies aimed at tackling this critical illness.

In response to an increasing demand for a systematic approach to sepsis, the Society of Critical Care Medicine, the European Society of Intensive Care Medicine, and the International Sepsis Forum launched the Surviving Sepsis Campaign (SSC) in the hope of decreasing mortality [3]. Updated versions of guidelines developed by SSC were published in 2008 and 2013, in which the Japanese Association for Acute Medicine (JAAM) evolved as an organization comprising various professional societies. In accordance with SSC, a set of interventions, referred to as severe sepsis bundles, was introduced to change bedside behavior, and chart review database software was freely distributed in several languages to evaluate the quality of care in each hospital and to register patients worldwide [4]. However, because this software was not available in a Japanese version, almost no Japanese patients were included in the international sepsis registry; therefore, quality of care standards and mortality associated with severe sepsis and septic shock remain poorly clarified in Japan.

The present study aimed to elucidate the epidemiology of severe sepsis and examine the SSC guidelines-based standard quality of care related to severe sepsis in Japan. To the best of our knowledge, this is the first report examining severe sepsis in Japan on the basis of a multicenter observational study.

Section snippets

Patients and methods

This multicenter, prospective, observational study was registered at the University Hospital Medical Information Network Clinical Trial Registry (UMIN-CTR ID: UMIN000008195). Patients fulfilling the original and revised definition of severe sepsis or septic shock according to the American College of Chest Physicians/Society of Critical Care Medicine consensus conference were registered [5], [6].

JAAM established a sepsis registry (SR) interim committee in 2007. The committee developed a

Results

Using the JAAM SR database, 1104 patients with severe sepsis from 39 hospitals were registered between June 1, 2010, and December 31, 2011 (information of participated sites is shown in a supplementary table). Overall sepsis-related hospital mortality was 29.3%. Patients with septic shock had a significantly higher mortality (n = 484, 40.7%) than those without (n = 620, 20.3%, P < 0.0005). When our results were compared with the 30.8% mortality rate of 509 patients included in the final quarter

Discussion

Between June 1, 2010, and December 31, 2011, 1104 patients with severe sepsis and septic shock from 39 Japanese hospitals were registered using a new web-based database equivalent to the SSC chart review database. Compliance with severe sepsis bundles was generally low in our study compared with that in the international sepsis registry study, and glycemic control was associated with the lowest OR for mortality. Despite higher complication rates of MODS and low compliance with severe sepsis

Acknowledgments

This study was funded and supported by the Japanese Association for Acute Medicine (JAAM), and in part by a Health Labor Sciences Research Grant (H22-Shinko-Ippan-013). Part of the study was presented at the 39th and 40th JAAM annual conferences and at the 2012 American Thoracic Society International Conference. We thank Dr. Takayuki Abe (Center for Clinical Research, School of Medicine, Keio University) for help with the statistical analyses, and Mr. Kiyohiko Sato (Japanese Association for

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