Use of drotrecogin alfa (activated) for severe sepsis in New Jersey acute care hospitals

Disseminating clinical trial results in critical care

Efficient translation of clinical evidence into clinical practice is among the greatest challenges to evidence-based medicine. The field of knowledge transfer seeks to understand the barriers to evidence uptake and develop new methods to effectively disseminate clinical trial results. Traditionally, barriers to evidence-based practice are categorized into those of knowledge, attitudes, and behavior. Efforts to improve translation of evidence into practice should uncover and address each of these barriers and be customized to the specific intervention. To help aid knowledge transfer, interventions in clinical trials should be as simple as possible and answer questions important to actual caregivers. Potentially innovative methods for improving knowledge transfer include expanding community research networks, clinical registries to monitor evidence uptake, and community-based participatory research. It is essential that investigators conducting clinical trials prioritize knowledge transfer to ensure that new therapies in critical care are actually reaching the critically ill.

Design, conduct, analysis and reporting of a multi-national placebo-controlled trial of activated protein C for persistent septic shock

The role of drotrecogin alfa (activated) (DAA) in severe sepsis remains controversial and clinicians are unsure whether or not to treat their patients with DAA. In response to a request from the European Medicines Agency, Eli Lilly will sponsor a new placebo-controlled trial and history suggests the results will be subject to great scrutiny. An academic steering committee will oversee the conduct of the study and will write the study manuscripts. The steering committee intends that the study will be conducted with the maximum possible transparency; this includes publication of the study protocol and a memorandum of understanding which delineates the role of the sponsor. The trial has the potential to provide clinicians with valuable data but patients will only benefit if clinicians have confidence in the conduct, analysis and reporting of the trial. This special article describes the process by which the trial was developed, major decisions regarding trial design, and plans for independent analysis, interpretation and reporting of the data.

Factors influencing variability in compliance rates and clinical outcomes among three different severe sepsis bundles

BACKGROUND

While 3 different quality indicator bundles are either approved (Voluntary Hospitals of America [VHA], Institute for Healthcare Improvement [IHI]) or proposed (Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) to rate clinical practices in treatment of severe sepsis, it is suspected that differences in the quality indicators among these bundles may lead to discrepant benchmarking data.

OBJECTIVE

To compare bundle compliance and patient factors associated with it among the IHI, JCAHO, and VHA severe sepsis bundles and explore possible reasons for any observed variability.

METHODS

Using a retrospective, noninterventional design, we evaluated 50 adults (APACHE II score 25 +/- 6, organ failure 2 +/- 1, and shock 52%) with severe sepsis who were admitted consecutively to an intensive care unit at a 450 bed university-affiliated hospital.

RESULTS

Few patients met 100% (IHI 6%, JCAHO 0%, VHA 6%) or 75% or greater (IHI 22%, JCAHO 6%, VHA 22%) of the quality indicators in each bundle. The number of patients who met 50% or more of the quality indicators varied significantly between JCAHO (28%) and both IHI (66%; p < 0.001) and VHA (60%; p < 0.001), but not between IHI and VHA (p = 0.53). Compliance with 50% or more of the quality indicators was more likely to occur when patients had shock (IHI, JCAHO, VHA), an APACHE II score greater than or equal to 25 (VHA), 2 or more organ failures (VHA), or survived hospitalization (IHI). We identified a number of factors that may help explain these differences.

CONCLUSIONS

Differences among the IHI, JCAHO, and VHA severe sepsis bundles lead to variability in bundle compliance rates and the patient factors associated with the variability and may lead to confusion when benchmarking practices among institutions. Future efforts should focus on developing a single valid and reliable bundle that allows providers to improve the quality of sepsis care.