Why do you think your paper is highly cited?

"Severe sepsis (infection-induced organ failure) usually develops as a consequence of infection in general medical and surgical wards, and is often initially managed by the non-intensive care medical team, although the patient’s usual destination is an intensive care unit (ICU)."

The paper provided the only worldwide evidence-base for the international guideline for management of severe sepsis. The paper described a regional prospective observational study in 2005 comparing compliance with the international Surviving Sepsis Campaign (SSC) guideline for management of severe sepsis with non-compliance. The non-compliant group had a twofold increase in hospital death rates.

  Does it describe a new discovery, methodology, or synthesis of knowledge?

To date, this is the first study to demonstrate the impact of compliance with an adaptation of the SSC 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis. Our findings add to the limited literature supporting the association between the uses of a group of evidence-based interventions, executed together, and improved outcomes.

  Would you summarize the significance of your paper in layman’s terms?

We conducted a prospective observational study on 101 consecutive adult patients with severe sepsis or septic shock on medical or surgical wards, or in accident and emergency areas at two acute National Health Service Trust teaching hospitals in England. The main outcome measures were: the rate of compliance with 6-hour and 24-hour sepsis care bundles adapted from the Surviving Sepsis Campaign guidelines on patients’ clinical care, and the difference in hospital mortality between the compliant and the non-compliant groups.

Compliance with the ventilator care bundle affects the rate of ventilator-associated pneumonia. It was not known, however, whether compliance with sepsis care bundles has an impact on outcome. The aims of the present study were to determine the rate of compliance with 6-hour and 24-hour sepsis bundles and to determine the impact of the compliance on hospital mortality in patients with severe sepsis or septic shock.

Non-compliance with the 6-hour sepsis bundle was associated with a more than twofold increase in hospital mortality. Non-compliance with the 24-hour sepsis bundle resulted in a 76% increase in risk for hospital death. All medical staff should practice these relatively simple, easy and cheap bundles within a strict timeframe to improve survival rates in patients with severe sepsis and septic shock.

The difference in compliance with guidelines for management of acute coronary syndrome (ACS) demonstrated significant differences in mortality, length of hospital stay, and National Health Service (NHS) costs. Prevalence of severe sepsis is similar to that of ACS and has poorer outcomes, whereas fewer medical workers are aware of SSC guidelines.

  Where do you see your research leading in the future?

As an international leader in the studies of sepsis and acute respiratory distress syndrome (ARDS).

  Are there any social or political implications for your research?

Yes. Infection in hospitals continues to be a major concern for health boards and trusts throughout the UK and the rest of the world. Severe sepsis (infection-induced organ failure) usually develops as a consequence of infection in general medical and surgical wards, and is often initially managed by the non-intensive care medical team, although the patient’s usual destination is an intensive care unit (ICU).

In addition, the results suggest that if the association between use of process, indicated by compliance with evidence-based treatments, and improved mortality holds true, using process measures rather than the more resource-intensive outcome measures may be the better way for the NHS healthcare system to monitor performance and for the NHS hospitals to compare performance.

Process measures based on the results of randomized controlled trials are able to detect relevant differences between hospitals that would not be identified by comparing hospital specific mortality, which is an insensitive indicator of the quality of care. Finally, if the number needed to treat (NNT) is confirmed by future studies, sepsis care bundles will become the most powerful interventions in clinical care.

Fang Gao Smith, M.B., B.S., M.D., M.Phil., F.R.C.A.
Professor and Head
Academic Department of Anaesthesia,
Critical Care and Pain
Heart of England NHS Foundation Trust
and University of Warwick