RESEARCH – February 2017

Management of severe sepsis and septic shock in Estonia: a summary of clinical audit

Authors: Raido Paasma, Joel Starkopf

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Background and aims. In 2010, national guidelines for management of severe sepsis and septic shock were issued in Estonia. The present clinical audit was conducted in 2015 to assess adherence to these guidelines at 12 Estonian acute care hospitals.

Methods. The cases for the audit were identified through the database of the Estonian Health Insurance Fund. The data of the patients treated in the period from 1.07.2013 to 30.06.2014 were searched to obtain a list of ICD-10 diagnoses, which was believed to cover most of possible infectious diseases by the auditors. From this cohort, 271 cases were randomly selected for detailed examination so that the weight of different hospitals was well balanced in the study group. Thereafter, the respective case reports, including all relevant documentation, were retrieved from the participating hospitals. A detailed examination of the 271 patients identified 141 cases where severe sepsis or septic shock was present already at admission. These cases were further analysed in depth.

Results. The main causes of sepsis were respiratory, urinary and abdominal infections. Of the patients 52% were aged over 70 years. Only 33% of cases there were assessed as critical conditions at admission (red or yellow triage category). Blood cultures were obtained within the first hour in 6 % of patients and within 4 hours in 48%. In 21% of the patients, blood cultures were not taken. Antibacterial treatment was started within the first hour in 6% of the cases and within 4 hours in 66%. Serum lactate at admission was measured in 53% of the patients. All patients received intravenous fluid therapy. The amount of fluids administered in emergency department was below 500 ml in 21%, 500 to 1000 ml in 30%, and 1000 to 1500 in 18% of the cases. Hospital mortality for all 271 patients was 42.4% and it was 59.2% at 6 months.

Conclusions. Adherence to the national and international guidelines of severe sepsis and septic shock management can be improved in Estonia. Obtaining of blood cultures and treatment with antibiotics are often delayed. Hospitals are encouraged to review standard operating procedures in emergency departments and to facilitate the training of the personnel. Necessary equipment for blood cultures, lactate measurement and stock of antibiotics for empiric therapy have to be immediately accessible for emergency admissions.