Success With Adherence to Sepsis Guidelines
In the WFPICCS endeavor, resuscitation bundle compliance ranged from 24–52 % while management bundle compliance range from 10–25 % across centers. Similarly, in the Surviving Sepsis Campaign, compliance with the entire management bundle started at 18 % and increased to approximately 36 % at the end of two years. In children in areas that were adequately resourced, the news is no better. Indeed, there was 19 % adherence to the resuscitation bundle at Boston Children's Hospital with significant delays in intravenous fluid administration and inotrope administration. In Utah and Texas, while intense efforts achieved an increase in compliance, this was still suboptimal, with the highest compliance - 80 % - for intravenous fluids, antibiotic administration and lactate evaluation. Delayed recognition and delayed intravenous fluids and inotropes were also reported, along with a 36 % adherence to pre-PICU care, in a follow-up assessment of treatment guidelines for meningococcemia in the UK. In India, a survey reported 12 % adherence to the ACCM guidelines among physicians; this low adherence was attributed mostly to lack of skills and knowledge. Adherence to guidelines has also been poor in other parts of the world, including in Africa, where less than 50 % of the Surviving Sepsis Campaign guidelines were implemented; the predominant reasons were resource-limitations and lack of education. In Asia (China, Hong Kong, India, Malaysia, Singapore and South Korea) adherence to Surviving Sepsis Campaign guidelines ranged from 5–15 %. Low adherence to sepsis guidelines was also found in Germany, where there was a perception reality gap; physicians perceived that adherence to low tidal volume ventilation was 80 %, whereas in reality it was 2.6–17 %. Similarly, the perception of adherence to glycemic control was 66 % whereas the reality was 6 %. Suboptimal management related to lack of adherence to sepsis guidelines has also been reported in children in France, England, and Australia. In most cases, suboptimal management resulted from underestimation of disease severity, physician delay in administrating antibiotics or fluids, insufficient fluid administration and inadequate inotropic support.