sepsis-powerpoint-slide-presentation---the-guidelines_-implementation-for-the-future.ppt

Tiffany M. Osborn, MD
University of Virginia
ACEP Chair Critical Care
Section
ACEP Representative
Surviving Sepsis Campaign

Angus DC. Crit Care Med. 2001;29(7):1303-1310.
Today
>750,000
cases of severe
sepsis/year
in the US*
Future
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
1,800,000
2001 2025 2050
Year
100,000
200,000
300,000
400,000
500,000
600,000
Severe Sepsis Cases
US Population
Sepsis
Cases
Total
US
Population/1,000
Incidence projected to
increase by 1.5% per year
Purpose for Existence?

Comparison With
Other Major Diseases
†National Center for Health Statistics, 2001. §American Cancer Society, 2001. *American Heart Association.
2000. ‡Angus DC et al. Crit Care Med. 2001;29(7):1303-1310.
AIDS* Colon Breast
Cancer§
CHF† Severe
Sepsis‡
Cases/100,000
0
50
100
150
200
250
300
Incidence of Severe Sepsis Mortality of Severe Sepsis
0
50,000
100,000
150,000
200,000
250,000
Deaths/Year
AIDS* Severe
Sepsis‡
AMI†
Breast
Cancer§

Comparable Global
Epidemiology
• 95 cases per 100,000
– 2 week surveillance
– 206 French ICUs
• 95 cases per 100,000
– 3 month survey
– 23 Australian/New
Zealand ICUs
• 51 cases per 100,000
– England, Wales and
Northern Ireland.

Emergency Department Critical
Care Volume Increases
1. National Center for Health Statistics;
2001
2. Ann Emerg Med 2002;39:389-96
3. Curr Opin Crit Care Dec.2002
-10
10
30
50
70
Visits
/
ED
(%
Change)
Visits/ED
Total visits/ED
Critical Care
Urgent
Nonurgent
P < 0.001 for all groups
• 102 million National ED visits in 1999
•17% (17.5 million) “immediately life threatening”1
• 57 California Emergency Departments (1990-1999)2
• 50% (387,616) Severe Sepsis Cases Initially Present ED

Surviving Sepsis Campaign
A global program to:
• Reduce mortality rates
•Improve standards of care
•Secure adequate funding

Phase 1 Barcelona declaration
Phase 2 Evidence based guidelines
Phase 3 Implementation and education
Surviving Sepsis

Sponsoring Organizations
• American Association of
Critical-Care Nurses
• American College of Chest
Physicians
• American College of
Emergency Physicians
• American Thoracic
Society
• Australian and New
Zealand Intensive Care
Society
• Episepsis
• European Society of
Clinical Microbiology and
Infectious Diseases
• European Society of
Intensive Care Medicine
• European Respiratory
Society
• German Sepsis Society
• Indian Society of Critical
Care Medicine
• International Sepsis
Forum
• Society of Critical Care
Medicine
• Surgical Infection Society

Clinical Inertia: Tales from
the Past
• National Registry MI 2
– 84,663 MI patients
eligible for reperfusion
– 24% got NO form of
reperfusion
• 10 years after therapy
shown to save lives
– 1 of 4 not treated
– 10,000 lives lost/year
– Estimated 100,000 lives
lost due to failure to treat
Barron, HV. Circulation. 1998;97:1150-1156.

0
5
10
15
20
ACE
inhibitor
use
(%)
SAVE site Non-SAVE site
0
5
10
15
20
ACE
inhibitor
use
(%)
Pre-SAVE Post-SAVE
• Cross-sectional analysis of
25,886 patients enrolled in GUSTO-1
• 659 hospitals, 22 SAVE sites
• SAVE: Survival and
Ventricular Enlargement, ACE
(angiotensin-converting enzyme)
benefits post-MI patients with LV
dysfunction
Clinical Inertia: Low Levels of
Compliance at Research Centers
Majumdar SR, et al. Am J Med 2002;113:140-5

“If those who generated the evidence
are slow to translate it into practice, it
is unlikely that passive forms of
dissemination can improve the quality
of care. To accelerate adoption of new
evidence, we need to understand
factors other than knowledge and
awareness that influence practice”.
Clinical Inertia: Low Levels of
Compliance at Research Centers
Majumdar SR, et al. Am J Med 2002;113:140-5

Phase 3: Collaboration for
Implementation
• Partner with Institute for
Healthcare Improvement
(IHI) www.IHI.org
• Non-profit organization
– Healthcare improvement
– Quality based initiatives
• Set Quality Benchmarks
– JCAHO
– Medicare
– Medicaid
– 3rd party payers

What is a Bundle?
• Specifically selected
care elements
– From evidence based
guidelines
– Implemented together
provide improved
outcomes compared to
individual elements
alone

SSC Steering Committee:
Global Consensus
13 September 2004
Catania, Sicily
• Steering
Committee Met
• 6 hour bundle
formed
• 24 hour bundle
formed

Gaining Consensus:
Finding Nemo

6 Hour Resuscitation Bundle
• Early Identification
• Early Antibiotics and
Cultures
• Early Goal Directed
Therapy

6 - hour Severe Sepsis/
Septic Shock Bundle
• Early Detection:
– Obtain serum lactate level.
• Early Blood Cx/Antibiotics:
– within 3 hours of
presentation.
• Early EGDT:
• Hypotension (SBP < 90, MAP
< 65) or lactate > 4 mmol/L:
– initial fluid bolus 20-40 ml of
crystalloid (or colloid equivalent)
per kg of body weight.
• Vasopressors:
– Hypotension not
responding to fluid
– Titrate to MAP > 65
mmHg.
• Septic shock or lactate > 4
mmol/L:
– CVP and ScvO2 measured.
– CVP maintained >8 mmHg.
– MAP maintain > 65 mmHg.
• ScvO2<70%with CVP > 8
mmHg, MAP > 65 mmHg:
– PRBCs if hematocrit < 30%.
– Inotropes.

185
148
90
95
106
11
20
40
60
80
100
120
140
160
180
200
50
100
150
200
250
300
350
50
100
150
200
250
300
350
400
450
500
Time from Entering ED
to Transfer to MICU
Reduced by 51%
to Catheter Insertion
Reduced by 60%
to Receiving Antibiotics
Reduced by 42%
Rhode Island Hospital EGDT Data

24 - hour Severe Sepsis
and Septic Shock Bundle
• Glucose control:
– maintained on average <150 mg/dL (8.3 mmol/L)
• Drotrecogin alfa (activated):
– administered in accordance with hospital guidelines
• Steroids:
– for septic shock requiring continued use of vasopressors
for equal to or greater than 6 hours.
• Lung protective strategy:
– Maintain plateau pressures < 30 cm H2O for
mechanically ventilated patients

Phase 3: Collaboration
for Implementation
• Partner with Institute for
Healthcare Improvement
(IHI)
– Develop sepsis
management “change
bundles”
– Provide tools and
systems for
implementation and
improvement
– Enhanced quality
– Improved mechanisms

SSC Educational Tool Kit
• Implementation Sepsis
Bundles
• Web-based and CD rom
• IHI Website (IHI.org)
• Tool Kit
– Educational material
– Process for developing
“Change teams”
– Data collection tools and
descriptions (database)
– Taylor: Culture Specific

The Future: ED and ICU
Interface
• Collaboration:
Emergency Medicine
and Critical Care
– Defining patient care
globally
– Setting standards for
ED/ICU collaborations
– Establishing new format
to change clinical
practice and improve
outcomes
• Providing tools
– JCAHO, Medicare

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