Tiffany M.

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

Purpose for Existence?

Today
1,800,000 1,600,000 1,400,000

Future
600,000 500,000

>750,000 cases of severe sepsis/year in the US*

1,200,000 1,000,000

400,000

300,000 800,000 600,000 400,000 200,000 200,000

Incidence projected to increase by 1.5% per year

2001 2025 2050

100,000

Year Angus DC. Crit Care Med. 2001;29(7):1303-1310.

Total US Population/1,000

Severe Sepsis Cases US Population

Sepsis Cases

Comparison With Other Major Diseases

Incidence of Severe Sepsis
300

Mortality of Severe Sepsis

250,000 200,000
Deaths/Year

Cases/100,000

250 200 150 100 50 0 AIDS* Colon Breast CHF Severe Cancer Sepsis

150,000 100,000 50,000 0

AIDS* Breast AMI Cancer Severe Sepsis

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.

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

102 million National ED visits in 1999
17% (17.5 million) immediately life threatening1

57 California Emergency Departments (1990-1999)2

50% (387,616) Severe Sepsis Cases Initially Present ED
70

Visits / ED (% Change)

50 30 10 -10 Visits/ED

Total visits/ED Critical Care Urgent Nonurgent

P < 0.001 for all groups

1. 2. 3. National Center for Health Statistics; 2001 Ann Emerg Med 2002;39:389-96 Curr Opin Crit Care Dec.2002

Surviving Sepsis Campaign

A global program to: Reduce mortality rates Improve standards of care Secure adequate funding

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

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

Sponsoring Organizations
American Association of Critical-Care Nurses American College of Chest Physicians 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

American College of Emergency Physicians

American Thoracic Society Australian and New Zealand Intensive Care Society Episepsis

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

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.

Clinical Inertia: Low Levels of Compliance at Research Centers

ACE inhibitor use (%)

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

SAVE site 20 15 10 5 0

Non-SAVE site

ACE inhibitor use (%)

20 15 10 5 0 Pre-SAVE Post-SAVE

Majumdar SR, et al. Am J Med 2002;113:140-5

Clinical Inertia: Low Levels of Compliance at Research Centers

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.

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

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

Rhode Island Hospital EGDT Data

Time from Entering ED to Receiving Antibiotics Time from Entering ED to Catheter Insertion

Time from Entering ED to Transfer to MICU

Reduced by 42%
200

Reduced by 60%
Reduced by 51%
350
500

185
180

300

450

160 140 120 100 80 60 40

148
250

400

350

11 106 90 95
150 200

300

250

200

100

150

100

50

20

50

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

THANK YOU!!