The impact of SSC 2012 on the panning and evaluation of my

hospital's performance

Critical Care Department - Hospital Vall d'HebronBarcelona, June, 10, 2013

Rui MorenoUCINC, Hospital de São José

Centro Hospitalar de Lisboa Central, E.P.E.

DECLARATION OF POTENTIAL (REAL) CONFLICT OF INTEREST

DECLARATION OF POTENTIAL CONFLICT OF INTEREST

• I am not an Anaesthesiologist• I am not and Internist• I am not a surgeon• I am not a GP

DECLARATION OF POTENTIAL CONFLICT OF INTEREST

• I am not an Anaesthesiologist• I am not and Internist• I am not a surgeon• I am not a GP

I AM AN INTENSIVIST!

THE PATIENT WITH SEPSIS NEED TEAMS, NOT TRIBES!

Sepsis = Decomposition, decay

Septic = RottenΣήψις

DEFINITIONS

Bone et al. Chest. 1992;101:1644;

Wheeler and Bernard. N Engl J Med. 1999;340:207.

SepsisSIRSInfection/Trauma

Severe Sepsis

Sepsis with ≥1 sign of organ failure

Cardiovascular (refractory hypotension)

Renal Respiratory

Hepatic Hematologic

CNS Unexplained metabolic

acidosis

Shock

800

1,000

1,200

1,400

1,600

1,800

2001 2025 2050

Year

300

400

500

600

Sep

sis

Cas

es (

x103 )

Tota

l US

Pop

ulat

ion

(mill

ion)

Angus DC, et al. JAMA 2000;284:2762-70.Angus DC, et al. Crit Care Med 2001;29:1303-10.

SEVERE SEPSIS IS INCREASING IN INCIDENCE

Severe Sepsis CasesUS Population

EPIDEMIOLOGY OF SEPSIS IN THE CRITICALLYILL PATIENT

0%

10%

20%

30%

40%

50%

60%

70%

80%

0-1 2-3 4-6 7-10 11-15 16-21

Days in ICU before the study day

Infe

cti

on

rate

N = 6010 1608 1857 1248 1176 742

(EPIC II, 2008)

?

?

INFECTION AND OUTCOME

0,0

5,0

10,0

15,0

20,0

25,0

30,0

35,0

40,0

45,0M

ort

alit

y, %

ICU mortality 13,9 32,2

Hospital mortality 18,7 41,8

No infection Infection

(Moreno et al. 2005 - data from the SAPS 3 study)

0%

25%

50%

75%

100%

% o

f p

atie

nts

0 2 4 6 8 10 12 14 16 18 20 22 24

SOFA score

Survivors Non-survivors

(R. Moreno, 1997)

EPIDEMIOLOGY OF SEPSIS IN THE CRITICALLYILL PATIENT

1 OSF

2 OSF

3 OSF

0

20

40

60

80

100

1 2 3 4 5 6 7

ICU

mor

tali

ty (

%)

Number of days in MOF

ORGAN FAILURE AND MORTALITY IN PATIENTS WITH SEPSISAND ORGAN FAILURE

(data from Moreno et al.)

DECLARATION OF BARCELA2002

Surviving Sepsis Campaign: Timeline

Barcelona Declaration

SSC Guidelines

2010

???Guidelines

And bundles Revision

2005

NEJM editorial

2004

2002

Guidelines Revision

Phase III starts:IHI partnership

2008 2012

Results published15,000 pts20% RRR

2006

2012--

Surviving Sepsis Campaign

Guidelines for Management of SevereSepsis/Septic Shock

2004

Surviving Sepsis Campaign

Guidelines for Management of SevereSepsis/Septic Shock

2008

Surviving Sepsis Campaign

Guidelines for Management of SevereSepsis/Septic Shock

2012

Surviving Sepsis — Practice Guidelines, Marketing Campaigns, and Eli LillyPeter Q. Eichacker, M.D., Charles Natanson, M.D., and Robert L. Danner, M.D

New Policy to deal with Potential Conflicts of Interest

GRADE PRO: Guideline development process

• Prioritize problems (and define specific question(s)• Perform systematic review• Summarize the evidence in evidence profiles (summary of

findings tables)• Judge which outcomes are critical • Judge overall quality of evidence• Judge balance of benefits and downsides• Generate recommendation• Judge strength of recommendation

42

43

4.5 potentials for a mishap per operation

NURSING WORK

Gets IV bags,

Checks

orders in binder

13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00

Hangs IV

IV push Oral meds,

topical cream

Checks updates

in computer

Hangs IV

Planning for new shift

Checks

orders in binderHangs IV

Hangs IV

Hangs IV

Oral meds

IV push

Oral meds

Insulin

Hangs IV

Pain med

Checks updates

in computer

Topical cream

Other RN needs binder

Nursing home assessment

Narcotic keys

Staffing

IV pump alarm

Fingerstick

machine

calibration

Hand off assessment

IV pump alarm

Narcotic meds too many to put in cart

Narcotic keys

Other RN leaves floor

Signature for narcotics

Move patient to new bed

Water for patient

New nursing assistant arrives

MD asks to tape down IV

LPN she is covering

Children on floor

Patient risk of falling

Other RN returns

Hang IV for her

Pain med request

BP machine problems

Dinner

Patient moved up in bed

Water for patient

Fingerstick machine

IV pump alarm

Beds

Weigh

patient

Staffing

Other RN

dinner

Hang IV

IV pump alarm

Cart

Wife of patient

Emily S. Patterson PhD

Surviving Sepsis Campaign

Guidelines for Management of SevereSepsis/Septic Shock

Version 2012

Direct medical costs

van Beeck et al. J Trauma 1997;42:1116

TRAFFIC INJURIES

0 10 20 30 40 50 60 70 80 900

10

20

Age in years

Mill

ion

s of

US

$Male

Female

van Beeck et al. J Trauma 1997;42:1116

OCCUPATIONAL INJURIES

0 10 20 30 40 50 60 70 80 900

1

2

3

4

5Male

Female

Age in years

Mill

ion

s of

US

$

DOMESTIC INJURIES

0 10 20 30 40 50 60 70 80 900

10

20

30

40

50

60

70

80

90

100

Age in years

Mill

ion

s of

US

$

van Beeck et al. J Trauma 1997;42:1116

Male

Female

1990 1991 1992 1993 1994 19952000

2200

2400

2600

2800

3000

3200

3400

3600

Years

Tot

al e

xpen

ditu

re in

acu

te c

are

- M

illi

on E

uro

Denmark

TOTAL EXPENDITURE IN HEALTH CARE

Direct medical costs

IF WE WANT TO AVOID A DISASTEROUR FOCUS SHOULD BE ON

THE EVALUATION AND OPTIMIZATIONOF THE SERVICES WE PROVIDE

HOW (UN)RELIABLE IS MEDICINE?

• 10-1 means that 1 to 9 times out of 10 the intended actions fail to produce the desired results or are defective. An example is if I have a 80% compliance with giving appropriate DVT prophylaxis there are 2 defects in our process in every 10 patients

• 10-2 means that 1 to 9 times out of 100 the intended action or results fail or are defective. An example is if I have 96% compliance with giving appropriate DVT prophylaxis there will be 4 defects in our process in every 100 patients

Average Percent

High Income

Zip Codes

Low Income

Zip Codes

Expected in One Year

Diabetic Eye Exams

47,9 53,2 44,9 100,0

Hgb A1c Monitoring

55,9 59,5 50,9 100,0

Mammography Screening

46,7 50,8 39,8 100,0

Colon Cancer Screening

9.0 (45%) 10,3 8,0 20,0

Influenza Vaccine 46,5 50,8 41,5 100,0Pneunococcal

Vaccine8 (80%) 8,7 7,3 10,0

Pham HH. Delivery of Preventive Services. JAMA

2005; 294:473-481

WHAT ARE OUR EXPECTATIONS OF RELIABILITY IN OTHER INDUSTRIES?

1. How many of you would put up with your automobile not starting two out of ten starts?

2. How many of you would fly commercially, if airplanes crashed or abandoned the trip one out of every ten flights?

3. How many of you would frequent a restaurant that served contaminated food three times out of every ten meals?

HEALTH CARE RELIABILITIES

(Un)Reliability Outcome/Process

10-1

Beta blockers and ASA in Acute MIHgA1c tested at least 3 times every 2 yrs Mammograms, ImmunizationLower Vt in ALI Patients.

10-2Serious adverse events in hospitalDeaths in high risk surgery

10-3Neonatal mortalityGeneral surgery deaths

10-4 Deaths in routine anesthesia

10-5 Blood Banking

10-6 ?

1996 1997 1998 1999 2000 2001 20020

5

10

15

20

25

30

35

10.3 10.5 10.3 9.6 8

7.7 6.9

2 2 2 2

12

21

31

Median Vt ml/kgMoving average (Median Vt ml/kg)% of ARDS Patients Recieving 6 ml/kg VtMoving average (% of ARDS Patients Recieving 6 ml/kg Vt)

ARDS Network Paper Published NEJM May 2000

Death deceased from 40% to 31% p= 0.007

(Am J. Respir & CCM 2004; 169 supp:A256)

1996 1997 1998 1999 2000 2001 20020

5

10

15

20

25

30

35

10.3 10.5 10.3 9.6 8

7.7 6.9

2 2 2 2

12

21

31

Median Vt ml/kgMoving average (Median Vt ml/kg)% of ARDS Patients Recieving 6 ml/kg VtMoving average (% of ARDS Patients Recieving 6 ml/kg Vt)

ARDS Network Paper Published NEJM May 2000

Death deceased from 40% to 31% p= 0.007

Two Years after publishing the evidence,

‘7’ of 10 patients are NOT receiving best care

(Am J. Respir & CCM 2004; 169 supp:A256)

TIDAL VOLUME IN THE ICU’S

Luhr 1999 Esteban 2000

Esteban 2002

Esteban 2002

ALIVE 2004 SAPS30

2

4

6

8

10

12mL/kg

(João Gouveia et al. Data from the SAPS 3 study)

PEEP IN THE ICU’S

0

2

4

6

8

10

12

14

Luhr 1999 Esteban2000

Esteban2002

Esteban2002

ALIVE 2004 SAPS3

cmH2O

(João Gouveia et al. Data from the SAPS 3 study)

We demand the right to make bad choices.

Bad choices yield bad results

4.5 potentials for a mishap per operation

NURSING WORK

Gets IV bags,

Checks

orders in binder

13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00

Hangs IV

IV push Oral meds,

topical cream

Checks updates

in computer

Hangs IV

Planning for new shift

Checks

orders in binderHangs IV

Hangs IV

Hangs IV

Oral meds

IV push

Oral meds

Insulin

Hangs IV

Pain med

Checks updates

in computer

Topical cream

Other RN needs binder

Nursing home assessment

Narcotic keys

Staffing

IV pump alarm

Fingerstick

machine

calibration

Hand off assessment

IV pump alarm

Narcotic meds too many to put in cart

Narcotic keys

Other RN leaves floor

Signature for narcotics

Move patient to new bed

Water for patient

New nursing assistant arrives

MD asks to tape down IV

LPN she is covering

Children on floor

Patient risk of falling

Other RN returns

Hang IV for her

Pain med request

BP machine problems

Dinner

Patient moved up in bed

Water for patient

Fingerstick machine

IV pump alarm

Beds

Weigh

patient

Staffing

Other RN

dinner

Hang IV

IV pump alarm

Cart

Wife of patient

Emily S. Patterson PhD

Revised SSC Bundles

• Based on 2012 SSC guideline Revision• Utilizing analysis of 28,000 pt in the SSC

database• New software to be developed• No industry funding utilized in revising guidelines or

bundles

Revised SSC Bundles

• Management bundle dropped• IPP: High compliance at outset of study

• No significant change in compliance• Glucose:

• Clouded by controversy• Steroids:

• OR > 1.0 in SSC analysis• rhAPC:

• Significant OR for survival but after the results of PROWESS-SHOCK was withdraw from all markets

Sepsis Resuscitation Bundle (To be started immediately and completed within 3 hours)

• Serum lactate measured in 3 hours.• Blood cultures obtained prior to antibiotic

administration.• Minimize time to administration of broad-spectrum

antibiotics with a maximum of 3 hours. • In the event of hypotension and/or lactate >

3mmol/L, deliver a minimum bolus of 30 ml/kg of crystalloid (or colloid equivalent) within 1 hour.

Septic Shock Bundle (To be started immediately and completed within 6 hours)

• Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg.

• In the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate > 4 mmol/L (36 mg/dl):

• Insert central line• Achieve central venous pressure (CVP) of > 8 mm Hg.• Achieve central venous oxygen saturation (ScvO2) of >

70%.

Role of Collaboration

ICUED

SOAP AND SEPSIS-ANALYZING WHAT COMES OUT IN THE WASH

• From the data they obtained, Dr. Vincent and colleagues make a number of observations:• First, sepsis occurs frequently, being reported in almost

40% of patients in the ICU• Second, the frequency of sepsis varies markedly

between countries, and countries with higher frequencies of sepsis have higher mortality rates among all patients admitted to the ICU.

• Finally, they report that the presence of a positive cumulative fluid balance over the first 72 hrs from the onset of sepsis is, among other variables, independently associated with higher ICU mortality.

Warren Lee & Niall Ferguson. Critical Care Medicine2006; 34:552-554)

SOAP AND SEPSIS-ANALYZING WHAT COMES OUT IN THE WASH

Warren Lee & Niall Ferguson. Critical Care Medicine2006; 34:552-554 )

SOAP AND SEPSIS-ANALYZING WHAT COMES OUT IN THE WASH

• Data demonstrate that the mortality rate from organ failure was the same for patients with severe sepsis as it was for those without sepsis, suggesting that organ dysfunction, rather than infection per se, is the key.

• What could account for these findings?• ...difference in case-mix and ICU admission

threshold• ...the higher mortality rate in the ICUs with higher

sepsis prevalence might be a marker of overtaxed resources in the ICU or during pre-ICU care

• ... it is tempting to speculate that baseline differences in antibiotic use between ICUs may have contributed both to the differences in the reported frequency of sepsis and to the mortality rates observed.

Warren Lee & Niall Ferguson. Critical Care Medicine2006; 34:552-554 )

(Crit Care Med 2006; 34:211–218)

FINDING OUT WHAT WE DO IN THE ICUMitchell M. Levy, MD, FCCM

• This task force represents a change in focus, not only for SCCM in particular but for the field of critical care in general.

• ...for a long time, SCCM, along with other critical care societies, focused on the model of critical care delivery.

• Regardless of the model of critical care delivery, the most important aspect of critical care is the quality of care patients receive in a given ICU.

• For many years, the assessment of this quality was based on measuring and reporting outcomes of care.

• Now, finally, there is a growing understanding that paying attention to the details or process of care is the truly essential aspect of quality measurement in the ICU. (Crit Care Med 2006; 34:227–228)

FINDING OUT WHAT WE DO IN THE ICUMitchell M. Levy, MD, FCCM

• Curtis et al., at the direction of SCCM, have provided clinicians in critical care units with a blue-print or mirror for self-examination. The next step is for critical care clinicians to look into that mirror and decide whether or not we like what we see.

(Crit Care Med 2006; 34:227–228)

NEGOVSKY IBSEN SAFAR

WE HAVE STRONG SCIENTIFIC FOUNDATIONS TO OUR SPECIALITY

FROM REANIMATION TO INTENSIVE CARE MEDICINE

REANIMATION INTENSIVE CARE

INTENSIVE CARE MEDICINE

20 years ago Dr Bill Knaus acknowledged:

• It’s the human resources of the ICU TEAM, their organization and distribution, and how we apply technology consistently, NOT the genius of individuals or the treatment “magic bullet” that leads to EFFICIENT and EFFECTIVE ICU.

Knaus et al Annals Int Med 1986: 104.410

DISEASES THAT MADE THE ICU

Polio: Mortality 60% to 20% ??? (but just in 2 or 3 countries)

Tetanus: Mortality approaches Zero

Guillian-Barré syndrome: Mortality approaches Zero

Acute organophosphate poisoning: almost disapeared

Most of the mortality relates to co-morbidity and complications of ICU treatment.

DEVELOPMENT AS A CHALENGE

• Education and training of new professionals.• Training in Intensive care of other professionals.• Better much between resources and workload.• The flux of patients within the hospital: admission

and discharge policies, readmissions.• Patient safety: prevention of adverse events.• Organisative aspects: leadership, communication,

team-work.

Current and projected workforce requirements for care of the critically ill.Angus D et al. JAMA 2000 : 284; 2762-70

RETIRE FROM ICU CARE AT 77 YEARS:

(Angus et. Al, JAMA 2002)

0

50

100

150

200

250

300

350

400IC

U a

dm

issio

ns,

thousan

ds

2001 2006 2011 2016 2021 2026 2031Year

At 2006 ratesModelling trend

ICN

AR

CIn

tensi

ve C

are

Nati

onal A

udit

& R

ese

arc

h C

entr

e 160% increase in demand over 10 years.

Projected ICU Bed Day RequirementsRowan K et al

INTENSIVE CARE IS NOT ABOUT MACHINES

IT IS ABOUT PEOPLE

IT IS ABOUT ORGANIZATION

127

129

NUMBER OF INTENSIVE CARE BEDS PER 100.000 INHABITANTS

0 2 4 6 8 100

5

10

15

20

25

30

Portugal

USA

França

UK

Canadá

Bélgica

Alemanha

HolandaEspanha

130

nº d

e ca

mas

de

Med

icin

a In

tens

iva

por

100.

000

habi

tant

es

Países(Data from Wunsch et all, 2008)

NUMBER OF INTENSIVE CARE BEDS PER 100.000 INHABITANTS

0 2 4 6 8 10 12 140

5

10

15

20

25

Portugal

USA

França

UK

Canadá

Suécia

Holanda

Espanha

CroáciaBélgica

Alemanha

Trinidá e Tobago

131

Países

nº d

e ca

mas

de

Med

icin

a In

tens

iva

por

100.

000

habi

tant

es

(Data from Adhikari et al., 2010)

132

Total n° Acute Care Beds

• ≈2 millions

Total N° IC Beds

• ≈ 60.000

IC Beds/AC Beds %

• ≈3%

Acute and intensive care beds in Europe…….

(Andrew Rhodes &Rui Moreno, 2012, ICM)

Acute care bedsAcute care hospital

beds / 100,000 population.

Total number of ICU and IMCU care beds

Total Adult ICU and IMCU beds / 100,000

populationAdult ICU beds as % of all

acute care beds %>65

Andorra 188 224 6 7.1 3.2 13Austria 48446 635 1833 21.8 3.4 18.2Belgium 50156 456 1900 17.3 3.8 18Bulgaria 57460 766 2154 28.7 3.7 18.2Croatia 15629 353 650 14.7 4.2 16.9Cyprus 2813 350 92 11.4 3.3 10.4Czech Republic 91068 865 1227 11.6 1.3 16.3Denmark 17124 308 372 6.7 2.2 17.1Estonia 5096 380 262 19.5 5.1 17.7Finland 12442 231 329 6.1 2.6 17.8France 232821 358 10540 16.2 4.5 16.8Germany 469791 575 23,890 29.2 5.1 20.6Greece 44411 392 680 6 1.5 19.6Hungary 41574 416 1374 13.8 3.3 16.9Iceland 1169 367 29 9.1 2.5 12.7Ireland 12202 272 289 6.5 2.4 11.6Italy 201932 333 7,550 12.5 3.7 20.3Latvia 11833 531 217 9.7 1.8 16.9Lithuania 17061 526 502 15.5 2.9 16.5Luxemberg 2511 491 127 24.8 5.1 14.9Netherlands 56085 337 1065 6.4 1.9 15.6Norway 13639 277 395 8 2.9 16Poland 156662 410 2635 6.9 1.7 13.7Portugal 31722 298 451 4.2 1.4 18Romania 108611 507 4574 21.4 4.2 14.8Slovakia 32560 599 500 9.2 1.5 12.8Slovenia 7656 373 131 6.4 1.7 16.8Spain 124194 269 4479 9.7 3.6 17.1Sweden 26131 278 550 5.8 2.1 19.7Switzerland 28096 357 866 11 3.1 17United Kingdom 147809 237 4114 6.6 2.8 16.5

Total size of Population Gross Domestic Product (GDP)

($millions)Gross Domestic Product (GDP) per

inhabitant ($)Total expenditure on health as a %

of GDP

Andorra 84082 2893 34,407 7.7Austria 8404252 377,382 44,904 8.6Belgium 11007020 467,779 42,498 8.2Bulgaria 7504868 47,702 6,356 4.4Croatia 4425747 60,834 13,745 7.8Cyprus 804435 23,174 28,808 6.0Czech Republic 10532770 192,030 18,232 6.9Denmark 5560628 309,866 55,725 9.8Estonia 1340194 19,253 14,366 5.3Finland 5375276 239,177 44,496 6.8France 65075310 2,562,742 39,381 9.2Germany 81748892 3,286,451 40,202 8.9Greece 11329618 305,415 26,957 5.8Hungary 9986000 130,421 13,060 5.2Iceland 318452 12,594 39,548 7.9Ireland 4480176 206,985 46,200 7.2Italy 60626508 2,055,114 33,898 7.4Latvia 2229641 24,013 10,770 8.1Lithuania 3244601 36,370 11,209 7.8Luxemberg 511840 54,950 107,358 4.1Netherlands 16654979 780,668 46,873 5.5Norway 4920305 412,990 83,936 8.1Poland 38200037 469,401 12,288 5.3Portugal 10636979 229,154 21,543 5.7Romania 21413815 161,629 7,548 5.4Slovakia 5435273 87,450 16,089 6.0Slovenia 2050189 47,733 23,282 6.8Spain 46152926 1,409,946 30,549 7.0Sweden 9415570 458,725 48,720 8.2Switzerland 7866500 527920 67,110 6.8United Kingdom 62435709 2,250,209 36,040 8.2

(Andrew Rhodes & Rui Moreno, 2012, ICM)

(Andrew Rhodes & Rui Moreno, 2012, ICM))

(Andrew Rhodes & Rui Moreno, 2012, ICM)

(Andrew Rhodes & Rui Moreno, 2012, ICM)

(Andrew Rhodes & Rui Moreno, 2012, ICM)

WE HAVE ARRIVED

DEVELOPMENT AS AN

OPPORTUNITY

• Intensivist model (closed) reduced mortality. (OR: 0.71 95%CI 0.62-0.82)

• Intensivist model (closed) reduced length of stay

Pronovost et al. JAMA; 2002-2151

Physician staffing patterns and clinical outcomes in critically ill patients.

Most Positive Factors Most Negative factors

Intellectual stimulation Lack of leisure time

Treating acutely ill patients Stress among faculty

Application of complex physiology

Treating chronically ill patients

Procedure orientated Inconsistent with my personality

Dealing with end-of-life issues

Dealing with complex ethical issues.

Attitudes and Perceptions of Internal Medicine Residents Regarding Pulmonary and Critical Care Subspecialty Training.Lorin S et al. Chest 2005 : 127; 630-6.

“Beauty comes first. Victory is secondary. What matters is joy.”

Sócrates Brasileiro Sampaio de Souza Vieira de Oliveira

147

STRESSED INTENSIVISTS ?

“The physician must be able to tell the antecedents, know the present, and foretell the future- must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm.

The art consists in three things- the disease, the patient, and the physician. The physician is the servant of the art, and the patient must combat the disease along with the physician.”

Hippocrates, in Epidemics, Book 1, section 11

Gràcies