Tiffany M. Osborn, MD

University of Virginia

ACEP Chair Critical Care Section

ACEP Representative Surviving Sepsis Campaign

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

TodayToday

>750,000 cases of severe

sepsis/year in the US*

FutureFuture

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

Sep

sis

Cas

es

To

tal

US

Po

pu

lati

on

/1,0

00

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;29(7):1303-1310.

AIDS* Colon BreastCancer§

CHF† Severe Sepsis‡

Cas

es/1

00,0

00

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

De

ath

s/Y

ea

r

AIDS* SevereSepsis‡

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

Vis

its /

ED

(%

Ch

an

ge)

Visits/ED

Total visits/ED

Critical Care

Urgent

NonurgentP < 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 declarationPhase 2 Evidence based guidelines

Phase 3 Implementation and education

Surviving Sepsis

Phase 1 Barcelona declarationPhase 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

Phase 1 Barcelona declarationPhase 2 Evidence based guidelines

Phase 3 Implementation and education

Surviving Sepsis

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

AC

E i

nh

ibit

or

us

e (

%)

SAVE site Non-SAVE site

0

5

10

15

20

AC

E i

nh

ibit

or

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 2004Catania, 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.

Time from Entering ED to Transfer to MICU

Reduced by 51%

Time from Entering ED to Catheter Insertion

Reduced by 60%

Time from Entering ED 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

THANK YOU!!