sepsis power point slide presentation - the guidelines_ implementation for the future
TRANSCRIPT
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Tiffany M. Osborn, MD
University of Virginia
ACEP Chair Critical Care Section
ACEP Representative Surviving Sepsis Campaign
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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?
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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§
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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.
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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
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Surviving Sepsis Campaign
A global program to:
• Reduce mortality rates•Improve standards of care•Secure adequate funding
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Phase 1 Barcelona declarationPhase 2 Evidence based guidelines
Phase 3 Implementation and education
Surviving Sepsis
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Phase 1 Barcelona declarationPhase 2 Evidence based guidelines
Phase 3 Implementation and education
Surviving Sepsis
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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
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Phase 1 Barcelona declarationPhase 2 Evidence based guidelines
Phase 3 Implementation and education
Surviving Sepsis
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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.
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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
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“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
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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
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What is a Bundle?
• Specifically selected care elements – From evidence based
guidelines
– Implemented together provide improved outcomes compared to individual elements alone
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SSC Steering Committee: Global Consensus
13 September 2004Catania, Sicily
• Steering Committee Met
• 6 hour bundle formed
• 24 hour bundle formed
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Gaining Consensus:Finding Nemo
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6 Hour Resuscitation Bundle
• Early Identification• Early Antibiotics and
Cultures• Early Goal Directed
Therapy
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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.
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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
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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
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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
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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
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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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THANK YOU!!