webcast slides levy time zero

8/16/2019 Webcast Slides Levy Time Zero

1/24

Faculty

Mitchell M. Levy, MD, FCCMProfessor of Medicine and DivisionChief

Alpert Medical School of Brown

UniversityMedical Director, MCU

!hode sland "ospital

Providence , !hode sland

Author #$$%, #$$& ' #$(# SSC)uidelines

SCCM SSC *+ecutive and Steerin

Co--ittees


2/24

Starting the Clock:

Time ZeroConsiderations

Mitchell M. Levy, MD, FCCMBrown University

Providence, RI


3/24

Funded y a rant fro- the)ordon and Betty rene

Moore Foundation


4/24

R. Phillip Dellinger, Mitchell M. Levy, ndre!Rhodes, D"illali nnane, #er!ig $erlach,Steven M. %pal, &onathan '. Sevransky,

Charles L. Spr(ng, )vor S. Do(glas, Roman

&aeschke, Ti*any M. %s+orn, Mark '.(nnally, Sean R. To!nsend, -onrad

Reinhart, R(th M. -leinpell, Derek C. ng(s,Cli*ord S. De(tschman, lavia R.

Machado,$ordon D. R(+en/eld, Steven .0e++, Richard &. 1eale, &ean2Lo(is 3incent,R(i Moreno, and the S(rviving Sepsis

Campaign $(idelines Committee incl(dingthe Pediatric S(+gro(p.

Surviving Sepsis Campaign: International guidelines for

management of severe sepsis and septic shock: 2012


5/24

C(rrent S(rviving Sepsis Campaign $(idelineSponsors

• merican ssociation o/ Critical2Care

(rses• merican College o/ Chest Physicians

• merican College o/ 'mergencyPhysicians

• (stralian and e! Zealand)ntensive Care Society

• sia Paci>c ssociation o/ CriticalCare Medicine

• merican Thoracic Society

• 1ra?ilian Society o/ CriticalCare@)M1A

• Canadian Critical Care Society

• Chinese Society o/ Critical CareMedicine

• 'mirates )ntensive Care Society

• '(ropean Respiratory Society

• '(ropean Society o/ ClinicalMicro+iology and )n/ectio(s Diseases

• '(ropean Society o/ )ntensive CareMedicine

• '(ropean Society o/ Pediatric andeonatal )ntensive Care

• )n/ectio(s Diseases Society o/merica

• Indian Society of Critical Care Medicine

• International Pan Arab Critical Care Medicine

Society

• Japanese Association for Acute Medicine

• Japanese Society of Intensive Care Medicine

• Pediatric Acute Lung Injury and Sepsis

Investigators

• Society Academic Emergency Medicine

• Society of Critical Care Medicine

• Society of Hospital Medicine

• Surgical Infection Society

• orld !ederation of Critical Care "urses

• orld !ederation of Pediatric Intensive and

Critical Care Societies

• orld !ederation of Societies of Intensive and

Critical Care Medicine

Participation and endorsement#erman Sepsis Society

Latin American Sepsis Institute


6/24

/0i-e 1ero2

• 0i-e 1ero 3 ti-e of presentation

!*D, Medical Floors, CU

• Both undles ti-e ased• Most i-portant ti-e ased ele-ents4

!Antiiotic ti-in

!!esuscitation ti-in 5*)D06


7/24

nti+iotic therapy

(. 7e reco--end that intravenousanti-icroial therapy e started asearly as possile and within the 8rst

hour of reconition of septic shoc95(B6 and severe sepsis withoutseptic shoc9 5rade(C6.


8/24

"ospital Mortality y 0i-e toAntiiotics


9/24

l(id therapy

%. 7e reco--end that initial :uidchallene in patients with sepsis;induced tissue hypoperfusion with

suspicion of hypovole-nic e startedwith < ($$$ -L of crystalloids 5toachieve a -ini-u- of =$-l>9 of

crystalloids in the 8rst % to ? hours6.5)rade (B6.


10/24

Loistic !eression Model


11/24

SSC>@F Bundle4 Sepsis $$$

0 B* CMPL*0*D 70"@ = "U!S F 0M* FP!*S*@0A0@ 4

(. Measure lactate level

#. tain lood cultures prior to ad-inistration of

antiiotics=. Ad-inister road spectru- antiiotics

%. Ad-inister =$-l>9 crystalloid for hypotension or lactateL

/ti-e of presentation2 is de8ned as the ti-e of triae inthe *-erency Depart-ent or, if presentin fro-another care venue, fro- the earliest chart annotationconsistent with all ele-ents severe sepsis or septic shoc9ascertained throuh chart review.


12/24

SSC>@F Bundle4 Sepsis $$$ 0 B* CMPL*0*D 70"@ ? "U!S F 0M* F

P!*S*@0A0@4

. Apply vasopressors 5for hypotension that does notrespond to initial :uid resuscitation to -aintain a -eanarterial pressure 5MAP6


13/24

So, 7hats the ssue

• Many roups, especially *D physicians advocate foralternative ti-e Kero

! 0i-e of /dianosis2

! Physician;ased

! Chart ased

• Las

• S

• @ot all patients ad-itted fro- *D with severe sepsis presentat triae with severe sepsis

! Deteriorate in *D over hours• 0riae ti-e -ay not re:ect true /ti-e Kero2 of severe sepsis

for all patients ad-itted to CU fro- *D


14/24

-plications for 0i-e 1ero

• @ew Nor9 State D"

! Mandated reportin of sepsis outco-es

! Adherence to /evidence;ased2 protocols

• @F sepsis -easures

! !ecently approved ! Appeal issued y ACCP>AC*P

• Fear of ein /dined2 for patients who did not -eetcriteria on triae in *D

! Pulic reportin

! Pay for Perfor-ance


15/24

Alternatives to 0riae 0i-e

as 0i-e 1ero• 7e considered several sources in -a9in our conclusions4

! Co--ents and concerns fro- other oraniKations

represented on the #$(# SSC )uidelines Co--ittee

! *+perts on the nfectious Disease Steerin Co--ittee ofthe @ational uality Foru- 5@F6

! Pulic co--ents durin @F consensus -easuresprocess

! SSC list serve discussion


16/24

0i-e 1ero Deter-ination4 A

Balancin Act• 0i-e Kero needs to oOer the est alance of 4 ! reliaility and reproduciility

! opti-iKin the overall perfor-ancei-prove-ent eOort as to4

(. early dianosis

#. appropriate treat-ent of severe sepsis.


17/24

0he -portance of *arlyDetection

• *Oorts to "(st treat recogni?ed sepsis alone are inco-plete

• A critical aspect of -ortality reduction in the Ca-pain has een pushinpractitioners to identify sepsis early.

! Levy MM, Delliner !P, 0ownsend S! ,et al. 0he Survivin SepsisCa-pain4 !esults f An nternational )uideline;Based Perfor-ance-prove-ent Prora- 0aretin Severe Sepsis. Crit Care Med. #$($Fe=&5#64=?H;H%.

• t -ay well e that earlier reconition accounts for -uch of the sinal in-ortality reduction and partially e+plains sharply increasin incidence.

! )aies9i DF, *dwards QM, Rallan MQ, et al. Bench-ar9in the ncidence

and Mortality of Severe Sepsis in the United States. Crit Care Med. #$(=Fe #. *pu ahead of printT

• 7ithout reconition that the cloc9 is tic9in, there is si-ply no incentive toreconiKe a challenin dianosis early.


18/24

Usin /0i-e of Docu-entation2 isFlawed as a Perfor-ance

-prove-ent Approach• Some patients will not meet severe sepsis criteria on ED

arrival, however altering time zero to chart annotation by a practitioner would:

! 0urn the undle into a treat-ent only undle 5not adianosis and treat-ent undle6.

! Di-inish practitioners incentives to identify patients atris9 ased on history, sy-pto-s and e+a- 8ndins at

*D presentation.

! !educe the reliaility and reproduciility of ti-e Kero.

! Ma9e data collection -ore onerous and costly.


19/24

7here Do 0he )ains Live " B

Lead #ime to Dia$nosis Delivery o% Proper #reatment

Lead time to Dia$nosis & #reatment

o( a a r cr er on or me ?ero


20/24

o( a a r cr er on or me ?ero+e onset o/ hypotension, !ith all

previo(s +lood press(res in the 'D

recorded as normotensiveB• Such a ti-e would4

! falsely penaliKe sites for initiation of treat-ent prior tothe onset of hypotension.

• Fluids iven 8rst A+ iven 8rst Blood culturesalready sent

! falsely decrease the nu-er of oserved cases -eetinsevere sepsis criteria.

! di-inish awareness of oran dysfunction other thanhypotension.

! not be the therapy that you want your loved one toreceive


21/24

Fairness and the Bell Curve

• Many discussions will e had aout the /fairness2 of -a9in

providers responsile for sins ' sy-pto-s that -ay not einitially present.

• Such a viewpoint presupposes the veracity of the notion thatthe patient truly presented acutely to the *D for so-e other

reason than i-pendin Iuanti8ale severe sepsis>shoc9.

! Really??? Does that meet the test of most of the time formost cases???

• 0i-e Kero as triae will lead to earlier and -ore freIuent

reconition increased total nu-er patients withi-proved outco-es.

• Lon *D stays are another real Iuality prole- and one thathospitals should separately solve. CMS already -easuresthis prole- and there is no persuasive reason to confusethe issues.


22/24

0he Patients Point of iew

• Despite a provider’s trueoccasional inaility to achieve theti-e sensitive indicators4

! due to late onset of sy-pto-s

! due to lon elapsed ti-e in the *D

*arly detection and treat-ent ofmy health problem is preferale.2

S i d R i l /


23/24

Strategies and Rational /orProceeding in the et Phase o/

Sepsis E(ality )mprovement• Continue to use triae ti-e as ti-e Kero in cases presentinto the *D.

• Ma+i-iKe the undles eOectiveness for dianosis as well astreat-ent.

• Ac9nowlede a percentae of patients will not -eet criteriafor severe sepsis or septic shoc9 at *D triae and -ay -issthe undle.

• !econiKe that whatever co-pliance can e achieved will e

converted to percentiles of perfor-ance y CMS forench-ar9in.

• Ac9nowlede that ench-ar9ed perfor-ance even atpossily low levels of averae raw co-pliance will still havea top decile the decile deter-ines co-pensation in CMSsvalue ased purchasin -etrics.


24/24

U*S0@S

webcast slides levy time zero

Documents