Transcript Participating in the Surviving Sepsis Campaign: How It Can

Participating in the Surviving Sepsis
Campaign: How It Can Help You!
Laura Evans, MD MSc
Medical Director of Critical Care
Bellevue Hospital
NYU School of Medicine
Disclosures
• No conflicts of interest to disclose
Outline
• Burden of sepsis
• Surviving Sepsis Campaign
– Background
– Results to date
– 2012 Update
• Benefits of Participating in the Surviving Sepsis
Campaign
• Public Reporting in New York State
Why Focus on Sepsis?
• Sepsis is the leading cause of death in noncoronary care intensive care units, with a
mortality rate between 30% and 50%
• From 2007 to 2009, over 2,047,038 patients were
admitted with a sepsis-related illness
– 52.4% are diagnosed in the ED
– 34.8% on the hospital wards
– 12.8% in the ICU
Hall, M.J, et al. NCHS data brief, 62. Hyattsville, MD: National Center for Health Statistics. 2011
Reed K et al. Health Grades. June, 2010 2011;The First Annual Report(1):1-28.
Why Sepsis?
• The cost to the US healthcare system for
sepsis, and pneumonia grew twice as fast as
the overall growth in hospital charges
– $54 billion per year
– Approximately 180 percent increase from 1997 to
2005
Hall, M.J, et al. NCHS data brief, no 62. Hyattsville, MD: National Center for Health Statistics. 2011
Reed K et al. Health Grades. June, 2010 2011;The First Annual Report(1):1-28.
Why Sepsis?
Why Sepsis?
Why Sepsis?
• It’s common and increasing in frequency as
the population ages
• It’s associated with high risk of death and long
length of stay
• It’s expensive
• AND…. The good new is:
We Can Make a Difference
• There are interventions proven to reduce
mortality and cost
• However, these interventions are not routinely
done in all settings
• Adherence to Surviving Sepsis Campaign
bundles is an effective approach to
significantly decrease mortality of patients
with severe sepsis or septic shock
Surviving Sepsis Campaign
• Phase 1:
–Barcelona Declaration (2002):
• Reduce mortality from severe sepsis and septic shock by 25%
• Phase 2:
–Development of Evidence-based Guidelines (2004)
• Second edition published 2008
• Third edition to be released January 2013
• Phase 3:
–Education and Implementation
• Development of Sepsis Bundles
Surviving Sepsis Campaign: International
guidelines for management of severe
sepsis and septic shock: 2008
Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM,
Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale
R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ,
Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson
BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL.
Crit Care Med 2008;32:858-873
Intensive Care Med 2008;30:536-555
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
• European Society of Clinical
Microbiology and Infectious
Diseases
• European Society of
Intensive Care Medicine
• European Respiratory Society
• Infectious Disease Society of
America
• International Sepsis Forum
• Society of Critical Care
Medicine
• Surgical Infection Society
• Canadian Critical Care Society
• Japanese Society of Critical
Care Medicine
• Japanese Association of Acute
Medicine
• German Sepsis Society
• Latin American Sepsis Institute
Surviving Sepsis Campaign Phase 3
• Partner with Institute for Healthcare
Improvement (IHI)
– Develop sepsis “bundles”
– 2 Bundles: Resuscitation (6 hours) and
Management (24 hours)
• Facilitate adoption of guidelines
• Benchmark performance
Phase 3: Multifaceted Intervention
National/regional/network “launch meetings”
•
•
•
•
•
Identify local champions
Introduce sepsis bundles
Educational tools
Staff support for coordinating sites
Regular conference calls
Website
Interactive database
Surviving Sepsis Campaign
• Facilitate early recognition of severe sepsis
– Provider education
– Screening tools
– Treat sepsis as an emergency
• Emphasize timely evidence-based management
–
–
–
–
Assessment of perfusion
Early antibiotics
Fluid resuscitation
Assessment of adequacy of resuscitation
Surviving Sepsis Campaign
Phase 3: Results
Surviving Sepsis Campaign Phase 3:
Demographics
•
•
•
•
252 sites in 18 countries
15,775 charts
Sites contributed from 1 to 471 patients
Sites entered patients from 1 to 37 months
Levy MM et al. CCM 38(2):367-374, February 2010.
Compliance with bundle elements
Compliance with each bundle element increased over time.
Compliance with ALL elements increase over time, but remained
low.
Levy MM et al. CCM 38(2):367-374, February 2010.
Change in Compliance Over Time
Levy MM et al. CCM 38(2):367-374, February 2010.
Change in Mortality Over Time
Site quarter Hospital
mortality
1
37.0%
2
36.1%
3
36.8%
4
33.2%
7% ARR
5
34.7%
19% RRR
6
30.6%
7
34.1%
8
30.0%
Mortality
Benefit:
P < .001
Levy MM et al. CCM 38(2):367-374, February 2010.
Change in Mortality Over Time
Levy MM et al. CCM 38(2):367-374, February 2010.
Longer Term Results
• Hospitals with 3 and 4 year participation in
the SSC showed continued improvement over
the entire period of participation
– No plateau seen in benefit
– Compliance with bundles continued to increase
– Hospital mortality continued to decrease
– Data in publication
What’s New
• Updated Surviving Sepsis Guidelines
• Updated Surviving Sepsis Bundles
• Ratification of National Quality Forum (NQF)
Measure 0500: Severe Sepsis and Septic
Shock: Management Bundle
• New York State Public Reporting
2012 SSC Guidelines
Dellinger, RP Critical Care Medicine. 41(2):580-637, February 2013.
Revised SSC Bundles
• Based on 2012 SSC guideline Revision
–Utilizing analysis of 28,000 pt SSC
database
• New software in development
• 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
• PROWESS-SHOCK negative
• Removed from market
Revised SSC Bundles
• Two resuscitation bundles
– Analysis of large database confirm importance of early
identification and resuscitation
– Initial resuscitation bundle
• To be initiated immediately upon identifying patients with severe
sepsis and septic shock
– Septic Shock bundle
• To be initiated immediately and completed within 6 hours for
patients with septic shock
• Bundles consistent with previous Resuscitation
bundle - No new metrics
Surviving Sepsis Campaign Bundles
TO BE COMPLETED WITHIN 3 HOURS:
1) Measure lactate level
2) Obtain blood cultures prior to administration
of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 ml/kg crystalloid for
hypotension or lactate ≥4mmol/L
Surviving Sepsis Campaign Bundles
TO BE COMPLETED WITHIN 6 HOURS:
5) Apply vasopressors (for hypotension that does not
respond to initial fluid resuscitation) to maintain a mean
arterial pressure (MAP) ≥65 mm Hg
6) In the event of persistent arterial hypotension despite
volume resuscitation (septic shock) or initial lactate ≥4
mmol/L (36 mg/dL):
--Measure central venous pressure (CVP)*
--Measure central venous oxygen saturation (ScvO2)*
7) Remeasure lactate if initial lactate was elevated*
*Targets for quantitative resuscitation included in the guidelines are
CVP of ≥8 mm Hg; ScvOs of ≥70%, and normalization of lactate.
SSC: The Next Phase
• Increase the number of hospitals contributing
data to the Surviving Sepsis Campaign to
10,000 worldwide
• Apply the guidelines to 100% of patients in
whom the diagnosis is suspected
• Develop a strategy to improve the care of
septic patients where healthcare resources
are limited
SSC: The Next Phase
• Assuming that the reduction in mortality seen
to date can be sustained and 10,000 hospitals
comply with the Campaign recommendations,
we could save 400,000 lives if we treat only
half of the eligible patients with the Surviving
Sepsis Campaign Bundles
SSC: The Next Phase
• Enhanced support for participating hospitals
coming soon
– Updated website with:
• Educational materials
• Implementation toolkit
• Screening tools
– Inpatient floors
– Updated database with new bundles from revised
guidelines
Surviving Sepsis Campaign – The next
phase
• Recognition of both the progress that has
been made and the work left to do
• Goals:
– Exponentially increase participation
– Increase compliance with sepsis bundles and
performance metrics
– Save more lives!
Why Participate in the SSC?
• Participating hospitals have:
– Access to free educational programs by worldrenowned sepsis experts
– Access to experienced, trained quality improvement
experts
– Access to colleagues at other institutions who share
the commitment to improving care for patients with
sepsis
– Benchmarking: Access to the SSC database to enter
your data and get reports on your performance
Why Participate in the SSC?
• Participating hospitals have:
–The opportunity to improve the care of severely
septic patients directly in the hospital using
evidence-based sepsis bundles
–The opportunity to advance the field of quality
improvement
Why Participate in the SSC?
• Build morale at your hospital
• Use a proven intervention that improves
survival of patients with sepsis
• Get ahead of the curve with performance
measures
–NQF
–NY State
NQF Sepsis Measures
• Measure # 0500: Severe Sepsis and Septic Shock
Management Bundle
• Proposed by:
– Henry Ford Hospital System(HFHS)
– California Pacific Medical Center/Sutter Health
(CPMC)
– Society of Critical Care Medicine (SCCM)
– Infectious Diseases Society of America (IDSA)
– Institute for Healthcare Improvement (IHI)
– Surviving Sepsis Campaign (SSC)
– Ohio State University (OSU)
NQF Measure
Within
3 Hours
Within
6 Hours
www.qualityforum.org
NQF Sepsis Measures
• March 2013 Update:
– Continued endorsement ratified
• NQF measures are derived from the Surviving
Sepsis Campaign and are aligned with the SSC
sepsis bundles
New York State Reporting
• Dr. Nirav Shah, New York
State Health
Commissioner announced
his intention to require
reporting of sepsis
performance measures
state-wide
• Expected to be public
reporting
• NY will be first state to do
this
New York State Reporting
Requirements
• Hospitals will be required to use an evidencebased protocol for identification and
management of patients with sepsis
• Hospitals will be required to report
– adherence to protocol elements
– sepsis rates
– risk-adjusted sepsis mortality