Tiffany M. Osborn, MD University of Virginia ACEP Chair Critical Care Section ACEP Representative Surviving Sepsis Campaign

Angus DC. Crit Care Med. 2001;29(7): Today >750,000 cases of severe sepsis/year in the US * Future 200, , , ,000 1,000,000 1,200,000 1,400,000 1,600,000 1,800, Year 100, , , , , ,000 Severe Sepsis Cases US Population Sepsis Cases Total US Population/1,000 Incidence projected to increase by 1.5% per year Purpose for Existence?

Comparison With Other Major Diseases ;29(7): † National Center for Health Statistics, § American Cancer Society, *American Heart Association ‡ Angus DC et al. Crit Care Med. 2001;29(7): AIDS*Colon Breast Cancer § CHF † Severe Sepsis ‡ Cases/100,000 Incidence of Severe SepsisMortality of Severe Sepsis AIDS* Severe Sepsis ‡ 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; Ann Emerg Med 2002;39: Curr Opin Crit Care Dec.2002 P < for all groups 102 million National ED visits in % (17.5 million) “immediately life threatening” 1 57 California Emergency Departments ( ) 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 declaration Phase 2 Evidence based guidelines Phase 3 Implementation and education Surviving Sepsis

Phase 1 Barcelona declaration Phase 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 declaration Phase 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:

Cross-sectional analysis of 25,886 patients enrolled in GUSTO 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) Non-profit organization – H ealthcare improvement –Quality based initiatives Set Quality Benchmarks – JCAHO –Medicare –Medicaid –3 rd 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 2004 Catania, 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 4 mmol/L : –initial fluid bolus 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 ScvO 2 measured. –CVP maintained >8 mmHg. –MAP maintain > 65 mmHg. ScvO2 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 H 2 O 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!!