Guidelines are the Future of Sepsis Management Pro

Transcription

1 Guidelines are the Future of Sepsis Management Pro R. Phillip Dellinger MD, MCCM Professor and Chair of Medicine Director Adult Health Institute Senior Critical Care Attending Camden NJ USA

2 Objectives Sepsis guideline experience to date Next steps A New American Revolution

3 Clinical Practice Guidelines Intent 1. Improve the quality of decisions 2. Create explicit recommendations 3. Improve consistency of care 4. Clarify proved benefit and document the quality of supporting evidence 5. Support quality improvement activities 6. Update guidelines as new evidence becomes available Adapted from Woolf SH et al. BMJ 1999;318:

4 Sepsis Guidelines How are we doing?

5 Current Sepsis Guidelines Are Good Validity References Evidence graded Supportive organizations Emphasis on performance improvement program Developed bundles of care 3 hour and 6 hour

6 Scholarly Activity for SSC Guidelines 2004 SSC Guidelines-Cited by SSC Guidelines-Cited by SSC Guidelines-Cited by 4030 Current guideline views at 6.5M since release and posting on the SSC website

7 Global Guideline Application Resource unlimited Resource limited

8 Utility of the SSC Guidelines Non Sepsis Expert Typical patient } Sepsis Expert Atypical Patient

9 Guidelines

10 Can Guidelines Be Modified To Individual Patients?

11 Mortality based on source of infection Infection source % Mortality % Pneumonia UTI Abdominal Meningitis Skin Bone Wound Catheter Endocarditis Device Other infection Levy M. Intensive Care Med. Feb 2010; 36(2): (n=15,022)

12 Mortality based on organ failures at T % % % 52.5% 63.6% Levy M. Intensive Care Med. Feb 2010; 36(2):

13 Precision Medicine in Sepsis: Enrich, Modify But Not Replace Secondary analysis of completed sepsis trials Optimize routine care Sepsis severity scoring system Biomarker Evaluation of Infectious source Contribution of age & comorbid condition Genetic predisposition

14 Things to consider for the future of the sepsis guidelines? Target clinician and lay public input into process Application to under-resourced areas Early identification of target patient Highlight prevention Offer a simplified version Promote a How to Guide

15 Early Identification and Rapid Treatment

16 Emphasis on Prevention Prevent stroke and heart disease Lower cholesterol

17 SSC Emphasis on Prevention Prevent organ dysfunction Screening every shift Early identification Blood Cultures Antibiotics Prevent progression of organ dysfunction 30 ml/kg Lactate Re-measure lactate Clear lactate

18 Grol R, et al. Med J Aust Mar 15;180(6 Suppl):S57-60.

19 Bensing J. Patient Educ Couns Jan;39(1):17-25.

20 45 pages 144 references 57 pages 636 references

21 SSC Guideline Layers Rationale Evidence Based Tables Recommendation

22 Simplify

23 Next Steps Surviving Sepsis Campaign Guidelines 2016 Surviving Sepsis Campaign Guidelines 2016 All-In-One Resource Expert commentary Notes and Definitions Exclusive Algorithms Handy Checklists NO FEAR The Guidelines PLUS a Translation Anyone Can Understand Surviving Sepsis Campaign Guidelines 2016 GUIDELINES IN PLAIN ENGLISH

24 Knowledge is like paint It does no good until it is applied

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26 Dissemination and Application

27 Guidelines are an essential starting point But guidelines are not enough Quality Indicators Protocols Performance Improvement Programs Audit and Feedback

28 Converting Goals to Measurable Indicators

29 Guidelines to Bundles

30 You say you want a revolution Revolution

31 National Quality Forum 2012 NQF: Sepsis 0500 TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION : 1. Measure lactate level 2. Obtain blood cultures prior to administration of antibiotics 3. Administer broad spectrum antibiotics 4. Administer 30ml/kg crystalloid for hypotension or lactate 4mmol/L

32 2012 NQF: Sepsis 0500 TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION: 5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure (MAP) 65mmHg) 6. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/l (36mg/dl): - Measure central venous pressure (CVP) - Measure central venous oxygen saturation (ScvO2) 7. Remeasure lactate if elevated.

33 N Engl J Med May 1;370(18): Over 1500 Patients N Engl J Med Oct 16;371(16): Patients

34 CMS- SEP1 3 Hrs 6 Hrs

35 You say you got a real solution Well, you know We d all love to see the plan Revolution

36 Grol R, et al. Med J Aust Mar 15;180(6 Suppl):S57-60.

37 You ask me for a contribution Well, you know We re all doing what we can Revolution

38 Grol R, et al. Med J Aust Mar 15;180(6 Suppl):S57-60.

39 You tell me it s (for) the institution Revolution

40 N Engl J Med May 1;370(18): Over 1500 Patients N Engl J Med Oct 16;371(16): Patients

41 SSC 2006 six hour bundle SSC 2012 three hour bundle NQF 0500 NQF 0500 (revised) CMS SEP 1

42 SSC TO SAVE LIVES... Early identification SSC NQF CMS Early antibiotics SSC NQF CMS Early fluid resuscitation

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44 Importance of reassessment

45 The Future of Sepsis Management Guidelines are the future of sepsis management And in the United States the future is now!