Sepsis Story At Intermountain Healthcare 2004-2012 Intensive Medicine Clinical Program
The International Surviving Sepsis Campaign Was Organized In 2002 During The ESICM International Meeting In Barcelona, Spain 10/14/2015 2
Phase I 2002 Organization of the Surviving Sepsis Campaign By an International Multidisciplinary Group and the Formulating The Barcelona Declaration 10/14/2015 3
Surviving Sepsis Campaign Goal Barcelona Declaration Reduce Sepsis Mortality By 25% within Five Years of the Gideline Publication (2009)
Phase II 2002-2003 Provide rationale for Change By Creating Credible Guidelines Published in CCM 2004;32(3):858-873 10/14/2015 5
Phase III 2004 Develop a Reliable Implementation Process Partner with Institute of Healthcare Improvement (IHI) Focus on a few key evidence based interventions Use bundling concepts to leverage improvement Implement them reliably Measure compliance Measure outcomes (mortality) 10/14/2015 6
Proposed Definition Of Reliability for Health Care The measurable capability of a process, procedure or service to perform its intended function correctly and/or achieve the intended results within the specified location and time frame. 10/14/2015 7
Surviving Sepsis Campaign: Timeline Barcelona Declaration Phase III starts: IHI partnership Guidelines Revision Guidelines And Bundle Revision??? 2004 2006 2010 2012 2002 2005 2008 2012 SSC Guidelines NEJM editorial Results published 15,000 pts 20% RRR
Intensive Medicine Clinical Program: Timeline Barcelona Declaration IMCP Adopts SSC Sepsis Bundle & Creates Metrics Board Goal of High Level Compliance with Lactate Guidelines and Bundles Revision HVHC All Elements Board Goal 2004 2006 2010 2013 2002 2005 2008 2009 2012 SSC Guidelines Education and Sharing Reliable Processes Results Compiled 4,329 patients Mortality < 10% Paper Publication
Sepsis Recognition Tool 1. Is the patient s history suggestive of a new infection? Yes No Pneumonia/empyema Meningitis Skin/soft tissue inflammation UTI Bone/joint infection Wound infection Acute abdominal infection Catheter or device infection Endocarditis 2. Are any of the following signs or symptoms of infection present? Yes No Hyperthermia > 38.4 C Tachycardia > 90 bpm Tachypnea > 20 bpm Hypothermia < 36 C SBP < 90 or MAP < 65 Headache with stiff neck Chills with rigors WBC>12,000 or- <4,000 Band forms > 10% If the answer is Yes to both question 1 and 2, Suspicion of Sepsis is Present. Obtain: Q1hVital Signs, CBC with Diff, BMP, Lactate, Bilirubin, PT-PTT, Blood Cultures (need for next question) At physicians discretion obtain: UA, Chest X-ray, Amylase, Lipase, LFT, CT, ABG 10/14/2015 ED Sepsis Lect. - April 2010 10
Severe Sepsis Recognition Tool 3. Are any of the following organ dysfunction criteria present at a site remote from the site of the infection that are not considered to be chronic conditions? Acutely altered mental status SBP < 90 or MAP < 65 mmhg SpO2 < 90% on room air or on supplemental O 2 Creatinine > 2.0 mg / dl or Urine Output < 0.5 ml/hour for > 2 hours Bilirubin > 2 mg / dl INR > 1.5 Platelet count < 100,000 Lactate > 2 mmol / liter If Suspicion of Infection is Present and there is any Organ Dysfunction Present, patient meets the criteria for SEVERE SEPSIS and should be entered into the Severe Sepsis Bundle pathway 10/14/2015 ED Sepsis Lect. - April 2010 11
Septic Shock Definition Is Defined As SBP <90 mmhg, MAP <60 mmhg, or a Reduction in SBP >40 mmhg From Baseline Despite Adequate Volume Resuscitation on 2 or More Measurements at Regular Intervals Septic Shock should be entered into the Severe Sepsis Bundle pathway 10/14/2015 12
Resuscitation Bundle 2005 1. Serum Lactate measured within first 3 hours. 2. Blood Cultures obtained prior to antibiotic administration. 3. Broad-Spectrum Antibiotics administered within 3 hours of ED or Unit admission. 4. Fluid Resuscitation for hypotension (SBP < 90, or MAP < 65) or LACTATE > 4 mmol/l, with a minimum of 20-40 ml of crystalloid per estimated kg of predicted body weight (PBW). 10/14/2015 13
70 60 Cryptic Septic Shock Lactate > 4 mmol / L & MBP > 100 mmhg 60.9 Donnino et al. Chest 2003 124: 90S 50 40 30 20 10 P < 0.004 # 23 20 # 25 30 45 0 MAP > 100 All Patients EGDT Control 10/14/2015 14
Resuscitation Bundle 2005 5. Vasopressors employed for life threatening hypotension during resuscitation and after initial fluid resuscitation if hypotension not responsive to fluids. 6. CVP and ScvO 2 obtained at regular intervals via central catheter with tip in the SVC in the event of Septic Shock or if Lactate is > 4 mmol/dl. Then continue to give fluids to CVP goal > 8 cm H 2 O 7. Inotropes and/or PRBC s (if hematocrit < 30%) for ScvO2 < 70% if CVP > 8 mmhg. 10/14/2015 15
Maintenance Bundle 2005 1. Glucose Control maintained on average < 140 (later 180) mg/dl. 2. Steroids should be given for septic shock requiring continued use of high levels of vasopressors. 3. Drotrecogin Alfa eligibility assessed for use employing hospital guidelines. 4. Use of a Lung Protective Strategy with V t 6 ml/kg PBW and plateau pressures < 30 cmh 2 0 for mechanically ventilated patients with Acute Lung Injury or ARDS. 10/14/2015 16
Surviving Sepsis Campaign Bundle compliance through two years ( Achieve Targets ) P <.0001
Hospital Mortality (%) Surviving Sepsis Campaign Hospital mortality through two years 39% 37% 35% 33% 31% 29% 27% 25% 1 2 3 4 5 6 7 8 Site quarter P value < 0.007
10/14/2015 Sepsis Guidlines Revision 2008 19
10/14/2015 Sepsis Guidlines Revision 2008 20
Center Line = 65.4%
20.2% Center Line = 14% 8.9%
Revision of SSC Bundles Based utilizing analysis of 28,000 patient in the SSC database: in 2012 SSC revised the guidelines New software was to be developed No industry funding utilized in revising guidelines or bundles
Multivariable Mortality Prediction Model: Population-averaged Panel Logistic Regression
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
SSC Sepsis Resuscitation Bundle 2012 (To be started immediately and completed within 3 hours) 1. Measure serum lactate 2. Obtain blood cultures prior to antibiotic administration 3. Minimize time to administration of broad-spectrum antibiotics with a maximum of 3 hours from ED triage and 1 hours for non-ed patients. 4. In the event of hypotension and/or lactate > 4mmol/L, deliver a minimum of 30 ml/kg of crystalloid (or colloid equivalent).
SSC Septic Shock Bundle 2012 (To be started immediately and completed within 6 hours) 5. Apply vasopressors for hypotension that does not respond to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg. 6. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate > 4 mmol/l (36 mg/dl): Achieve central venous pressure (CVP) of > 8 mm Hg. Achieve central venous oxygen saturation (ScvO2) of > 70%.*
Severe Sepsis/Septic Shock New Cohort Definition for Intermountain Include adults patient 18 years or older with discharge ICD9 codes 995.92 (Severe Sepsis), 785.52 (Septic Shock) or 995.91 (sepsis) + an organ failure code admitted to ICU from ER or FLOOR (using encounter ICD9 codes)» Organ failure codes» 584.5 Acute Renal Failure» 584.51 Acute Renal Failure» 584.52 Acute Renal Failure» 584.53 Acute Renal Failure» 584.54 Acute Renal Failure» 584.55 Acute Renal Failure» 584.56 Acute Renal Failure» 584.57 Acute Renal Failure» 584.58 Acute Renal Failure» 584.59 Acute Renal Failure» 581.18 Acute Respiratory Failure» 359.81 Myopathy» 357.82 Critical Illness Polyneuropathy» 286.6 DIC /Coagulopathy» 348.31 Metabolic Encephalopathy» 570 Acute liver failure
Old Method 2004 From Combined Query (n=11,877) New Method 2013 From IMCP screening table uses a very broad search (n=11,549) From Casemix by ICD 9 (n=5,288) Captured by IMCP table but 6,589 did not match Matched from both queries (n=4,960) Captured by ICD9 codes only 328 did not match 94% Disqualified by RN (n=6,201) 6% Qualified by RN (n=388) Septic shock=68 Severe sepsis=296 Blank=24 Septic shock (785.52) = 58 Severe sepsis (995.92) = 79 Sepsis W AOF = 53 Mild/moderate sepsis = 138 Only 46% patients screened positive by old method were not verified by RN as severe sepsis or septic shock
HVHC-CCMI Study Population: A subset of patients of IMCP study population Inclusion criteria: Include adults patient 18 years or older with discharge ICD9 codes 995.92 (Severe Sepsis), 785.52 (Septic Shock) admitted to ICU from ER, OR or Floor (using encounter ICD9 codes) Participated hospitals: Intensive Care Units at IMC, LDS, McKay-Dee, Utah Valley and Dixie Exclusion criteria: Patients transferred from other facility are excluded from the study
2013 Severe Sepsis Resuscitation Bundle: To be done within a maximum of 3 hours from ED triage or within 1 hour for non-ed patients from the time of ICU admission 1. Measure serum lactate 2. Obtain blood cultures prior to antibiotic administration 3. Minimize time to administration of broad-spectrum antibiotics within a maximum of 3 hours from ED triage or within 1 hour for non-ed patients from the time of diagnosis. 4. In the event of hypotension and/or lactate > 4 mmol/l, start a fluid bolus of 30 ml/kg of crystalloid IV to run over not more than 60 minutes.
2013 Septic Shock Bundle: To be done within a max. of 6 hours from ED triage or within 6 hour for non-ed patients from the time of ICU admission 5. Apply vasopressors for hypotension that does not respond to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg. (Norepinephrine is the preferred vasopressor for initial therapy starting at 0.02 mcg/kg/minute if not contraindicated) Shock defined as hypotension (SBP persistently < 90mmHg on 2 or more readings) or Lactate > 4.0mmol/L that is not responsive to 30 ml/kg PBW crystalloid fluid bolus by returning to and remaining at normal values
2013 Septic Shock Bundle: 6. In the event of persistent arterial hypotension (SBP < 90) despite volume resuscitation of 30 ml/kg PBW and/or lactate > 4 mmol/l, begin further volume resuscitation** and vasopressor support as needed to: 6a. Achieve central venous pressure CVP> 8 mm Hg. or if using NICOM protocol, until either patient is no longer fluid responsive (has < 10% increase in stroke volume index following passive leg raise) or patient becomes stable off vasopressors. 6b. Achieve central venous oxygen saturation (ScvO2) of > 70%. or if using NICOM protocol achieve a cardiac index (CI) greater than 2.5 L/minute/M 2 7. If initial lactate is elevated > 2 mmol/l, repeat measurement within 6 hours of time zero.
Maintenance Bundle: 8. If on ventilator and on A/C target Vt at 6 ml/kg PBW (range 4-7 ml/kg PBW 9. Achieve and maintain an average glucose between 80-180 within the last 12 hours of the first 24 hour period using bedside measurements done at least every 4 hour or less intervals.**** 10. If on high dose vasopressors*** give hydrocortisone 200 mg/24 hours in divided doses of 50 mg Q6 hours or as a continuous infusion. NOTE: The telemedicine system will facilitate bundle tracking and performance for non- ED patients.