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):1303-1310.
Today
>750,000
cases of severe
sepsis/year
in the US
*
Future
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
1,800,000
2001 2025 2050
Year
100,000
200,000
300,000
400,000
500,000
600,000
Severe Sepsis Cases
US Population
S
e
p
s
i
s

C
a
s
e
s

T
o
t
a
l

U
S

P
o
p
u
l
a
t
i
o
n
/
1
,
0
0
0

Incidence projected to
increase by 1.5% per year
Purpose for Existence?
Comparison With
Other Major Diseases

National Center for Health Statistics, 2001.

American Cancer Society, 2001. *American Heart Association.

2000.

Angus DC et al. Crit Care Med. 2001;29(7):1303-1310.

AIDS* Colon Breast
Cancer

CHF

Severe
Sepsis

C
a
s
e
s
/
1
0
0
,
0
0
0

0
50
100
150
200
250
300
Incidence of Severe Sepsis Mortality of Severe Sepsis
0
50,000
100,000
150,000
200,000
250,000
D
e
a
t
h
s
/
Y
e
a
r
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;
2001
2. Ann Emerg Med 2002;39:389-96
3. Curr Opin Crit Care Dec.2002

-10
10
30
50
70
V
i
s
i
t
s

/

E
D

(
%

C
h
a
n
g
e
)
Visits/ED
Total visits/ED
Critical Care
Urgent
Nonurgent
P < 0.001 for all groups
102 million National ED visits in 1999
17% (17.5 million) immediately life threatening
1
57 California Emergency Departments (1990-1999)
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;97:1150-1156.
0
5
10
15
20
A
C
E

i
n
h
i
b
i
t
o
r

u
s
e

(
%
)
SAVE site Non-SAVE site
0
5
10
15
20
A
C
E

i
n
h
i
b
i
t
o
r

u
s
e

(
%
)
Pre-SAVE Post-SAVE
Cross-sectional analysis of
25,886 patients enrolled in GUSTO-1
659 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) www.IHI.org
Non-profit organization
Healthcare 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 < 90, MAP
< 65) or lactate > 4 mmol/L:
initial fluid bolus 20-40 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<70%with CVP > 8
mmHg, MAP > 65 mmHg:
PRBCs if hematocrit < 30%.
Inotropes.
185
148
90
95
106
11
0
20
40
60
80
100
120
140
160
180
200
1 2 3 4 5 6
Month
0
50
100
150
200
250
300
350
1 2 3 4 5 6
Month
0
50
100
150
200
250
300
350
400
450
500
1 2 3 4 5 6
Month
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!!