Tiffany M.

Osborn, MD
University of Virginia
ACEP Chair Critical Care
Section
ACEP Representative
Surviving Sepsis Campaign
 Purpose for Existence?

Today Future
1,800,000 600,000
Severe Sepsis Cases

Total US Population/1,000
1,600,000 US Population
500,000
1,400,000

>750,000
Sepsis Cases
1,200,000 400,000

cases of severe 1,000,000

sepsis/year 800,000
300,000

in the US* 600,000 200,000

400,000 Incidence projected to

100,000
200,000 increase by 1.5% per year

2001 2025 2050

Year

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

 Comparison With
Other Major Diseases
Incidence of Severe Sepsis Mortality of Severe Sepsis
300 250,000
250
200,000
Cases/100,000

Deaths/Year
200
150,000
150
100,000
100
50,000
50
0
0
AIDS* Colon Breast CHF† Severe AIDS* Breast AMI† Severe
Cancer§ Sepsis‡ Cancer§ Sepsis‡

†NationalCenter for Health Statistics, 2001. §American Cancer Society, 2001. *American Heart Association.
2000. ‡Angus DC et al. Crit Care Med. 2001;29(7):1303-1310.
 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
• 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
70
Total visits/ED
Visits / ED (% Change)

Critical Care
50
Urgent
Nonurgent
30 P < 0.001 for all groups

10 1. National Center for Health Statistics;

2001
-10 2. Ann Emerg Med 2002;39:389-96
Visits/ED 3. Curr Opin Crit Care Dec.2002
 Surviving Sepsis Campaign
A global program to:

• Reduce mortality rates

•Improve standards of care
•Secure adequate funding
 Surviving Sepsis
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
Sponsoring Organizations
• American Association of • European Society of
Critical-Care Nurses Clinical Microbiology and
Infectious Diseases
• American College of Chest
Physicians • European Society of
Intensive Care Medicine
• American College of • European Respiratory
Emergency Physicians Society
• American Thoracic • German Sepsis Society
Society • Indian Society of Critical
• Australian and New Care Medicine
Zealand Intensive Care • International Sepsis
Society Forum
• Episepsis • Society of Critical Care
Medicine
• Surgical Infection Society
 Surviving Sepsis
Phase 1 Barcelona declaration
Phase 2 Evidence based guidelines
Phase 3 Implementation and education
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.
 Clinical Inertia: Low Levels of
Compliance at Research Centers

SAVE site Non-SAVE site

• Cross-sectional analysis of

ACE inhibitor use (%)

20

25,886 patients enrolled in GUSTO-1 15

• 659 hospitals, 22 SAVE sites 10
• SAVE: Survival and 5
Ventricular Enlargement, ACE 0
(angiotensin-converting enzyme)

ACE inhibitor use (%)

benefits post-MI patients with LV 20
dysfunction 15

10

0
Pre-SAVE Post-SAVE
Majumdar SR, et al. Am J Med 2002;113:140-5
 Clinical Inertia: Low Levels of
Compliance at Research Centers

“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”.

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
– 3rd 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 ScvO2 measured.
– CVP maintained >8 mmHg.
– MAP maintain > 65 mmHg.
• ScvO2<70%with CVP > 8
mmHg, MAP > 65 mmHg:
– PRBCs if hematocrit < 30%.
– Inotropes.
 Rhode Island Hospital EGDT Data

Time from Entering ED Time from Entering ED

to Receiving Antibiotics to Catheter Insertion Time from Entering ED
to Transfer to MICU
Reduced by 42% Reduced by 60%
Reduced by 51%
200 350
185 500

180
450
300
160
148 400

140 250
350

120 11 300
106 200

100 95
90 250

150
80 200

60 150
100

100
40
50
50
20
 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 H2O 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!!