Bundles of Care and Sepsis

Dr Raymond McKeeConsultant in Intensive Care Medicine and Anaesthesia

Craigavon Area Hospital30th August 2013

Overview

• Brief history of “care bundles”

– Why are they used?

• What’s in a bundle?• How do they work?

– And what is the evidence they do (or don’t)?

• Surviving Sepsis: Guidelines and bundles

• What I’m not going to do– A line by line dissection of the SSC Guidelines• You can do that yourself!

– Lists of bundles and what they contain• …!

– Repeat much of what you’ve heard already• Stop me if I do…

Why “bundles of care”?

• Definitions, in recent years, have added clarity• Patients, however, do not readily fit into the

neat boxes as described“There is no such thing as a typical patient with sepsis; we should avoid ‘lumping

together’ all these patients”1

1 The Problem of Sepsis JL Vincent et al ICM 1994

Why “bundles of care”?

• While undoubtedly true…– Previous practical experience was that there was NO degree of consistency of approach• Huge variation in individual and institutional practice• Huge outcome variation

= NOT GOOD

A Brief History…

• American initiative– Not entirely altruistic…– IHI considered high-risk, high-cost interventions

• Radically different approach– Considered systems approach to care delivery– Also critically examined any/all assumptions made

in delivering that care

A Brief History…

• Using IHI approach– Easiest areas to tackle are those with• Significant potential problems• Strong evidence base to direct change

• Also identified important basic aspects– Multi-disciplinary teamworking– Communication

A Brief History…

• 2 subject areas fitted these criteria– Care of patients on ventilators– Central line care

Already researchedKnown individual interventions to improve outcome• Widely accepted• Previously considered individually

A Brief History…

• The difference was they combined the interventions in a “bundle”– Small group, to increase buy-in and adoption– Initially to small group of ICUs (13 in US)

• A “bundle of care”…

What’s in a Bundle?

• Primary aim was reduction of complications associated with mechanical ventilation

• Contents straightforwardInitial reaction: “of course we do that”

• Required that, to achieve bundle compliance, all elements must be enacted

Ventilated Care Bundle

• Before participation, units predicted c. 90% compliance– This was a little optimistic; even if 90% compliant

90% of the time, with 5 bundle elements, the overall compliance is (0.9)5 = 60%

– In reality, initial recording showed these units to have compliance 10-20%

Ventilated Care Bundle

• The poor initial results acted as a catalyst– Individual units had hard evidence they were not

as good as they thought– Direct challenge to assumed practice– “Kick start” to allow systems change

Do they work?

• Yes…and no– Ventilated bundles: those with >95% compliance

showed that VAP rates were reduced by c. 40%; and sustained2

• Great; but why?? These were high-performing units, which had already considered the individual elements in the bundle, but without these results.

2 Resar et al (2005)

More Results

• Other studies have shown comparable results345

– Interestingly, these studies didn’t follow all IHI recommendations

– 1 study6 used only 2 IHI recommendations• Sedation breaks; daily chlorhexidineBut with similar, sustained results

Why??

3Burger et al, Mayo Clin Proc 20064Youngquist et al JCJQPS 20075Bird et al Arch Surg 20106Rello et al VAP Care Contributors 2010

The Theory…

• Realisation that change is necessary– First find out what you think you do; then measure

this against the “benchmark”• Multi-disciplinary approach to design and

implementation– Means more likely that all bases covered• Makes ongoing commitment easier

The Theory…

• Small changes grouped together: this requires a level of teamwork and co-operation which results in high levels of sustained performance– Not seen if working on individual items separately

Or…

• If implemented correctly, a bundle will improve patient care by improving collaborative teamwork– This is what improves care, and therefore

outcomes

• This can happen pretty much independently of the actual contents of the care bundle

Back to the point…

• First published 2004; updated 2008, 2012.• 2 phases: initial resuscitation

ongoing care

Surviving Sepsis

Surviving Sepsis

• These are the summary points from SSC• How to get from there to a bundle…?

Surviving Sepsis Bundle

• Initial resuscitation– Cut down to minimum: lactate; fluid

• Sepsis screening– Culture; antibiotics

• Ongoing care– Vasopressors if non-fluid responsive– Target interventions and reassess

Surviving Sepsis Bundle

• The current Sepsis Care bundle from the expert advisory group therefore:– Relatively short– Independent elements– Defined timescale– Largely descriptive (except fluids)– Compliance…??

Sepsis Bundles: do they work?

• Plenty of evidence to show that implementing a sepsis care bundle is associated with improved outcome– Gao7: prospective study. Age and severity

matched: Mortality 49% - 23% following implementation

However…

7 Gao et al Crit Care 2005

• Gao7: study variables deconstructed.– Compliance with all elements of bundle: 52%

• Simmonds8 :UK teaching hospital– Retrospective look at 46 pts meeting severe sepsis

criteria• Received Abx within 3hrs: 52%• Appropriate fluid resus within 6hrs: 57%• Time from diagnosis to admission to Critical Care: 12.9hrs• No patient had all relevant bundle elements enacted

within specified time frame7 Gao et al Crit Care 20058 Simmonds et al JICS 9:124-7

Sepsis bundles: do they work?

• Surprised??– Not really9…– No facility in ED/MAU in UK to allow all aspects of

6hr bundle to be reliably enacted– HDU bed capacity often does not allow patients to

be admitted in a timely fashion

9 McNeill et al Clin Med 8:163-5

Problems

• Guidelines behind the bundles are not the subject of unanimous, or even majority, agreement– Pretty much ignored in Australasia– Lactate: generally agreed that, in isolation, not

especially useful• Lactate clearance has more utility10

– Fluid: much discussion in literature over the dangers of a blanket fluid requirement• Over and significant under-resuscitation

10Nguyen et al Crit Care Med 2006

Problems

• Guidelines behind the bundles are not the subject of unanimous, or even majority, agreement– Vasopressors: finally, the realisation that

dopamine is no use– Quantitative resuscitation:• CVP and ScvO2 endpoints from Rivers EGDT• Significant discussion regarding generalizability of these

endpoints to a varied population of sepsis patients

• The magic bullet

• The magic bullet…??????

Ongoing Discussion…

• Steroids remain a controversial topic– And I think we’ll hear more about this

• Immunoglobulins– Playing an increasing role in certain shock states in

specific aetiologies• This needs further work; again, I think guidelines here

will change…

To finish…

• Back to the start:– JL Vincent: one size most certainly does not fit all

• So why bother with guidelines and bundles?– Complex subject matter– Lack of overall agreement on treatments– Inability to carry out many of the required actions

for a multitude of reasons

• Short answer: because they work; because they have been shown to work, in terms of improved outcome– But for the reasons outlined at the start• Improved multi-disciplinary care • Better, more efficient team-working• Realisation that the problem exists

• Care bundles are an excellent idea– Should be our aim to ensure all our patients are

managed appropriately and aggressively• Reduced organ failures• Reduced mortality

• No care bundle for an area as diverse as sepsis management, will ever be perfect– Creating a set of broadly applicable interventions

to consider in all patients, all the time IS important

• A Bundle can– Bring together these ideas– Crystallise them into a small set of bullets – Allow wide dissemination to ALL those caring for a

defined patient group – Allow realisation that intervention early will

improve mortality– Establish and reinforce application of best practice