Participating in the Surviving Sepsis Campaign: How It Can Help You!

Laura Evans, MD MScMedical Director of Critical Care

Bellevue HospitalNYU School of Medicine

Disclosures

• No conflicts of interest to disclose

Outline• Burden of sepsis• Surviving Sepsis Campaign– Background– Results to date– 2012 Update

• Benefits of Participating in the Surviving Sepsis Campaign

• Public Reporting in New York State

Why Focus on Sepsis?• Sepsis is the leading cause of death in non-

coronary care intensive care units, with a mortality rate between 30% and 50%

• From 2007 to 2009, over 2,047,038 patients were admitted with a sepsis-related illness– 52.4% are diagnosed in the ED– 34.8% on the hospital wards– 12.8% in the ICU

Hall, M.J, et al. NCHS data brief, 62. Hyattsville, MD: National Center for Health Statistics. 2011Reed K et al. Health Grades. June, 2010 2011;The First Annual Report(1):1-28.

Why Sepsis?• The cost to the US healthcare system for

sepsis, and pneumonia grew twice as fast as the overall growth in hospital charges– $54 billion per year– Approximately 180 percent increase from 1997 to

2005

Hall, M.J, et al. NCHS data brief, no 62. Hyattsville, MD: National Center for Health Statistics. 2011Reed K et al. Health Grades. June, 2010 2011;The First Annual Report(1):1-28.

Why Sepsis?

Why Sepsis?

Why Sepsis?

• It’s common and increasing in frequency as the population ages

• It’s associated with high risk of death and long length of stay

• It’s expensive• AND…. The good new is:

We Can Make a Difference• There are interventions proven to reduce

mortality and cost• However, these interventions are not routinely

done in all settings• Adherence to Surviving Sepsis Campaign

bundles is an effective approach to significantly decrease mortality of patients with severe sepsis or septic shock

Surviving Sepsis Campaign• Phase 1:–Barcelona Declaration (2002):• Reduce mortality from severe sepsis and septic shock by 25%

• Phase 2: –Development of Evidence-based Guidelines (2004)• Second edition published 2008• Third edition to be released January 2013

• Phase 3:–Education and Implementation • Development of Sepsis Bundles

Surviving Sepsis Campaign: International guidelines for management of severe sepsis

and septic shock: 2008

Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T,

Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S,

Vender JS, Zimmerman JL, Vincent JL.

Crit Care Med 2008;32:858-873Intensive Care Med 2008;30:536-555

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• European Society of Clinical

Microbiology and Infectious Diseases• European Society of Intensive Care

Medicine• European Respiratory Society

• Infectious Disease Society of America

• International Sepsis Forum• Society of Critical Care

Medicine• Surgical Infection Society• Canadian Critical Care Society• Japanese Society of Critical Care

Medicine• Japanese Association of Acute

Medicine• German Sepsis Society• Latin American Sepsis Institute

Surviving Sepsis Campaign Phase 3

• Partner with Institute for Healthcare Improvement (IHI) – Develop sepsis “bundles” – 2 Bundles: Resuscitation (6 hours) and

Management (24 hours)• Facilitate adoption of guidelines• Benchmark performance

Phase 3: Multifaceted Intervention

National/regional/network “launch meetings”• Identify local champions• Introduce sepsis bundles• Educational tools• Staff support for coordinating sites• Regular conference calls

Website

Interactive database

Surviving Sepsis Campaign • Facilitate early recognition of severe sepsis– Provider education– Screening tools– Treat sepsis as an emergency

• Emphasize timely evidence-based management– Assessment of perfusion– Early antibiotics– Fluid resuscitation– Assessment of adequacy of resuscitation

Surviving Sepsis Campaign Phase 3: Results

Surviving Sepsis Campaign Phase 3: Demographics

• 252 sites in 18 countries• 15,775 charts• Sites contributed from 1 to 471 patients• Sites entered patients from 1 to 37 months

Levy MM et al. CCM 38(2):367-374, February 2010.

Compliance with bundle elements

Levy MM et al. CCM 38(2):367-374, February 2010.

Compliance with each bundle element increased over time. Compliance with ALL elements increase over time, but remained low.

Levy MM et al. CCM 38(2):367-374, February 2010.

Change in Compliance Over Time

Levy MM et al. CCM 38(2):367-374, February 2010.

Change in Mortality Over TimeSite quarter Hospital

mortality1 37.0%2 36.1%3 36.8%4 33.2%5 34.7%6 30.6%7 34.1%8 30.0%

Mortality Benefit:

7% ARR

19% RRRP < .001

Levy MM et al. CCM 38(2):367-374, February 2010.

Change in Mortality Over Time

Longer Term Results

• Hospitals with 3 and 4 year participation in the SSC showed continued improvement over the entire period of participation– No plateau seen in benefit– Compliance with bundles continued to increase– Hospital mortality continued to decrease– Data in publication

What’s New

• Updated Surviving Sepsis Guidelines• Updated Surviving Sepsis Bundles• Ratification of National Quality Forum (NQF)

Measure 0500: Severe Sepsis and Septic Shock: Management Bundle

• New York State Public Reporting

2012 SSC Guidelines

Dellinger, RP Critical Care Medicine. 41(2):580-637, February 2013.

Revised SSC Bundles

•Based on 2012 SSC guideline Revision–Utilizing analysis of 28,000 pt SSC

database•New software in development•No industry funding utilized in revising

guidelines or bundles

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

Surviving Sepsis Campaign BundlesTO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level2) Obtain blood cultures prior to administration of antibiotics3) Administer broad spectrum antibiotics4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L

Surviving Sepsis Campaign BundlesTO BE COMPLETED WITHIN 6 HOURS:

5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36 mg/dL): --Measure central venous pressure (CVP)* --Measure central venous oxygen saturation (ScvO2)*7) Remeasure lactate if initial lactate was elevated*

*Targets for quantitative resuscitation included in the guidelines are CVP of ≥8 mm Hg; ScvOs of ≥70%, and normalization of lactate.

SSC: The Next Phase• Increase the number of hospitals contributing

data to the Surviving Sepsis Campaign to 10,000 worldwide

• Apply the guidelines to 100% of patients in whom the diagnosis is suspected

• Develop a strategy to improve the care of septic patients where healthcare resources are limited

SSC: The Next Phase

• Assuming that the reduction in mortality seen to date can be sustained and 10,000 hospitals comply with the Campaign recommendations, we could save 400,000 lives if we treat only half of the eligible patients with the Surviving Sepsis Campaign Bundles

SSC: The Next Phase• Enhanced support for participating hospitals

coming soon– Updated website with:• Educational materials• Implementation toolkit• Screening tools

– Inpatient floors

– Updated database with new bundles from revised guidelines

Surviving Sepsis Campaign – The next phase

• Recognition of both the progress that has been made and the work left to do

• Goals:– Exponentially increase participation – Increase compliance with sepsis bundles and

performance metrics– Save more lives!

Why Participate in the SSC?• Participating hospitals have:–Access to free educational programs by world-

renowned sepsis experts –Access to experienced, trained quality improvement

experts –Access to colleagues at other institutions who share

the commitment to improving care for patients with sepsis–Benchmarking: Access to the SSC database to enter

your data and get reports on your performance

Why Participate in the SSC?

• Participating hospitals have:–The opportunity to improve the care of severely

septic patients directly in the hospital using evidence-based sepsis bundles–The opportunity to advance the field of quality

improvement

Why Participate in the SSC?

• Build morale at your hospital • Use a proven intervention that improves

survival of patients with sepsis• Get ahead of the curve with performance

measures–NQF–NY State

NQF Sepsis Measures• Measure # 0500: Severe Sepsis and Septic Shock

Management Bundle• Proposed by:– Henry Ford Hospital System(HFHS)– California Pacific Medical Center/Sutter Health

(CPMC)– Society of Critical Care Medicine (SCCM)– Infectious Diseases Society of America (IDSA)– Institute for Healthcare Improvement (IHI)– Surviving Sepsis Campaign (SSC)– Ohio State University (OSU)

NQF Measure

www.qualityforum.org

Within 3 HoursWithin 6 Hours

NQF Sepsis Measures• March 2013 Update:– Continued endorsement ratified

• NQF measures are derived from the Surviving Sepsis Campaign and are aligned with the SSC sepsis bundles

New York State Reporting• Dr. Nirav Shah, New York

State Health Commissioner announced his intention to require reporting of sepsis performance measures state-wide

• Expected to be public reporting

• NY will be first state to do this

New York State Reporting Requirements

• Hospitals will be required to use an evidence-based protocol for identification and management of patients with sepsis

• Hospitals will be required to report– adherence to protocol elements– sepsis rates– risk-adjusted sepsis mortality