Reducing Sepsis Mortality Richard Crowell, MD Senior Vice Chair Department of Internal Medicine...

Reducing Sepsis MortalityReducing Sepsis Mortality

Richard Crowell, MDRichard Crowell, MDSenior Vice ChairSenior Vice Chair

Department of Internal MedicineDepartment of Internal MedicineProfessor and ChiefProfessor and Chief

Pulmonary, Critical Care, and Sleep MedicinePulmonary, Critical Care, and Sleep MedicineUNM School of MedicineUNM School of Medicine

ObjectivesObjectives

• Discuss pathophysiology and treatment of Discuss pathophysiology and treatment of sepsis and septic shock, and advent of sepsis and septic shock, and advent of Early Goal-Directed TherapyEarly Goal-Directed Therapy

• Describe approach to Early Goal-Directed Describe approach to Early Goal-Directed Therapy at UNM Hospital: SMITeTherapy at UNM Hospital: SMITe

Severe Sepsis vs. Other Critical IllnessesSevere Sepsis vs. Other Critical IllnessesIn the US, more than 500 patients die of severe In the US, more than 500 patients die of severe

sepsis daily sepsis daily (Angus, Crit Care Med 2001)(Angus, Crit Care Med 2001)

ConditionCondition PrevalencePrevalence DeathsDeaths MortalityMortality

AMI AMI (1)(1) 900,000900,000 225,000225,000 25%25%

Stroke Stroke (2)(2) 700,000700,000 163,500163,500 23%23%Trauma Trauma (3) (3)

(Motor Vehicle)(Motor Vehicle)2.9 million 2.9 million 42,64342,643 1.5%1.5%

Severe Severe Sepsis Sepsis (4)(4) 751,000751,000 215,000215,000 29%29%

Source: (1) Ryan TJ, et al. ACC/AHA Guidelines for management of patients with AMI. JACC. 1996; 28: 1328-1428. (2) American Heart Association. Heart Disease and Stroke Statistics – 2005 Update. Available at: www.americanheart.org. (3) National Highway Traffic Safety Administration. Traffic Safety Facts 2003: A Compilation of Motor Vehicle Crash Data from the Fatality Analysis Reporting System and the General Estimates System. Available at http://www.nhtsa.dot.gov/. (4) Angus DC et al. Crit Care Med 2001;29(7): 1303-1310.

http://www.nhtsa.dot.gov/

Angus DC, et al. Crit Care Med. 2001.

Age Related Incidence of Severe SepsisAge Related Incidence of Severe Sepsis

Age (y)

Inci

den

ce (

per

100

0 p

op

)

0

5

10

15

20

25

30Cases Incidence

0

20,000

40,000

60,000

80,000

100,000

120,000

No

. of

Cas

es

Sepsis: A Complex DiseaseSepsis: A Complex Disease

Adapted from: Bone RC et al. Adapted from: Bone RC et al. Chest.Chest. 1992;101:1644- 1992;101:1644-5555..Used with permission, S.Simpson, MD, KU, 2008Used with permission, S.Simpson, MD, KU, 2008

SevereSevereSepsisSepsis

Trauma

Infection

SepsisOther

Pancreatitis

Burns

SIRS

Sepsis: A Deadly ContinuumSepsis: A Deadly Continuum

• A clinical response arising from a nonspecific insult, with 2 of the following:• T >38oC or <36oC• HR >90 beats/min• RR >20/min• WBC >12,000/mm3 or <4,000/mm3

or >10% bands

SIRS with a presumed

or confirmed infectious process

Chest 1992;101:1644.Chest 1992;101:1644.

SepsisSepsisSIRSSIRSSevere Severe

SepsisSepsisShockShock

SepticSeptic

Sepsis with organ

dysfunction

RefractoryHypotension

Related toSepsis

Natural History of SIRS• Prospectively enrolled 2527 patients who met SIRS criteriaProspectively enrolled 2527 patients who met SIRS criteria

• Followed for 28 days or discharge for development of any Followed for 28 days or discharge for development of any stage of the sepsis continuumstage of the sepsis continuum

Incidence (No. pts, (%)) Mortality (%)

No progression 1301 (52%) 7%

Sepsis 649 (26%) 16%

Severe Sepsis 467 (18%) 25%

Septic Shock 110 (4%) 46%

Rangel-Frausto MS, et.al. JAMA 273:117-23, 1995

•Note: median interval from SIRS to sepsis was inversely Note: median interval from SIRS to sepsis was inversely related to number of SIRS criteriarelated to number of SIRS criteria

Prognosis based sepsis severityMortality

Severe Sepsis: 20-35%Severe Sepsis: 20-35%

Septic shock: 35-60%Septic shock: 35-60%

Figure B, page 948, reproduced with permission from Dellinger RP. Cardiovascular Figure B, page 948, reproduced with permission from Dellinger RP. Cardiovascular management of septic shock. management of septic shock. Crit Care MedCrit Care Med 2003;31:946-955. 2003;31:946-955.

Clinical Alterations in Severe SepsisClinical Alterations in Severe Sepsis

• VasculopathyVasculopathy• Loss of regional autoregulationLoss of regional autoregulation• VasodilationVasodilation• Relative intravascular hypovolemiaRelative intravascular hypovolemia

• CardiopathyCardiopathy• ↓ ↓ contractility, ↑ compliancecontractility, ↑ compliance• ↑ ↑ CO, but ↓ EFCO, but ↓ EF

• Acute organ dysfunctionAcute organ dysfunction• Toxin and cytokine actions on Toxin and cytokine actions on

vascular / tissue barriersvascular / tissue barriers

Inflammatory MediatorsCardiovascular Insufficiency

Global Tissue HypoxiaGlobal Tissue Hypoxia

Increased MetabolicDemands

Hypovolemia VasodilationMyocardial Depression

Microvascular AlterationsOO22 Delivery DeliveryOO22 Demand Demand

After Fink. Crit Care Clin 2002.After Fink. Crit Care Clin 2002.Used with permission, S.Simpson, MD, KU, 2008Used with permission, S.Simpson, MD, KU, 2008

Acute Organ Dysfunction as the Hallmark of Acute Organ Dysfunction as the Hallmark of Severe SepsisSevere Sepsis

TachycardiaTachycardiaHypotensionHypotension

OliguriaOliguriaAnuriaAnuria

CreatinineCreatinine

PlateletsPlatelets PT/APTTPT/APTT Protein CProtein C D-dimerD-dimer

Altered Altered ConsciousnessConsciousness

ConfusionConfusionPsychosisPsychosis

TachypneaTachypneaPaOPaO22 <70 mm Hg <70 mm Hg

SaOSaO22 <90% <90%

PaOPaO22/FiO/FiO22 300 300

JaundiceJaundice EnzymesEnzymes AlbuminAlbumin

PTPT

Lactic acidosisLactic acidosis

Used with permission, S.Simpson, MD, KU, 2008Used with permission, S.Simpson, MD, KU, 2008

Treatment of SepsisTreatment of Sepsis

• Address cause: Treat infectionAddress cause: Treat infection

• Intravascular volume resuscitationIntravascular volume resuscitation

• Cardiovascular supportCardiovascular support

• Support of dysfunctional organ systemsSupport of dysfunctional organ systems

.

Figure 2

Has the mortality of septic shock changed with time?Friedman, Gilberto; Silva, Eliezer; Vincent, Jean-Louis; MD, PhD

Critical Care Medicine. 26(12):2078-2086, December 1998.

Time Sensitive InterventionsTime Sensitive Interventions

• Patients enrolled on entry into EDPatients enrolled on entry into ED

• Evidence of Infection Evidence of Infection

• Met SIRS criteria Met SIRS criteria

• Hypotensive Hypotensive

OROR

• Lactic acidosis (>4 mmol/L)Lactic acidosis (>4 mmol/L)

• Rapid recognitionRapid recognition• Protocol of treatment w/in 6 hours:Protocol of treatment w/in 6 hours:

• Cultures and appropriate antibioticsCultures and appropriate antibiotics

• Fluid resuscitation to CVP 8-12Fluid resuscitation to CVP 8-12

• Cardiovascular support with Cardiovascular support with pressors, augmented O2 deliverypressors, augmented O2 delivery

The Importance of Early Goal-DirectedThe Importance of Early Goal-DirectedTherapy for Sepsis Induced Hypoperfusion Therapy for Sepsis Induced Hypoperfusion

Adapted from Table 3, page 1374, from Rivers E, Nguyen B, Havstad S, et al. Early goal-directed Adapted from Table 3, page 1374, from Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. therapy in the treatment of severe sepsis and septic shock. N Engl J MedN Engl J Med 2001; 345:1368-1377 2001; 345:1368-1377

In-hospital In-hospital mortality mortality

(all (all patients)patients)

00

1010

2020

3030

4040

5050

6060 Standard therapyStandard therapy

EGDTEGDT

28-day 28-day mortalitymortality

60-day 60-day mortality mortality

NNT to prevent 1 event (death) = 6-8NNT to prevent 1 event (death) = 6-8

Mort

ality

(%

)M

ort

ality

(%

)

Surviving Sepsis Campaignwww.survivingsepsis.org

Surviving Sepsis Campaign: International Guidelines for Management of Severe

Sepsis and Septic Shock 2012Crit Care Med 2013; 41:580-637

Institute for Healthcare Improvement www.IHI.org

Early Goal-Direct Therapy (EGDT)Early Goal-Direct Therapy (EGDT)

EGDT is designed to: EGDT is designed to:

Recognize patients with severe sepsis as early as Recognize patients with severe sepsis as early as possible and begin treatment quicklypossible and begin treatment quickly

Assess laboratory and clinical variables for acute Assess laboratory and clinical variables for acute organ dysfunction, hemodynamic instabilityorgan dysfunction, hemodynamic instability

Delineate time targets for delivery of treatment of Delineate time targets for delivery of treatment of patients with sepsispatients with sepsis

Develop hospital-specific bundled protocolsDevelop hospital-specific bundled protocols

Earlier treatment leads to better outcomesEarlier treatment leads to better outcomes

Surviving Sepsis Campaign Surviving Sepsis Campaign Recommendations for EGDT BundleRecommendations for EGDT Bundle

Bundles should be developed based on the systems and expertise available to providers

Goal: perform all indicated tasks 100% of the time within the first 6 hours of identification

Good Evidence-based Data for EGDTGood Evidence-based Data for EGDT

• Mortality improvement Mortality improvement

• Use of lactate as severity and prognostic indicatorUse of lactate as severity and prognostic indicator

• Bundled protocols improve outcomesBundled protocols improve outcomes• But not all individual bundle elements have been But not all individual bundle elements have been

shown to specifically improve mortalityshown to specifically improve mortality

• Early and appropriate antibioticsEarly and appropriate antibiotics

• Aggressive fluid resuscitation improve outcomesAggressive fluid resuscitation improve outcomes

• But how much fluid?But how much fluid?

• Enough to improve end organ dysfunctionEnough to improve end organ dysfunction

• But not too much…But not too much…

Best current, generally available measure of Best current, generally available measure of Global Tissue Hypoxia is Global Tissue Hypoxia is LactateLactate

• What is role of lactate ?What is role of lactate ?

• Patient assessmentPatient assessment

• Assigning prognosisAssigning prognosis

• Guiding treatment decisionsGuiding treatment decisions

Serum Lactate as a predictor of mortality in Serum Lactate as a predictor of mortality in patients with infectionpatients with infection

Trzeciak S, et.al. Intensive Care Medicine 33:970-77, 2007

•Retrospective analysis of patients with dx of infection and lactate measured•Did not evaluate +/- shock

© 2009 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 4

Lactate is associated with mortality in Severe Sepsis Independent of organ failure and shock

Prospective cohort study

Critical Care Medicine. 37(5):1670-1677, May 2009.


Figure 3.


Lactate is associated with mortality in Severe Lactate is associated with mortality in Severe Sepsis Independent of organ failure and shockSepsis Independent of organ failure and shock


Lactate is associated with mortality in Severe Sepsis Independent of organ failure and shock 2.





• Bundled protocols improve outcomesBundled protocols improve outcomes• Even though not all individual bundle elements have Even though not all individual bundle elements have

been shown to specifically improve mortalitybeen shown to specifically improve mortality






EGDT: Bundled approaches to protocolsEGDT: Bundled approaches to protocols

• Use is evidence-based:Use is evidence-based:

• Combine multiple effective elementsCombine multiple effective elements

• Outcome is additive or synergisticOutcome is additive or synergistic

• Framework that leverages changeFramework that leverages change

• Avoids a piecemeal approachAvoids a piecemeal approach

Do Bundles Work?Do Bundles Work?

Gao, et al. Gao, et al. Critical CareCritical Care 2005, 2005, 9:9:R764-R770.R764-R770.With Permission from S. Simpson, MD,, Kansas University, 2008With Permission from S. Simpson, MD,, Kansas University, 2008

Multicenter implementation of a severe sepsisand septic shock treatment bundle. Miller RR, et.al. Am Journal Respir Crit Care Med, 2013; 188, 77-82

A. All subjects with Severe Sepsis/Septic Shock

B. Only subjects with Septic Shock




• Bundled protocols improve outcomesBundled protocols improve outcomes• Even though all individual bundle elements have not Even though all individual bundle elements have not

been shown to specifically improve mortalitybeen shown to specifically improve mortality






Timeliness of Antibiotics in Septic Shock

• Kumar, et.al. reviewed medical records of 2731 adults Kumar, et.al. reviewed medical records of 2731 adults with septic shock over 25 years in Manitoba, Canadawith septic shock over 25 years in Manitoba, Canada

• Focused on 2,154 patients who received Ab ONLY Focused on 2,154 patients who received Ab ONLY after onset of hypotensionafter onset of hypotension

• Clinical site infectionsClinical site infections

• 37.2% lung37.2% lung

• 29.3% intraabdominal29.3% intraabdominal

• 10.7% genitourinary10.7% genitourinary

• Documented infection (by cx) in 78% of casesDocumented infection (by cx) in 78% of cases

• Others by definitive xray, surgical, biopsy, or Others by definitive xray, surgical, biopsy, or autopsy evidenceautopsy evidence

• Microbiology: Gram (-) 47.9%, Gram (+) 38.3%Microbiology: Gram (-) 47.9%, Gram (+) 38.3%

Kumar A, et.al. Crit Care Med 34:1589, 2006

Septic Shock: Timing of AntibioticsSeptic Shock: Timing of AntibioticsKumar et al, CCM. 2006:34:1589-96

0.00.0

.20.20

.40.40

.60.60

.80.80

1.001.00

% Survival

% Total receiving antibiotics

0 - .5

.5 – 1.01 - 2 2 - 3 3-4 4 - 5 5 - 6 6 - 9 9 - 1

212 - 2

424 - 3

6> 36

Percent of Percent of total ptstotal pts

Time (hrs) from hypotension onset

14 ICUs; n = 2,731

Only 50% of patients in Septic Shock

received antibiotics w/in 6 hrs.

Timeliness of Antibiotics in Septic Shock

• Antibiotics w/in first hour: 79.9% survivalAntibiotics w/in first hour: 79.9% survival

• Every hour delay decreased survival by 7.6%Every hour delay decreased survival by 7.6%

• OR of in-hospital mortality increased by 12% for OR of in-hospital mortality increased by 12% for each hour delay in administrationeach hour delay in administration

• In Multivariate analysis:In Multivariate analysis:

• Time to antimicrobial therapy most strongly Time to antimicrobial therapy most strongly associated with survivalassociated with survival

• Others: APACHE score, volume of fluid in first Others: APACHE score, volume of fluid in first hour of resuscitationhour of resuscitation

•Kumar A, et.al. Crit Care Med 34:1589, 2006Kumar A, et.al. Crit Care Med 34:1589, 2006

Antibiotic administration, UNMH ED → MICUAntibiotic administration, UNMH ED → MICUMay 1, 2011 thru May 31, 2012; 296 total casesMay 1, 2011 thru May 31, 2012; 296 total cases

* Percent of Bundle patients who received Ab in this time frame

Mortality (%)

Antibiotics in < 3 hrs

Month

Perc

ent

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 150

20

40

60

80

100

% patients Ab <3hrs% patients Ab <3hrs

With Permission of Jon Femling, MD

Antibiotics < 60 minutes

Month

Pe

rce

nt

6 7 8 9 10 11 12 13 14 150

20

40

60

80

100The challenge

Antibiotics within 60 minutes is the goal. As this data reveals we meet this

goal less than 50% of the time.


20

40

60

80

12/129/126/123/1212/119/116/11 3/13

Per

cent

MonthIntervention begins

Time to AntibioticsPercent of patients who receive Antibiotics in less than 1 Hour

(monthly)

Intervention begins

Time to Antibiotics (individual patients)

July 2012 – Feb 2013 March - present,2013

Min

utes

88 min66 min

Individual patients

Cardiovascular Resuscitation-Based EGDTLin, et.al. 2006

• 241 consecutive patients enrolled, randomized to protocol vs no protocol

• Protocol focused on rapid fluids to:

• 1) attain CVP ≥ 8-12

then

2) MAP ≥ 65 (pressors, steroids as needed)

then

• 2) urine output ≥ 0.5 ml/kg/hr

• All patients got antibiotics per clinician; no differences in groups

Lin SM, et.al. Shock 6:551-7, 2006Lin SM, et.al. Shock 6:551-7, 2006

Cardiovascular Resuscitation-Based EGDT

Outcome Protocol (n=108)

No Protocol (n=116)

p

Hosp Mortality 53.7 % 71.6% 0.006

Shock reversal (hrs) 47 ± 22.8 65.4 ± 32.1 0.006

Resuscitation fluids 136.2 ± 119 88.6 ± 57.7 0.034

Time to pressors 78 22.2 104.4 29 0.001

Length of ICU stay 14.3 ± 11.7 20.3 ± 16.6 0.003

Renal failure 42 (38.9%) 64 (55.2%) 0.015

CNS failure 20 (18.5%) 42 (36.2%) 0.003

Lin SM, et.al. Shock 6:551-7, 2006Lin SM, et.al. Shock 6:551-7, 2006

Successful fluid resuscitation in EGDTSuccessful fluid resuscitation in EGDT

• What are appropriate endpoints for “successful” What are appropriate endpoints for “successful” volume resuscitation?volume resuscitation?

• Depends on “volume responsiveness”Depends on “volume responsiveness”• where is the patient on the Starling curve?where is the patient on the Starling curve?

• CVP: may not be best measure for volume CVP: may not be best measure for volume responsivenessresponsiveness

• Pulse pressure variation: accurate only in non-Pulse pressure variation: accurate only in non-spontaneously breathing patientsspontaneously breathing patients

• IVC diameter before/after fluid challenges: IVC diameter before/after fluid challenges: limited by body habituslimited by body habitus

Is optimization of oxygen delivery/utilization Is optimization of oxygen delivery/utilization necessary for successful EGDT?necessary for successful EGDT?

• Is ScVOIs ScVO22 the appropriate surrogate measure for the appropriate surrogate measure for

optimizing oxygen delivery/utilization in septic optimizing oxygen delivery/utilization in septic shock? shock?

• Role of transfusion, inotropic supportRole of transfusion, inotropic support

• Can lactate clearance be used as a measure of Can lactate clearance be used as a measure of successful EGDT ?successful EGDT ?

Surviving Sepsis Campaign:Surviving Sepsis Campaign:Early Recognition is Crucial!!!Early Recognition is Crucial!!!

• Use of screening tools improves overall Use of screening tools improves overall awareness, educates, and increases awareness, educates, and increases recognitionrecognition

• UNM: UNM: • Wards/MICU: qshift screening by Wards/MICU: qshift screening by

nursing staffnursing staff• ED: Triage nurses, EMS do initial ED: Triage nurses, EMS do initial

evaluationevaluation

Figure 1Figure 1

Figure 1. Surviving Sepsis Campaign Care Figure 1. Surviving Sepsis Campaign Care Bundles.Bundles.

Copyright © 2013 Critical Care Medicine. Published by Lippincott Williams & Wilkins. 49

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012

Dellinger, R. Phillip; Levy, Mitchell M.; Rhodes, Andrew; Annane, Djillali; Gerlach, Herwig; Opal, Steven M.; Sevransky, Jonathan E.; Sprung, Charles L.; Douglas, Ivor S.; Jaeschke, Roman; Dellinger, R. Phillip; Levy, Mitchell M.; Rhodes, Andrew; Annane, Djillali; Gerlach, Herwig; Opal, Steven M.; Sevransky, Jonathan E.; Sprung, Charles L.; Douglas, Ivor S.; Jaeschke, Roman; Osborn, Tiffany M.; Nunnally, Mark E.; Townsend, Sean R.; Reinhart, Konrad; Kleinpell, Ruth M.; Angus, Derek C.; Deutschman, Clifford S.; Machado, Flavia R.; Rubenfeld, Gordon D.; Osborn, Tiffany M.; Nunnally, Mark E.; Townsend, Sean R.; Reinhart, Konrad; Kleinpell, Ruth M.; Angus, Derek C.; Deutschman, Clifford S.; Machado, Flavia R.; Rubenfeld, Gordon D.; Webb, Steven A.; Beale, Richard J.; Vincent, Jean-Louis; Moreno, Rui; and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric SubgroupWebb, Steven A.; Beale, Richard J.; Vincent, Jean-Louis; Moreno, Rui; and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup

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

doi: 10.1097/CCM.0b013e31827e83afdoi: 10.1097/CCM.0b013e31827e83af

•

http://journals.lww.com/ccmjournal/Fulltext/2013/02000/Surviving_Sepsis_Campaign___International.24.aspx

Table 2Table 2

TABLE 2. Severe SepsisTABLE 2. Severe Sepsis

Copyright © 2013 Critical Care Medicine. Published by Lippincott Williams & Wilkins. 50

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012

Dellinger, R. Phillip; Levy, Mitchell M.; Rhodes, Andrew; Annane, Djillali; Gerlach, Herwig; Opal, Steven M.; Sevransky, Jonathan E.; Sprung, Charles L.; Douglas, Ivor S.; Jaeschke, Dellinger, R. Phillip; Levy, Mitchell M.; Rhodes, Andrew; Annane, Djillali; Gerlach, Herwig; Opal, Steven M.; Sevransky, Jonathan E.; Sprung, Charles L.; Douglas, Ivor S.; Jaeschke, Roman; Osborn, Tiffany M.; Nunnally, Mark E.; Townsend, Sean R.; Reinhart, Konrad; Kleinpell, Ruth M.; Angus, Derek C.; Deutschman, Clifford S.; Machado, Flavia R.; Rubenfeld, Roman; Osborn, Tiffany M.; Nunnally, Mark E.; Townsend, Sean R.; Reinhart, Konrad; Kleinpell, Ruth M.; Angus, Derek C.; Deutschman, Clifford S.; Machado, Flavia R.; Rubenfeld, Gordon D.; Webb, Steven A.; Beale, Richard J.; Vincent, Jean-Louis; Moreno, Rui; and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric SubgroupGordon D.; Webb, Steven A.; Beale, Richard J.; Vincent, Jean-Louis; Moreno, Rui; and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup

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

doi: 10.1097/CCM.0b013e31827e83afdoi: 10.1097/CCM.0b013e31827e83af

•

http://journals.lww.com/ccmjournal/Fulltext/2013/02000/Surviving_Sepsis_Campaign___International.24.aspx

UNM 6 Hour Sepsis Resuscitation BundleUNM 6 Hour Sepsis Resuscitation BundleCompleted ASAP (w/in 6 hrs) after (+) SIRS/Sepsis screenCompleted ASAP (w/in 6 hrs) after (+) SIRS/Sepsis screen

1. Organ function labs, Serum lactate 1. Organ function labs, Serum lactate

measuredmeasured

2. Blood Cultures obtained2. Blood Cultures obtained

3. Appropriate antibiotics administered 3. Appropriate antibiotics administered (within 1 hr)(within 1 hr)


4.4. If Lactate >4, SBP<90, MAP <65, or SBP If Lactate >4, SBP<90, MAP <65, or SBP >30mm decrease from baseline: >30mm decrease from baseline:

a.a. Give 30 ml/kg IVF bolusGive 30 ml/kg IVF bolus

b.b. Transfer to MICUTransfer to MICU


5.5. Place central venous catheterPlace central venous catheter

6.6. Apply vasopressors for hypotension not Apply vasopressors for hypotension not responding to initial fluid resuscitation to responding to initial fluid resuscitation to maintain mean arterial pressure maintain mean arterial pressure >> 65 mmHg 65 mmHg

• Norepi, then vasopressinNorepi, then vasopressin• Avoid dopamineAvoid dopamine

7.7. Consider SvO2 measurement, improve Consider SvO2 measurement, improve oxygen delivery if <65-70%oxygen delivery if <65-70%

Identification of sepsis severity !!

3 pathways

Green (sepsis)

Yellow (lactate 2-4)

Red (severe sepsis or septic shock)

• Protocol was based on literature and input from all areas involved

• Several revisions before consensus

Electronic OrderElectronic OrderSetSet

IHI Severe Sepsis Collaborative IHI Severe Sepsis Collaborative Expanded SMITe to EDExpanded SMITe to ED

• Fall 2009 Fall 2009 Joined IHI collaborative Joined IHI collaborative• Aims:Aims:

• Improve ED recognition of Improve ED recognition of severe sepsissevere sepsis• Facilitate transfers to the Facilitate transfers to the MICUMICU• Improve communication between both unitsImprove communication between both units

• ED-specific screening tool for triageED-specific screening tool for triage• Concurrent patient trackingConcurrent patient tracking• Still have twice-monthly group meetingStill have twice-monthly group meeting

““If youIf you’’re not keeping score, youre not keeping score, you’’re just re just practicing”practicing”

EGDT: Outcomes MeasuresEGDT: Outcomes Measures

• Establish institutional data baselinesEstablish institutional data baselines

““where are we starting from?where are we starting from?””

• UNM: In 2007 ~38% of all deaths on Medicine UNM: In 2007 ~38% of all deaths on Medicine service were coded for sepsis or infection as service were coded for sepsis or infection as primary cause of deathprimary cause of death

• Severe sepsis/septic shock mortality: 46%Severe sepsis/septic shock mortality: 46%

Our ED->MICU Our ED->MICU EGDTEGDT Performance Performance (2/12 -5/13) (2/12 -5/13)

~24 patients / month~24 patients / month

30% Mortality30% Mortality

LactateLactate 100%100%

CulturesCultures 94%94%

FluidsFluids 97%97%

AntibioticsAntibiotics 88%88%

PressorsPressors 79%79%

CVPCVP 68%68%


Observed Severe Sepsis MortalityObserved Severe Sepsis Mortality% Mortality Adult Severe Sepsis Observed

Severe Sepsis: UNMHSevere Sepsis: UNMHMortality Index (O/E Ratio)Mortality Index (O/E Ratio)

Documentation of Disease Severity: Documentation of Disease Severity: Severe Sepsis/Septic ShockSevere Sepsis/Septic Shock

• Severe sepsis w/o MV 96+ hours Severe sepsis w/o MV 96+ hours

with MCCwith MCC• DRG 871 DRG 871 RW: 1.9090RW: 1.9090

Est. Payment: $17,654Est. Payment: $17,654

• Severe sepsis w/o MV 96+ hoursSevere sepsis w/o MV 96+ hours

without MCCwithout MCC• DRG 872 DRG 872 RW 1.1339 RW 1.1339

Est. Payment: $10,486Est. Payment: $10,48661

Severity of Illness and Risk of Severity of Illness and Risk of MortalityMortality

Comorbidity and/or Complication (CC)Comorbidity and/or Complication (CC)•Comorbitidy: Comorbitidy: A pre-existing condition/illness A pre-existing condition/illness that will cause an increase in length of stay because that will cause an increase in length of stay because of its presence with the condition that caused the of its presence with the condition that caused the admission.admission.

•ComplicationComplication: A condition that arises during the : A condition that arises during the hospital stay that may prolong the length of stay. hospital stay that may prolong the length of stay.

•Major comordibity/complication (MCC)Major comordibity/complication (MCC)

62

MCCs for Sepsis MCCs for Sepsis

Example of MCCs for SepsisExample of MCCs for Sepsis

•Respiratory Failure due to SepsisRespiratory Failure due to Sepsis• Acute Respiratory FailureAcute Respiratory Failure

• Lung AbcessLung Abcess

• EmpyemaEmpyema

• Ventilator Dependent (can’t use unable to wean)Ventilator Dependent (can’t use unable to wean)

63

Summary of recent data on EGDTSummary of recent data on EGDT

• EGDT bundle completion improves mortalityEGDT bundle completion improves mortality

• Antibiotics within 1 hour saves livesAntibiotics within 1 hour saves lives

• Hospital-derived Sepsis much higher mortality Hospital-derived Sepsis much higher mortality than if present on admissionthan if present on admission

• UH Sepsis mortality NOT POA 2x that if UH Sepsis mortality NOT POA 2x that if Present On Admission (PAO)Present On Admission (PAO)

Brought to you by Brought to you by SMITeSMITe

SSepsisepsis

MMortalityortality

IImprovement mprovement

TeTeamam

at UNMat UNM

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