Sepsis A Medical Emergency State of the Science Symposium Best Critical Care Practices 2011 Jim O Brien, MD, MSc James.OBrien@osumc.edu
Disclosures, 2004-May 2011 University grant monies: Davis/Bremer Medical Research Award ($50K, 3/05 2/07) Non-industry grant monies: NHLBI K23 HL075076 ($520,992, 4/05 3/09); NIH Clinical Research I think sepsis Loan Repayment is under appreciated. Program ($152,781, 10/03-6/05, 7/06-6/10 ) Industry grant monies: PI for aerosolized amikacin (Aerogen, $0, 8/05 6/06) PI for calfactant (Pneuma, $0, 9/08 current) I think sepsis is under funded. d d I think we over complicate sepsis care (MD effect) Consultant/Speakers Bureau: Unrestricted educational grant from Lilly to present talk at SCCM (2005) Consultant to Medical Simulation Corporation ($4000, 2005-2006) ICU. Co-author on manuscript with Lilly employees Consultant to Keimar, Inc ($0) Board of Directors, Sepsis Alliance Honoraria to Sepsis question Alliance is how (Travel/accomodations many of us will may die have first. been provided) Lecture on future perspectives on sepsis definitions (Brahms, 2009). Lecture on sepsis treatment (GE, 2011) Video on sepsis communication (GE, 2011) Webinar on sepsis (Siemens, 2011) I think that I have less to offer septic patients once they are in the I think that it is inevitable that we will get our act together. Only
Goals today Review the definition of sepsis Review why ideal sepsis care continues to elude us Quality and Safety Make the case for simplifying sepsis care ( Lean Sepsis ) Antibiotics Fluids Medical emergency At least one of you will save someone s life as a result
Suspicion 6 hours Resuscitation rhapc 24 hours Glucose control Hospitalization Vasopressors Initial lmanagement PACs Steroids tifacogin ibuprofen Maintenance PAFase antitnf antiil 1 Pre and post discharge Recovery 4
Suspicion 6 hours Resuscitation 24 hours Hospitalization Initial lmanagement Maintenance Pre and post discharge Recovery
6 So what is sepsis anyway?
According to the Consensus definition, what is sepsis? 1. Blood poisoning i 2. Bacteremia 3. Shock due to infection 4. Fever due to infection 5. None of the above
Sepsis: Defining a Disease Continuum SIRS = Systemic Inflammatory Response Syndrome Infection/ Trauma SIRS Sepsis Severe Sepsis SIRS with a presumed or confirmed infectious process 8 Adapted from: Bone RC, et al. Chest 1992;101:1644, Opal SM, et al. Crit Care Med 2000;28:S81
According to the Consensus Conference definition, which of the following is NOT a SIRS criterion? 1. SBP<90 and/or MAP <70 2. Heart rate >90 3. Respiratory rate >20 or PaCO2<32 4. Temperature >38 C or <36 C 5. WBC >12K or <4K or >10% bands
Sepsis: Defining a Disease Continuum SIRS = Systemic Inflammatory Response Syndrome Infection/ Trauma SIRS Sepsis Severe Sepsis A clinical response arising from a nonspecific insult, including 2 of the following: Temperature 38 o C or 36 o C HR 90 beats/min Respirations 20/min WBC count 12,000/mm 3 or 4,000/mm 3 or >10% immature neutrophils 10 Adapted from: Bone RC, et al. Chest 1992;101:1644 Opal SM, et al. Crit Care Med 2000;28:S81
What do MDs think about sepsis? Poeze et al. Crit Care 2004; 8: R409-13 1058 in US and Europe surveyed by telephone by professional survey company Based on everything you know, how do you define sepsis? 22% of intensivist gave Consensus definition (5% other MDs) 17% agreed on one definition 6 different definitions were mentioned by at least 10% of respondents
What do MDs think about sepsis? Poeze et al. Crit Care 2004; 8: R409-13 1058 in US and Europe surveyed by telephone by professional survey company How do you communicate about sepsis? 81% find it difficult to communicate with families about sepsis 85% describe sepsis as complication from underlying condition
What do MDs think about sepsis? Poeze et al. Crit Care 2004; 8: R409-13 1058 in US and Europe surveyed by telephone by professional survey company How do you communicate about sepsis? 10% say SEPSIS
What does the public know about sepsis? Harris Poll Funded by Sepsis Alliance 1004 in US surveyed by telephone by professional survey company from June 23-27, 2010 Have you heard the term sepsis? No in 67%
Talk the talk Sepsis is a life threatening condition that arises when the body s response to infection injures its own tissues and organs. 15
Sepsis incidence, 1999-2003 In ncidence e X10 3 22% 44% 73% Sepsis Severe Sepsis Septic shock Death in sepsis Source: Nationwide Inpatient Sample
Sepsis incidence, 1999-2003 In 2003, In ncidence e X10 3 1 in 35 of ALL hospital admissions involved sepsis 1 in 66 involved severe sepsis 1 in 233 involved septic shock Sepsis Severe Sepsis Septic shock Death in sepsis Source: Nationwide Inpatient Sample
Sepsis incidence, 1999-2003 In ncidence e X10 3 21.7% 16% 20.7% Sepsis Severe Sepsis Septic shock Death in sepsis Source: Nationwide Inpatient Sample
Sepsis incidence, 1999-2003 In ncidence e X10 3 21.7% In 2003, In 2003, 23.2% of all deaths during hospitalization involved sepsis 1 in 35 of ALL hospital admissions involved sepsis (up from 19.4% in 1999) 22 2% 1 in 66 involved severe sepsis In other words. 1 in 4.3 deaths of hospitalized patients 20.7% involves sepsis 1 in 233 involved septic shock 44% 1 16% 73% Sepsis Severe Sepsis Septic shock Death in sepsis Source: Nationwide Inpatient Sample
215,000 deaths a year in US Deaths from Breast cancer Lung Cancer + Prostate Cancer 228 Deaths every ~9 h TOTAL < Deaths 3212 deaths every ~5.5 days 2974 Deaths Every ~5 days from Sepsis
The greatest trick the Devil ever pulled was convincing the world he didn t exist. Roger Kint 21
Sepsis Recognition at OSUMC Patients admitted through ED Main Jan March 2009 (n = 4951) Received ATBs within 24 hrs of admission (n = 941, 19.0%) That extrapolates Randomly selected to 768 charts unrecognized reviewed septic patients/year (n = at 500, OSU 53.1%) Main ED alone! Patients with sepsis upon ED presentation (n = 137, 27.4%) Recognized as septic in ED Not recognized as septic in notes and/or H&P ED notes and/or H&P (n = 35, 25.5%) (n = 102, 74.4%) Dreher et al Manuscript in preparation
Antibiotic Therapy & Blood Cultures All Subjects: 56.2% 30.7% 77.4% p = 0.004 p = 0.165 p = 0.001 All subjects Recognized Not recognized P value Hours to Order 1.9 (1.1 3.0) 1.3 (1.0 2.0) 2.1 (1.3 3.5) 0.012 Hours to 2.6 2.1 2.8 0.043 Administration (1.9 3.9) (1.7 3.7) (2.0 4.5) Dreher et al Manuscript in preparation
What can YOU do? Say Sepsis Causes you to think about diagnosis Raises awareness May improve care
Which of these is sepsis? 1. Confusion, cough, nausea 2. Fever, shortness of breath, chest pain We have to ACT when we are 3. Abdominal pain, lightheadedness, diarrhea uncertain. 4. Rash, leg swelling, anorexia 5. Tachycardia, chills, sweating
Stop RECOGNIZING Start SUSPECTING Levy et al, Crit Care Med 2003; 31: 1250 6
Antibiotics - Minutes Matter Every E hour in delay of appropriate it atbx = 76%l 7.6% lower survival Median time to appropriate atbx = 6h Kumar et al. Crit Care Med 2006; 34: 1589 96.
Shock to effective antibiotic time and mortality in septic shock* Per rcentage of patients 90 *Assuming 130,000 septic shock cases per year 80 70 60 50 40 30 20 10 0 0 2h >2 3h >3 4h >4 6h >6 12h >12h %Mortality 26.7 36.1 36.6 46.8 62.3 83.1 % of patients 26.8 9.0 7.8 12.8 18.8 24.9 Adapted from Kumar et al. Crit Care Med 2006; 34: 1589 96.
Door to balloon time and mortality in STEMI* 25 *Assuming 400,000 STEMIs per year Pe ercentage of patients 20 By getting door to balloon times of <2h for ALL STEMI patients, we would save 5 4775 lives per year. (13 people a day) 15 10 0 0 2h >2 3h >3 4h >4 6h >6 12h >12h % Mortality 4.9 5.2 6.5 6.7 6.9 5.5 % of patients 8 23.5 21.1 21.6 17.3 8.5 Adapted from Cannon et al. JAMA 2000; 283: 2941 7.
Shock to effective antibiotic time and mortality in septic shock* Per rcentage of patients 90 *Assuming 130,000 septic shock cases per year 80 70 By getting shock to antibiotic times of <2h 60 50 for ALL septic shock patients, 40 we would save 30 32,360360 lives per year. 20 (89 people a day) 10 (3.7 people an hour) 0 0 2h >2 3h >3 4h >4 6h >6 12h >12h (3.5 times the effect of STEMI intervention) %Mortality 26.7 36.1 36.6 46.8 62.3 83.1 % of patients 26.8 9.0 7.8 12.8 18.8 24.9 Adapted from Kumar et al. Crit Care Med 2006; 34: 1589 96.
The first 12 hours matters even more For first 12 hours, 1% mortality per 5 minute delay Funk and Kumar, Crit Care Clinics 2011; 53 76.
What can YOU do? Say Sepsis Suspect Sepsis Common in hospitalized patients No single symptom/sign Effective communcation
Affecting the emergency response to sepsis: Antibiotics Education Automatic triggers Processes Structures Is there any situation in which you are giving antibiotics for an infection in which you want the initial dose delayed? Decision support ABX Sepsis onset ABX order administration ABX order time (Clinician Action) ABX order to administration time (System Response) Maybe we should focus on time from order to administration? Sepsis to ABX administration time (Performance measure) 33
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Not all orders are created equal ROUTINE will be scheduled for next usual scheduled administration time. QD = 9am NOW will be prepared in usual queue then delivered with next scheduled delivery and administered when it arrives STAT prints on different printer, different color paper, prepped immediately, immediately delivered to unit
Order Priority Comparisons
Timeline Preintervention Intervention Post intervention 8/24/08 1/1/09 3/31/09 6/7/10 Data collection platform Educational Sepsis Order Set Antibiotics by Site Antibiotics in Pyxis
ATB By Site of Infection ICU
ATB By Site of Infection ICU-CAP
Order Priority STAT NOW ROUTINE
330 Median time to antibiotics (min) in septic shock 300 270 240 210 180 150 120 90 60 30 0 42
70% Patients receiving antibiotics within 2h of sepsis in septic shock 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% -5% 43
Mean Times - STAT doses only
Septic Shock in OSUMC MICUs Pre During Post intervention Intervention Intervention 8/24/08 12/31/08 1/1/09 3/31/09 4/1/09 5/2/11 Hospital 26.8% 23.5% 22.2% mortality Adjusted relative 0.93 0.89 risk of dying Lives saved 1.3 13.1 That s a life saved for every 39 patients treated. Patients with sepsis onset within 24h of ICU admission SOFA shock score of >0
Septic Shock in OSUMC MICUs Pre intervention Since Intervention 8/24/08 12/31/08 1/1/09 5/2/11 Hospital LOS (mean) 13.4 10.8 Hospital days saved 1461 (19.4% decrease) ICU LOS (mean) 7.7 5.6 ICU days saved 1180 (27.3% decrease) Patients with sepsis onset within 24h of ICU admission Patients with sepsis onset within 24h of ICU admission SOFA shock score of >0
47 But 20% are still dying. It must be more complex than this.
The person you care about the most has chest pressure and the ECG shown below. Would you prefer a response that A. Utilizes the expertise and commitment of the staff on duty to assess the situation and provide what they deem to be the appropriate care. B. Has an action plan in place which activates particular structures and processes to provide default evidence- based actions for all such events. 50
The person you care about the most is on a plane which is failing after flying through a flock of birds. Would you prefer a response that A. Utilizes the B. Has an action plan expertise and in place which commitment of the activates specific staff on duty to assess structures and the situation and processes to provide provide what they default evidence- deem to be the based actions for all appropriate care. such events. 51
The person you care about the most is febrile, confused and lightheaded. Would you prefer a response that A. Utilizes the B. Has an action plan expertise and in place which commitment of the activates specific staff on duty to assess structures and the situation and processes to provide provide what they default evidence- deem to be the based actions for all appropriate care. such events. 52
The Surviving Sepsis Campaign Plan (Bundles) 6 hours Educational 1. Check lactate materials 2. Web Blood site cultures 3. CD Antibiotics within 3h for Protocols ED, 1h for non-ed ICU Advertising admits 4. Cards If shock, and give posters fluids Data ( 20ml/kg) collection ± pressors 5. If shock continues, CVP>8 and CVO2>70% 24 hours SSC Intervention: 1. Steroids per protocol 2. Drotrecogin per protocol 3. Goldilocks glucose 4. Pplat<30 53 Crit Care Med 2010;38:367 74
SSC Results Hospital mortality 37.0% 30.8% by 2 years NNT = 16.1 Crit Care Med 2010;38:367 74
SSC Results Initial Care (within 6h) Crit Care Med 2010;38:367 74
Systematically Raising Suspicion and Simplifying Intervention Bedside RN MEWS score every 4 hours Trigger if >4 New SIRS Suspected infection SBAR Communication to MD WBC>14 Sepsis Team (nursing led) Lab Sepsis Six Daniels et al. Emerg Med J 2010
The Sepsis Six to be delivered within 1 hour 3 Investigations 3T Treatments t High-flow oxygen IV antibiotics Fluid challenge Blood cultures Measure lactate Measure urine output and Identify Severe Sepsis and Septic Shock Daniels et al. Emerg Med J 2010 57
Results (within 1 hour) Frequency Mortality when Mortality when Number needed achieved not achieved achieved to treat High flow oxygen 74.3% 43.1% 31.8% 9 Antibiotics 61.6% 45.4% 28.1% 6 Fluids 67.7% 44.8% 30.0% 7 Blood cultures 63.0% 49.1% 26.3% 4 Lactate 69.1% 43.4% 4% 30.9% 8 Urine output 68.8% 42.9% 31.0% 8 All Sepsis 6 38.6% 44.1% 20.0% 4 Daniels et al. Emerg Med J 2010
Do you want a Sepsis 6 Nurse? N=567 % patients Sepsis 6 Achieved (1h) Resuscitation Bundle Achieved (SSC 6h) Mortality Sepsis 6 Nurse 25.4% 82.6% 72.9% 25.5% 5% No Sepsis 6 Nurse 74.6% 23.9% 23.4% 38.4% NNT 7.8 So, presuming 567 patients per year One could conclude a 24/7 program could save 73 lives a year that s one person saved ever 5 days AT THAT HOSPITAL Daniels et al. Emerg Med J 2010
Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years Sebat et al CHEST 2007; 35: 2568-2575 2575 HYPOTENSION (low BP) OR Normal BP with ih3 of following: Mental status change, cool extremities, RR 20, Low urine output, Elevated lactate, Fever Fluid Bolus (over 10 15 min) 1000mL if ED 250mL if ward 43% of patients with septic shock (46% hypovolemic ) Reassess for Presence of Criteria ACTIVATE TEAM
Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years Sebat et al Crit Care Med 2007; 35: 2568-2575 2575 40.0% NNT = 4 11.8%
Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years Sebat et al Crit Care Med 2007; 35: 2568-2575 2575 e onset tes since Minu Among septic shock patients, mortality decreased from 50% to 10% NNT = 2.5 Time to Antibiotics
Speed Up, Simplify and Specialize? Mortality ARR NNT Time to 1 Pre Post life saved* SSC 37.0% 30.8% 6.2% 16.1 11.8 days Sepsis 6 RN 38.4% 25.5% 12.9% 7.8 5 days Shock Team 50% 10% 40% 2.5 1.8 days *assuming 500 patients per year
Speed Up, Simplify and Specialize? That s also between 8074 and 52,000 deaths from septic shock caused by our Mortality ARR NNT Time to 1 current care. Pre Post life saved* Time to 1 life saved** SSC 37.0% 30.8% 6.2% 16.1 11.8 days 65 min Sepsis 6 RN 38.4% 25.5% 12.9% 7.8 5 days 31 min ShockTeam 50% 10% 40% 2.5 1.8days 6 min Considering severe sepsis, between 28,057 and 132,859 people die because we don t *assuming provide 500 this patients type of per care. year **assuming 130,000 patients per year
You can save lives Say Sepsis Suspect Sepsis Simplify Sepsis Treat it like a medical emergency Antibiotics Fluids
Talk the talk Sepsis is a life threatening condition that arises when the body s response to infection injures its own tissues and organs. Walk the walk Recognize sepsis as a medical emergency requiring the administration of fluids, antibiotics and other appropriate treatments of infection within one hour of suspicion of sepsis. 66
We choose to go to the 7/20/1969 / moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize andmeasure the best of our energies and skills, because the challenge is one we are willing to accept, one we are unwilling to postpone, p and one which we intend to win." JFK, 9/12/1962 67
System awareness and systems design areimportant for health professionals, but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system s success. Ultimately, the secret of quality is love If you have love, you can then work backward to monitor and improve the system. Avedis Donabedian, bdi 1919 2000