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Improving Compliance with Surviving Sepsis Goals

Improving Compliance with Surviving Sepsis Goals. Bela Patel, MD Tammy Campos RN Lillian Kao MD. Sepsis. 10 th most common cause of death in US Leading cause of death in ICU 17 billion dollars/year Sepsis is the body’s response to infection Severe sepsis: multiple organ dysfunction

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Improving Compliance with Surviving Sepsis Goals

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  1. Improving Compliance with Surviving Sepsis Goals Bela Patel, MD Tammy Campos RN Lillian Kao MD

  2. Sepsis • 10th most common cause of death in US • Leading cause of death in ICU • 17 billion dollars/year • Sepsis is the body’s response to infection • Severe sepsis: multiple organ dysfunction • Septic shock: hypotension • Septicemia: bloodstream infection • Estimated 800,000 cases of severe sepsis per year in the US • Rate increasing by 1.5% per year – estimated additional 1 million cases by 2020

  3. Incidence of Severe Sepsis & Septic Shock Approximate Cases/Year 800,000 Severe sepsis 800,000 600,000 400,000 Septic shock 400,000 200,000 Deaths from septic shock 200,000 0

  4. Projected Incidence of Severe Sepsis 600,000 1,800,000 Severe Sepsis Cases 1,600,000 US Population 500,000 1,400,000 400,000 1,200,000 Sepsis Cases 1,000,000 Total U.S. Population/1,000 300,000 800,000 200,000 600,000 400,000 100,000 200,000 2001 2025 2050 Year Angus DC, et al. Crit Care Med. 2001.

  5. Severe Sepsis: Incidence and Mortality Incidence Mortality Deaths/Year Cases/100,000

  6. Sepsis and Mortality • Mortality 30-50% • 1,400 people per day worldwide die from sepsis • The 28-day mortality rate from sepsis is similar to 1960’s rates for acute myocardial infarction

  7. Surviving Sepsis Campaign • Goal of 25% reduction in mortality by 2009 • Potential lives saved in US: 50,000/ year • Potential lives saved in world: 1,100,000/ year

  8. Sepsis Bundles • Bundle: group of interventions when performed together result in better outcomes than each individually • Sepsis Resuscitation Bundle: Evidence-based goals that must be completed within 6 hours for patients with severe sepsis, septic shock and/or lactate > 4 mmol/L • Sepsis Management Bundle: completion of tasks by 24 hours after presentation

  9. Resuscitation Bundle • Serum lactate measured • Blood cultures prior to antibiotic administration • Broad-spectrum antibiotics administered • Within 3 hours of ED arrival or 1 hour non-ED admission • Treat hypotension with fluids +/- vasopressors • Initial minimum of 20 mL/kg of crystalloid  • Vasopressors to keep MAP > 65 mm Hg • Persistant hypotension • Maintain central venous pressure > 8 mm Hg • Central venous O2 saturation (Scvo2) > 70%

  10. Rivers E et al. NEJM 2001. Resuscitation Bundle

  11. Importance of Early Goal-Directed Therapy NNT to prevent 1 event (death) = 6-8 Standard therapy 60 EGDT 50 40 Mortality (%) 30 20 10 0 In-hospital mortality (all patients) 28-day mortality 60-day mortality Rivers E, Nguyen B, Havstad S, et al.. N Engl J Med 2001; 345:1368-1377

  12. Management Bundle • Administration of low dose steroids in septic shock per ICU policy. • Administration of drotrecogin alfa by a standard ICU policy. • Glycemic control > lower limit of normal but < 180 mg/dl • Maintenance of inspiratory plateau pressure < 30 cm H2O in mechanically ventilated patients.

  13. MICU – ED collaboration • The Medical ICU • 16 bed unit that admits approximately 1100 patients per year. • Chief diagnoses include septicemia, respiratory failure, renal failure, and multisystem organ failure secondary to multiple co-morbid conditions • The Emergency Department • Level 1 Trauma Center • 65,000 annual visits

  14. Aims To increase mean overall compliance with the Sepsis Resuscitation within 6 hours of arrival from <5% to ≥ 50% within 6 months. To achieve an absolute reduction in mortality in septic MICU patients and decrease length of stay for these patients.

  15. Measures of Success • Increased compliance with the individual SRB elements within 6 hours of arrival • Increased compliance with all 6 SRB elements for each patient within 6 hours of arrival • Decreased mortality for sepsis patients • Decreased cost per case • Decreased length of stay

  16. What’s so hard?

  17. How should we do it?

  18. Where do we start?

  19. Interventions: Education • Education of multidisciplinary staff including nurses, physicians, nutritionists, respiratory therapists on the resuscitation bundle • National experts invited to provide optimal dialogue for change • Interdepartmental meetings for team building • Sepsis screen checklist placed in each chart for physician screening • Appointed unit champions to assure education was available 24/7 in the ICU and EC • Implemented standardized Sepsis Order Sets to improve compliance • Posted compliance rates in the unit for staff and MDs to see • Posted posters explaining process in ICUs for staff reference

  20. Interventions: Tools

  21. Interventions: Monitors • Daily audit rounds sheet to track bundle compliance for the physician team • Bundle compliance review regularly in multidisciplinary team meetings • Daily nursing manager rounds to assure bundle compliance • Routine feedback to the EC • Decrease time to initiation of bundle elements • Decrease time to transfer to ICU

  22. Interventions: Work Flow • Implemented mini-RCA process to review all failures • Decreased time to central line placement via Clinical Skills Center at UT and ultrasound placement education • Decreased EC to ICU delays with collaborative workflow changes • Transitioned Rapid Response Team (RRT) nurses to incorporate sepsis screening and resuscitation outside of the ICU • Decreased pharmacy time by limiting drug options • Added additional drugs to the Pyxis to assure rapid access • Decreased time to blood transfusion via standardization of order on the sepsis order sets

  23. Outcomes: Bundle

  24. Outcomes: 6 of 6

  25. Outcomes: Mortality

  26. Outcomes: Mortality

  27. Outcomes: Mortality 33 total lives 19% Reduction

  28. Outcomes: LOS, Cost • There has been a $1200 cost per case reduction in direct costs for a total savings of $525,600 based on 440 cases between January 2007 and July 2009.

  29. Conclusion • With focused effort, we were able to improve both compliance with individual bundle components and with patients receiving all 6 within 6 hours of arrival. In addition mortality rates, cost per case and length of stay decreased. • This methodology is readily transferrable to additional ICUs and to community hospitals using existing protocols.

  30. Acknowlegements • UT Divisions of Critical Care, Pulmonary and Sleep Medicine • UT Department of Emergency Medicine • MHH ICU Nursing Staff • UT-MHH Academy of Patient Safety & Effectiveness • MD Anderson Cancer Center

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