1. Participating in the Surviving Sepsis Campaign: How It Can Help You! Laura Evans, MD MSc Medical Director of Critical Care Bellevue Hospital NYU School of Medicine

2. Disclosures No conflicts of interest to disclose

3. 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

4. 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. 2011 Reed K et al. Health Grades. June, 2010 2011;The First Annual Report(1):1-28.

5. 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. 2011 Reed K et al. Health Grades. June, 2010 2011;The First Annual Report(1):1-28.

6. Why Sepsis?

8. 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:

9. 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

10. 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

11. 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;32:858-873 Intensive Care Med 2008;30:536-555

12. 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

13. 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

14. 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 WebsiteInteractive database

15. 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

16. Surviving Sepsis Campaign Phase 3: Results

17. 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.

18. 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.

19. Levy MM et al. CCM 38(2):367-374, February 2010. Change in Compliance Over Time

20. Levy MM et al. CCM 38(2):367-374, February 2010. Change in Mortality Over Time Site quarter Hospital mortality 137.0% 236.1% 336.8% 433.2% 534.7% 630.6% 734.1% 830.0% Mortality Benefit: 7% ARR 19% RRR P <.001

21. Levy MM et al. CCM 38(2):367-374, February 2010. Change in Mortality Over Time

22. 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

23. 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

24. 2012 SSC Guidelines Dellinger, RP Critical Care Medicine. 41(2):580-637, February 2013.

25. 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

26. 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

27. 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

28. Surviving Sepsis Campaign Bundles TO BE COMPLETED WITHIN 3 HOURS: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L

29. Surviving Sepsis Campaign Bundles TO 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 Hg 6) 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.

30. 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

31. 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

32. 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

33. 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!

34. 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

35. 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

36. 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

37. 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)

38. NQF Measure www.qualityforum.org Within 3 Hours Within 6 Hours

39. 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

40. 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

41. 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