Can we help “solve” sepsis together?P a r t 2 o f t h e W e b i n a r S e r i e s

J u l y 2 3 , 2 0 1 9

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JB68929US

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W H Y T H I S P A R T N E R S H I P ?

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www.gehealthcare.com/virtual-collaboratortom.zimmerman@ge.com

Comprehensive Lab Testing

Patient Imaging & Monitoring

Complete view of patient

I n t r o d u c t i o n s

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Today’s Speakers

• Mervyn Singer, MB BS MD FRCP(Lon) FRCP(Edin) FFICMProfessor of Intensive Care Medicine

University College of London

• Dr. Singer has led on a number of important multi-center trials in critical

care. He has also authored various papers and textbooks including the

Oxford Handbook of Critical Care, now in its 3rd Edition, and is a Council member of the International Sepsis Forum..

• Tom Zimmerman - Moderator

Director of Acute Care Commercial Marketing

GE Healthcare

A G E N D A

5*Disclaimer: Technology in development that represents ongoing research and development efforts. These technologies are not products and may never become products. Not for sale. This product cannot be placed on the market or put into service until it has been made to comply with CE marking.

Sepsis and Fake NewsLooking beyond the hype…

• “Misleading” epidemiology• Confusing management policies and their impact• Patient frailty implications• Discussion: “Avoidable” vs. unavoidable death

• Live chat Q & A with Dr. Singer

P o l l i n g Q u e s t i o n # 1

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Regarding incidence & mortality rate from sepsis past 5 years

Has your enterprise experienced,

a) More cases, better survival

b) More cases, unchanged survival

c) Same number of cases, unchanged survival

d) Same number of cases, better survival

Incidence & Mortality rates

P o l l i n g Q u e s t i o n # 2

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Every hour’s delay in antibiotics costs lives…agree?

a) Yes, for all septic patients

b) Only for those in shock

c) Only for those in shock who are rapidly deteriorating

d) No

Antibiotics delay costs live?

Live Chat with Dr. Singer

Please submit your questions online!

We’ll pause to answer the first batch in just a few minutes….

MERVYN SINGER

BLOOMSBURY INSTITUTE OF INTENSIVE CARE MEDICINE

UNIVERSITY COLLEGE LONDON, UK

S E P S I S A N D F A K E N E W S

( 1 ) I S S E P S I S A M A J O R K I L L E R ?

. . A N D T H E R E W A S A

R O B U S T R E S P O N S E

O U R W O N D E R F U L U K

M I N I S T E R F O R

H E A L T H R E C E N T L Y

T W E E T E D . .

( 2 ) S E P S I S I S T H E T I P O F T H E I N F E C T I O N I C E B E R G

P U T T I N G T H E N U M B E R S I N C O N T E X T . .

• England has a population of 56 million people

• 33.6 million antibiotic prescriptions by English GPs from Apr 2016 - Mar 2017

• ~1.9 million emergency hospital episodes with an ICD discharge code of sepsis/infection

• .. of whom ~122,000 (6.8%) died in-hospital

• … ~14,000 of these deaths had an ICU admission

S O U R C E S : S U S P I C I O N O F S E P S I S D A S H B O A R D , E S P A U R , I C N A R C

( 3 ) T H E S E P S I S E P I D E M I C

… L I E S , D A M N L I E S A N D C O D I N G

R I S E I N S E P S I S I N U S ( 1 9 9 3 - 2 0 1 4 ) - A H R Q D A T A

C H A N G E I N D R G R E I M B U R S E M E N T

C H A N G E I N I C D D I S C H A R G E

C O D I N G

N H S E N G L A N D S E P S I S D A S H B O A R D

1,313,2371,436,427 1,467,670

1,612,495 1,691,1531,802,928

1,907,883

0

500000

1000000

1500000

2000000

2500000

2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18

patients with infection + sepsis discharge codes

NHSEnglanddata

+45%

409 US hospitals

( 4 ) A R E S E P S I S O U T C O M E S I M P R O V I N G ?

… L I E S , D A M N L I E S A N D C O D I N G

D O N ’ T J U S T L O O K A T T H E P E R C E N T A G E C H A N G E ,

… B E W A R E T H E R I S I N G D E N O M I N A T O R

118,676

213,124300,270

781,725

??? under-reported

??? over-reported

101,608109,926 105,124

117,110 114,992 122,263 128,803

0

50000

100000

150000

200000

250000

2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18

patients dying in hospital

NHSEnglanddata

1,313,2371,436,427 1,467,670

1,612,495 1,691,1531,802,928

1,907,883

0

500000

1000000

1500000

2000000

2500000

2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18

patients with infection + sepsis discharge codes

+45%

+27%

-13%

( 6 ) I S I T R E A L L Y S E P S I S ?

I’ve recently seen other sepsis mimics …

• Haemophagocytic syndrome (HLH)

• Beri-beri

• aHUS

• TTP

• Phaeocromocytoma ….

n= 211

( 7 ) D O P A T I E N T S D I E O F O R W I T H S E P S I S ?

0

200000

400000

600000

800000

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+

‘SUSPICION OF SEPSIS’ ADMISSIONS IN ENGLAND 2011-17N

Age

Mortality (%)

0

10

20

30

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+

‘SUSPICION OF SEPSIS’ MORTALITY 2011-17

Age

45

6

11

5

11

3

20

8

30

6

39

6

60

3

93

3

18

12

31

96

51

65

83

59

14

70

8

24

76

7

35

27

0

55

62

6

82

54

4

95

92

5

98

03

9

77.5% OF DEATHS8% OF DEATHS

~ 8000 DEATHS

Patients may be allowed to die from/with sepsis due to the severity of their underlying comorbidity - terminal cancer,

end-stage organ failure, severe stroke, severe dementia …

• 12,477 patients screened over two 24-hr periods in 14 Welsh hospitals

• 839 patients identified, of whom 521 fulfilled Sepsis-3 criteria (SOFA ≥2)

• 136 died in hospital, 96 for non-sepsis reasons

• Of 40 sepsis-attributable deaths (12 definite, 28 possible):

• 77.5% had high frailty score (≥6)

• 70% had existing DNA-CPR order

• 42.5% had limitation-of-care order

( 8 ) A R E A L L S E P S I S D E A T H S P R E V E N T A B L E ?

( 9 ) D O B U N D L E S O F C A R E S A V E L I V E S ?

Q U A L I T Y I M P R O V E M E N T P R O G R A M S ,

M A N D A T E S … .

.. of patients

Immediate 30 ml/kg fluid!

Immediate antibiotics!

• Well-intentioned clinicians

• … but enthusiasm spilling over into evangelism

• Supportive data all based on retrospective analysis of databases with

heavy statistical adjustments .. + much missing data and with

biological/clinical implausibilities

• Governments pressured into launching mandated care bundles and

(financially penalizing) quality improvement programs

• No prospective study of early antibiotic Rx has shown benefit - including

quality improvement programs

• n=4183

• n=2628

• mortality

30.5% pre- vs. 29.4% post-

intervention (p=0.54)

p<0.002

2672 patients

Intervention group: TTA 26 min (IQR 19–34) pre-arrival at ED

Usual care group: TTA 70 min (IQR 36–128) post-arrival at ED

96 min

difference

G O V E R N M E N T M A N D A T E

“ Q U A L I T Y I M P R O V E M E N T ”

C H A N G E I N P R A C T I C E

O U T C O M E B E N E F I T ? ? ?

U N I N T E N D E D

C O N S E Q U E N C E S

U K H O S P I T A L A N T I B I O T I C U S E

… B U T C A N N O T D E M O N S T R A T E

A N Y R E D U C T I O N I N M O R T A L I T Y

• One size does not fit all

• Need appropriate response to suit the individual patient

• Not 30 ml/kg fluid in the first hour .. but rather titrate to what’s

needed to restore euvolaemia

• Not a rush to throw in antibiotics unless patient is very ill - can

take up to 4 hours to perform tests, seek advice etc to confirm

likelihood of infection, best choice of antibiotic and need for

source control .. but avoid unnecessary delay

P E R S O N A L V I E W O N M A N A G E M E N T

CERTAINTY OF

BACTERIAL INFECTION

ILLNESS SEVERITY

Jump in quickly (<1 hr)

with empiric RxSeek advice,

run tests ..

(3-4 hr window …

…but avoid

unnecessary delay)

Jump in if

worried about

possible infection

Sepsis Shock

No antibiotic

Watchful waiting

± tests

F U T U R E T H O U G H T S

• If appropriate intervention occurs before patient becomes very ill, then

outcomes should be better

• Need biomarkers to:

• distinguish between infectious and non-infectious causes of illness

• detect deterioration - organ dysfunction - early

• select any specific therapies to suit that patient (theranostic)

• .. and be able to titrate therapy to optimal degree

S U M M A R Y

• Current practice is largely driven by dogma, propaganda, institutional pressures and

Twitter … rather than hard fact

• Challenge the dogma where facts are lacking e.g. antibiotics

• One size doesn’t fit all .. personalisation not rigid protocolization

• Apply physiology - and thought - to individual patient management

• Don’t unnecessarily delay and give a proportionate response

Questions?

Live Chat with Dr. Singer

Please submit your questions online!

Questions?

Live Chat with Dr. Singer

Please submit your questions online!

Next: August 22nd series edition

“Can we help ‘solve’ sepsis together?”

Jeffrey Hersh, Chief Medical Officer, GE HealthcareInteractive Augmented Intelligence for Medical Care

O U R P L E D G E T O Y O U

High quality insights to guide

collaborative care for individual patients

before sepsis-related decline requires

heroic and expensive measures.

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Learn more:

www.gehealthcare.com/virtual-collaborator

tom.zimmerman@ge.com

Technology in development that represents ongoing research and development efforts. These technologies are not products and may never become products. Not for sale. Not cleared or approved by the U.S. FDA or any other global regulator for commercial availability.

Thank you!

August 22nd edition

“Can we help ‘solve’ sepsis together?”

Jeffrey Hersh, Chief Medical OfficerInteractive Augmented Intelligence for Medical Care

T H E V I S I O N

We envision a digital

platform – augmented

Intelligence – that

activates data and

liberates clinicians

to reveal patient

deterioration sooner.

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