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R. Phillip Dellinger MD, MSc, MCCMProfessor and Chair of MedicineCooper Medical School of Rowan UniversityMedical Director Adult Health InstituteSenior Critical Care AttendingCooper University HospitalCamden NJ USA
SEPSIS TREATMENT AND
BUNDLES
MANDATED PERFORMANCE:
GOOD OR BAD?
Potential Conflicts of Interest
• Hold leadership position in Surviving Sepsis Campaign
Objectives
Sepsis in the U.S.Evolution of Sepsis
Performance
Improvement
New CMS Measures
State of Sepsis in the U.S.
Photo: http://www.npr.org/sections/health-shots/2015/07/28/426740179/happy-50th-birthday-medicare-your-patients-
are-getting-healthier
Severe Sepsis in the U.S
Photo: http://www.npr.org/sections/health-shots
National Center for Health Statistics Data Brief No. 62 June 2011; PharmacoEconomics. 2004;22(14):895-906.
.
• Strikes more than one million
Americans annually1
• 28-50% mortality2
• Sepsis cases on the rise
.http://www.cdc.gov/nchs/data/databriefs/db62.pdf accessed August 7, 2015
In-hospital death 8X higher
compared to other diagnoses
2004 Guidelines
Guidelines to bundles - 2004
6 hour
24 hour
SSC Database and Implementation Guide
2008 Guidelines
February 2013
New Database - 3 & 6 hour bundle
2012 NQF: Sepsis 0500
TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION :
1.Measure lactate level
2.Obtain blood cultures prior to administration of antibiotics
3.Administer broad spectrum antibiotics
4.Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L
2012 NQF: Sepsis 0500
TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:
5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure (MAP) ≥65mmHg)
6. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36mg/dl):
- Measure central venous pressure (CVP) - Measure central venous oxygen saturation (ScvO2)*
7. Remeasure lactate if elevated.
Over 1500 Patients
Measure 0500-
Public Comment-Member Voting-Decision
? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? April 20, 2014
F
SEPSIS BUNDLE PROJECT (SEP)
NATIONAL HOSPITAL INPATIENT QUALITY
MEASURES
SEP-1 EARLY MANAGEMENT BUNDLE,
SEVERE SEPSIS/SEPTIC SHOCK
Discharges 10-01-2015 (4Q15)
through 06-30-16 (2Q16)
Measure Set Description
Focus on adults ≥18 years with a diagnosis of severe sepsis or
septic shock. Consistent with the Surviving Sepsis Campaign
Guidelines, the measure set assesses:
1. Measurement of lactate,
2. Obtaining blood cultures,
3. Administering broad spectrum antibiotics,
4. Fluid resuscitation,
5. Vasopressor administration,
6. Reassessment of volume status and tissue perfusion and
7. Repeat lactate measurement.
21
Severe Sepsis Criteria “a” & “b”
22
All three criteria refers to a, b, and c.
Criteria “c” - Organ Dysfunction
23
Septic Shock Definition
24
Specifications Alphabetical Data Dictionary page1-331
SEP-1 Two Clocks
3
hour
Set Measure ID # SEP-1-8; Early Management Bundle, Severe Sepsis/Septic Shock
3 hr.
6 hr.
SEP-1: Early Management Bundle,
Severe Sepsis/Septic Shock
26
Septic Shock ONLY Measures
27
3 hr.
6 hr.
POTENTIAL MEASURE
MODIFICATIONS ON THE
HORIZON
Missing Organ Dysfunction Criteria?
29
Respiratory dysfunction?
Antibiotic Stewardship
Repeat Volume Assessment &
Tissue PerfusionBundle
31
Documentation consisting of either:
A focused exam including documentation of all 5 of the elements
• Vital signs AND
• Cardiopulmonary exam AND
• Capillary refill examination, AND
• Peripheral pulse evaluation AND
• Skin examination
OR
Any two of the following four:
• Central venous pressure measurement
• Central venous oxygen measurement
• Bedside cardiovascular ultrasound
• Passive leg raise or fluid challenge
Shoemaker WC et al, Arch Surg 1973;106:630-6
We believe that almost any reasonable
plan is better than no plan at all
Good or Bad?
CMS Measures (Sep-1)Within 3 hours
Within 6 hours
>
>
>
CMS Measures (Sep-1)Within 3 hours
Within 6 hours
>
>
>
>
>
>
Over 1500 Patients
ProCESS ARISE
Enrollment <2 hours from
detection of
shock
2.8 hours
(median) from
presentation to
ED
Antibiotics 75% received
prior to
enrollment
70 minutes
(median) from
presentation to
ED
Fluids >2 liters prior ot
enrollment
2515ml (mean)
prior to
enrollment
TO SAVE LIVES.....
Early fluid resuscitation
Early antibiotics
Early identification
Importance of reassessment
Good or Bad?
ThankYou