Improving Compliance with
Surviving Sepsis Goals
Bela Patel, MD
Tammy Campos RN
Lillian Kao MD
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
Incidence of Severe Sepsis
& Septic Shock
800,000
600,000
Severe sepsis
800,000
400,000
Septic shock
400,000
200,000
Deaths from septic shock
200,000
0
Approximate Cases/Year
Projected Incidence of
Severe Sepsis
Severe Sepsis Cases
US Population
Sepsis Cases
1,600,000
500,000
1,400,000
400,000
1,200,000
1,000,000
300,000
800,000
200,000
600,000
400,000
100,000
200,000
2001
2025
Year
Angus DC, et al. Crit Care Med. 2001.
2050
Total U.S. Population/1,000
600,000
1,800,000
Severe Sepsis:
Incidence and Mortality
Incidence
Mortality
250000
250
Deaths/Year
Cases/100,000
300
200
150
200000
150000
100000
100
50000
50
0
0
AIDS
Breast
Cancer
1st MI
Severe
Sepsis
AIDS
Breast
Cancer
AMI
Severe
Sepsis
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
• 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
Sepsis Bundles
• Bundle: group of interventions when
performed together result in better
outcomes than each individually
• Sepsis Resuscitation Bundle: Evidencebased 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
Resuscitation Bundle
1. Serum lactate measured
2. Blood cultures prior to antibiotic
administration
3. Broad-spectrum antibiotics administered

Within 3 hours of ED arrival or 1 hour non-ED admission
4. Treat hypotension with fluids +/vasopressors


Initial minimum of 20 mL/kg of crystalloid
Vasopressors to keep MAP > 65 mm Hg
5. Persistant hypotension


Maintain central venous pressure > 8 mm Hg
Central venous O2 saturation (Scvo2) > 70%
Resuscitation Bundle
Rivers E et al. NEJM 2001.
Importance of Early
Goal-Directed Therapy
NNT to prevent 1 event (death) = 6-8
Mortality (%)
60
50
Standard therapy
EGDT
40
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
Management Bundle
1. Administration of low dose steroids in
septic shock per ICU policy.
2. Administration of drotrecogin alfa by a
standard ICU policy.
3. Glycemic control > lower limit of normal
but < 180 mg/dl
4. Maintenance of inspiratory plateau
pressure < 30 cm H2O in mechanically
ventilated patients.
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
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.
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
What’s so hard?
Bundle Compliance for Severe Sepsis
Equipment/
Supplies
People
Lab results
not available
on computer
Drugs and fluids
not available in Pyxis
Lack of buy-in
from key people
Bundle increases
workload
Lack of education
about potential
to improve outcome
Competing tasks deemed
more important
by residents and nurses
ScVO2 catheters not placed
prior to ICU
transfers from floor
Nurses, Residents
sidetracked
by other patients
MICU residents fail
to recognize need
for intervention
Failure of EC residents
to identify sepsis
Lab tests not ordered
in timely way
MICU resident unaware
that sepsis protocols I
nitiated in EC
Delay of transfer
from EC to MICU of
up to 6 hours
Residents unaware
of change
in patient’s condition
Protocol not automated
-dependent on residents
ordering appropriately
Lack of standardization
delays key interventions
Policy, Procedure
Communication
Non-compliance with
resuscitation bundle
for severe sepsis
Nurses
unaware
of residents orders
How should we do it?
Process Map
DIAGNOSIS OF
SEPSIIS
REQUIRING ICU
ADMISSION
EC
DIRECT
MICU ADMISSION
FLOOR
RRT
BLOOD CULTURES
LACTATE
ABG
EGDT
SEPSIIS
NURSE
SCREENING
TOOL
CONFIRM SEPIS
ICU
TEAM
RESIDENT
FELLOW
ATTENDING
24 HOUR
BUNDLE
6 HOUR
BUNDLE
STEROIDS
DROTRECOGIN
ALPHA
LACTATE
BLOOD
CX
GLYCEMIC
CONTROL
AB
WITHIN
1 HOUR
POLICY
FOLLOWED
PLATEAU
PRESSURE
HYPOTENSION
NO
YES
EGDT
ScVO2.>70
NO
MONITOR
AND GUIDE
TREATMENT
BLOOD
DOBUTAMINE
CONTACT
MICU MD
Where do we start?
Percent Incorrect per Bundle Item
400
100
60
200
40
100
0
C2
C3
Percent
Cum %
20
ScVO2
97.2
25.7
25.7
CVP >8
81.0
21.4
47.1
Antibiotics Fluids/Vaso
65.4
59.0
17.3
15.6
64.4
80.0
Lactat e Blood Cultures
40.4
35.2
10.7
9.3
90.7
100.0
0
Percent
80
300
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
Interventions: Tools
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
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
Lactate
Blood Cultures
Antibiotics
Fluids/Vaso
CVP >8
ScVO2
Aug-09
Jul-09
Jun-09
May-09
Apr-09
Mar-09
Feb-09
Jan-09
Dec-08
Nov-08
Oct-08
Sep-08
Aug-08
Jul-08
Jun-08
May-08
Apr-08
Mar-08
Feb-08
Jan-08
Dec-07
Nov-07
Oct-07
Sep-07
Aug-07
Jul-07
Jun-07
May-07
Apr-07
Mar-07
Feb-07
Jan-07
Dec-06
Nov-06
Oct-06
Sep-06
Aug-06
Outcomes: Bundle
Compliance with Bundle Elements
100
90
80
70
60
50
40
30
20
10
0
Aug-06
Sep-06
Oct-06
Nov-06
Dec-06
Jan-07
Feb-07
Mar-07
Apr-07
May-07
Jun-07
Jul-07
Aug-07
Sep-07
Oct-07
Nov-07
Dec-07
Jan-08
Feb-08
Mar-08
Apr-08
May-08
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Per Cent Compliance
Outcomes: 6 of 6
Overall Compliance
Patients Who Received 6 of 6 -- Goal 50%
80
60
40
20
0
Outcomes: Mortality
Sepsis -Illness Risk 4- Mortality Rate Reduction
Jan 04 to Dec 06
Jan-04
EGDT
Jan-07- began Jan-07
1.0
UCL=0.887
Proportion
0.8
0.6
_
P=0.398
0.4
0.2
0.0
LCL=0
1
8
15
22
29
Tests performed with unequal sample sizes
36
43
50
57
64
Outcomes: Mortality
Sepsis Illness Risk 3 Mortality Reduction
EGDT - began Jan - 07
29
1
Jan-04
1.0
Proportion
0.8
0.6
UCL=0.473
0.4
0.2
_
P=0.102
0.0
LCL=0
1
6
11
16
21
26
Tests performed with unequal sample sizes
31
36
41
46
51
Outcomes: Mortality
Mortality Rates
APR-DRG 720 Septicemia
49%
40%
33 total
lives
14%
19% Reduction
10%
26% Reduction
Illness Risk 4
Illness Risk 3
Before
After
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.
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.
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