Presented by:
Laura Messineo
System Manager eICU Operations
Objectives
Sepsis Facts
Case Studies
Early Goal Directed Therapy
Presence Health’s Sepsis Initiative
Final Words
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Sepsis Facts
National Incidence of Sepsis
Every year, severe sepsis strikes about 750,000 Americans1.
Severe Sepsis kills 266,464 patients per year in the U.S.
50% of these deaths are preventable
Sepsis kills someone in the United States every 2.5 minutes
The rate of sepsis cases increases by 9% every year
According to the CDC: Patients hospitalized for septicemia
or sepsis were more than eight times as likely to die during
their hospitalization.
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Patients hospitalized for septicemia or sepsis were more
severely ill than patients hospitalized for another
diagnosis.
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Sepsis is Costly
Severe sepsis is estimated as 40% of all ICU expenditures1;
$16.7B in the US alone.2
The ALOS is 19.6 days and costs $22,100 per case.2
The ICU patient with sepsis costs 6 X more than that care of a
patient without sepsis.3
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National Focus on Sepsis
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Case Studies
Rory Staunton
A Preventable Death,
An Opportunity for Improvement
•
Critical sepsis diagnosis missed by
healthcare providers, leading to
12-year-old Rory’s untimely
death in New York
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Jennifer Ludwin: Septic Shock Survivor
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Malia’s Story
The Great Unknown
Sepsis Survivors
– Number of Disabilities
• Amputation
• Thinking
• Memory
• Calculations
• Post Traumatic Stress Disorder
Many carry the scars of sepsis for the rest of their lives
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Suspect Sepsis
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What is Sepsis?
Sepsis: Invasion of a normally sterile
organ/system by bacteria
INFECTION
KIDNEY
GI
C Difficile
LUNG
Pneumonia
HEART
Endocarditis
Urosepsis
Suspect Infection
Pneumonia/empyema
Urinary Tract Infection
Acute Abdomen Infection
Meningitis
Acutely Altered Mental Status
Chills with Rigor
Skin /Soft Tissue
Inflammation
Bone/Joint Infection
Wound Infection
Blood Stream Catheter
Infection
Implantable Device Infection
Endocarditis
Other Infections
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2 SIRS Criteria
Hyperthermia >38.3 C/ 101F
Hypothermia <36 C/ 96.8 F
Acutely Altered Mental Status
Tachycardia >90bpm
Tachypnea >20bpm
Leukocytosis (WBC >12,000)
Leukopenia (WBC <4,000)
Bands ≥ 10%
Hyperglycemia >140 ( in
absence of diabetes)
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Is There Organ Dysfunction?
HYPOPERFUSION - Lactate > 2 mg/dL
CARDIOVASCULAR - SBP < 90 mmHg, MAP < 65 mmHg, or decrease
SBP decrease 40 mmHg from normal
RENAL - Acutely elevated serum creatinine, or urine output < 0.5
ml/kg/hr
PULMONARY - Bilateral infiltrates with P/F ratio < 300
HEMATOLOGIC - Platelets < 100,000 or INR > 1.5
GASTROINTESTINAL - Total bilirubin > 2 mg/dL
From Sepsis to
Septic Shock
Severe Sepsis Definitions
SEVERE SEPSIS:
Source of infection
Two SIRS criteria
One organ dysfunction
SEPTIC SHOCK:
Source of infection
Two SIRS criteria
Lactate > 4 mg/dl
AND/OR
Hypotension requiring
pressors after adequate
fluid resuscitation
Early Goal Directed Therapy
Time Sensitive Interventions
ACUTE MYOCARDIAL INFARCTION:
Time is Myocardium
SEPSIS:
ACUTE STROKE: Time is Brain
The Three and Six Hour Bundle
TRAUMA: “Golden Hour”
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Early Goal Directed Therapy (EGDT) In The Treatment Of
Severe Sepsis And Septic Shock
• Rivers, et al; NEJM 2001
3 Hour Bundle
– Measure Lactate level
– Obtain Blood Cultures
– Administer Broad
Spectrum Antibiotics
– Administer 30ml/kg
crystalloid for
hypotension or lactate ≥4
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6 Hour Bundle
– Apply Vasopressors (for hypotension
unresponsive to fluid resuscitation) Maintain
MAP≥65 mm Hg
– Septic Shock patients with persistent
hypotension despite fluid resuscitation
• Measure Central Venous pressure
(CVP)
• Measure central venous oxygen
saturation (Scvo2)
– Remeasure lactate if initial lactate was
elevated
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Presence Health’s Sepsis
Initiative
Sepsis Council
Representation from all 12 ministries
Sepsis Champions identified at each ministry
Goals
– Implement 2012 Surviving Sepsis Campaign Guidelines
– Standardize order sets in Epic and Meditech
– Standardize screening process
– Standardize data collection and distribute monthly
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Q4 2012
Q3 2012
Q2 2012
Q1 2012
Q4 2011
Q3 2011
Q2 2011
Q1 2011
Q4 2010
Q3 2010
Q2 2010
Q1 2010
Q4 2009
Q3 2010
Q2 2009
Q1 2009
Q4 2008
Q3 2008
Q2 2008
Q1 2008
Q4 2007
Q3 2007
Q2 2007
Q1 2007
Q4 2006
Q3 2006
Q2 2006
Q1 2006
Q4 2005
Q3 2005
Q2 2005
Q1 2005
Raw Mortality (%)
Septic Shock Mortality Utilizing ICD 9 Codes
ICU Septic Shock Mortality Provena Health
60
50
40
30
20
10
0
Quarter
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Potential Impact of EGDT for Sepsis –
at PRESENCE Health
Hospital's Total Discharges
Hospital Specific Data
95,155
(2011)
per Year
Estimated Number of
Severe Sepsis Patients
= Total Hospital Discharges per
year x 2.26%
2150
= Estimated Number of Severe
Sepsis Patients x 51.2%
1101
= (Number of Treated Severe
Sepsis patients x 28.6% - Number
of Treated Severe patients x 15.4%
EGDT mortality rate)
146
= Number of Treated Severe
Sepsis patients x $5,882
$6,476,082
(based on 2.26% Incidence [Angus] – )
Estimated Severe Sepsis
Patients Treated
(based on 51.2% Compliance Rate1)
Potential Lives Saved
(15.4% EGDT mortality based on 46% relative
reduction in mortality rate of 28.6% [Rivers and
others] – slides 11 &3)
Potential Cost Reduction
(based on 27% reduction [Shorr] – slide 12)
1Nguyen, HB
2Angus,
et al. Critical Care Medicine. 2007; 35:1105-1112
DC et al. Critical Care Medicine. 2001; 29:1303-1310
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Mobile Simulation Lab
Closing Thoughts……
Suspect Sepsis
Implement EGDT
Decrease Disabilities
SAVE LIVES!!!
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Join Me……
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