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