Intervention: Sepsis Date: Thursday, May 8, 2014 Sponsor: •Canadian Patient Safety Institute •Canadian ICU Collaborative Speakers: •John C. Marshall, MD FACS, St. Michael’s Hospital, University of Toronto Purpose of the Call: Provide update on the Surviving Sepsis Campaign

1. SURVIVING SEPSIS: STATE OF THE ART
Thursday, May 8 2014
Jeudi 8 mai 2014

2. Your Hosts & Presenters
Vos hôtes et présentateurs
Bruce Harries, Moderator
Denny Laporta, MD, FRCPC, CSPQ
Ardis Eliason, Technical Host
John C. Marshall, MD, FRCSC, FACS
208/05/2014

3. Interacting in WebEx: Today’s Tools
Interagir dans Webex : outils à utiliser
3
Be prepared to use:
- Pointer
- Raise hand
- CHAT
- Text Tool
“writing on the slide”
- Shape Tools
Have you used WebEx before?
Avez-vous déjà utilisé WebEx?
 YES / OUI NO / NON 
Soyez prêts à
utiliser les outils :
- le pointeur
- lever la main
- clavardage
- Outil textuel
pour « écrire sur la
diapo »
- Outils de forme08/05/2014
Type your
message
& click
‘send’
Select
‘send to’

4. 4
Who’s Online?
Qui est en ligne?
POINTER
08/05/2014

5. What professions are represented?
Quelles professions sont représentées?
Nurse MD
Educator / Quality
Improvement
Professional
Infection
Control
Administrator /
Senior Leader
Other
POINTER
Respiratory
Therapist
Nutritionist
508/05/2014

6. Dr. John C. Marshall
Surviving Sepsis: State of the Art

7. The Surviving Sepsis Campaign:
State of the Art
St. Michael’s Hospital University of Toronto
John C. Marshall MD FACS
Safer Healthcare Now
May 8, 2014

8. Paris, 1997 …

9. • Definitions
• Diagnosis of infection
• Antibiotics
• Hemodynamic support
• Source control
• ICU care
• Adjunctive therapies
• Novel therapies

10. Phase 1 Barcelona declaration
Phase 2 Evidence-based guidelines
Phase 3 Implementation and
evaluation

11. A global program to reduce
mortality rates in severe sepsis
ESICM, ISF and SCCM
Partially funded by unrestricted educational grants
from Baxter, Edwards, Philips and Lilly

12. Sponsoring Organizations
• American Association of Critical Care Nurses
• American College of Chest Physicians
• American College of Emergency Physicians
• American Thoracic Society
• Australian and New Zealand Intensive Care Society
• European Society of Clinical Microbiology and Infectious
Diseases
• European Society of Intensive Care Medicine
• European Respiratory Society
• International Sepsis Forum
• Society of Critical Care Medicine
• Surgical Infection Society

13. Guidelines Meeting
London, England
June 2003

14. - Crit Care Med 32:858, 2004

15. The Sepsis Bundles
• Institute for Healthcare
Improvement (IHI)
• Measurable activities that
indicate compliance with
guidelines

17. - N Engl J Med 355:1640, 2006

18. San Francisco, January 2006

19. American Association of Critical-Care Nurses
American College of Chest Physicians
American College of Emergency Physicians
American Thoracic Society
Canadian Critical Care Society
European Society of Clinical Microbiology and Infectious Diseases
European Society of Intensive Care Medicine
European Respiratory Society
International Sepsis Forum
Society of Critical Care Medicine
Japanese Association for Acute Medicine
Japanese Society of Intensive Care Medicine
Surgical Infection Society
Participation and endorsement by the German Sepsis Society and
the Latin American Sepsis Institute.
Sponsors 2006

20. - Crit Care Med 36:296, 2008

21. Miami 2010

22. - Crit Care Med 41:580, 2013

24. Grading of
Recommendations
Assessment, Development,
and Evaluation
• Strength of the Evidence
• Strength of the Recommendation

26. Improving Sepsis Care
• Recognition
• Resuscitation
• Diagnosis and treatment of
infection
• Physiologic support

27. Improving Sepsis Care
• Recognition
• Resuscitation
• Diagnosis and treatment of
infection
• Physiologic support

28. Rates of Sepsis, U.S. 1979 - 2001
- Martin, N Engl J Med 348:1546, 2003

29. Sepsis in the
Emergency
Department
• Acute change in health status
• Unexplained organ dysfunction
• Febrile illness
• Underlying co-morbidities

30. Sepsis on the
Hospital Ward
• Fever, tachycardia
• Altered mental status
• Fluid retention
• New organ dysfunction
• Often subtle presentation

31. Sepsis
Think of it!

32. Improving Sepsis Care
• Recognition
• Resuscitation
• Diagnosis and treatment of
infection
• Physiologic support

33. Optimize Oxygen Delivery to Tissues
• Restore intravascular volume
• Support cardiac function
• Provide oxygen
• Enhance O2 carrying capacity

34. Lactate Metabolism
Anerobic
Aerobic

35. Resuscitation

36. Early Goal-directed Therapy
for Septic Shock
Standard Goal-Directed
(N=133) (N=130)
MVO2 65.3+11.4 70.4+10.7*
APACHE II 15.9+6.4 13.0+6.3*
Mortality 46.5% 30.5%*
* p<0.02 - Rivers, N Engl J Med 345:1368, 2001

37. CVP
Mean Arterial Pressure
> 8
<8
Fluids
ScvO2
> 65
<65
Pressors
Goals achieved
> 70Transfusion,
Inotropes

38. - Angus, N Engl J Med
370:1683, 2014

39. The SAFE Study Investigators, N Engl J Med 2004;350:2247
Saline and Albumin are Equally Efficacious

40. Mortality is Increased with Starches
- Zarychanski, JAMA 309:678, 2013

41. - N Engl J Med 370:1583,
2014

42. - N Engl J Med 370:1583, 2014

43. Improving Sepsis Care
• Recognition
• Resuscitation
• Diagnosis and treatment of
infection
• Physiologic support

44. Diagnosis
Antibiotics
Source
Control

45. OddsRatioforDeath
(95%CI)
1
10
100
Time from Onset of Hypotension
(Hours)
-Kumar, Crit Care Med 34:1589, 2006
Impact of Delayed Antibiotic
Therapy on Clinical Outcome

47. “Early versus late necrosectomy
in severe necrotizing pancreatitis”
Number Mortality
Early 25 58%
Late 11 27%
- Mier et al Am.J.Surg 173:71, 1997

48. Improving Sepsis Care
• Recognition
• Resuscitation
• Diagnosis and treatment of
infection
• Physiologic support

49. Ventilation with lower tidal volumes as compared
with traditional tidal volumes for acute lung injury
and the acute respiratory distress syndrome
Mortality
(%)Controls 39.8
Volume-limited 31.0*
ARDSNet; NEJM 342:1301, 2000
*P=0.007

50. Impact of Fluid Strategy in ARDS
Conservative Liberal p.
(N=503) (N=497)
60 day mortality 25.5% 28.4% 0.30
Ventilator-free days 14.6±0.5 12.1±0.5 <0.001
ICU-free days 13.4±0.4 11.2±0.4 <0.001
CNS failure FD 18.8±0.5 17.2±0.5 0.03
- ARDSNet, N Engl J Med 354:2564, 2006

52. Survival in NICE/SUGAR

53. Drotrecogin alfa was ineffective in
low risk patients …
Abraham E N Engl J Med 2005;353:1332

54. Time to
Shock Reversal
Survival
Sprung et al, N Engl J
Med 358:111,2008
CORTICUS
N=499

55. Has It Made a
Difference?

56. • Global process change initiative
based on “sepsis bundles”
• 15,022 patients enrolled
• 7% absolute, 5.4% relative mortality
reduction (p<0.001)
Surviving Sepsis
Campaign

57. Unadjusted
Risk-adjusted
Bundle target Population N
OR p-value
OR 95% CI p-value
Measure Lactate All 15,022
0.86 <0.0001
0.97 [0.90, 1.05] 0.48
Obtain blood cultures before
antibiotics
All 15,022
0.70 <0.0001
0.76 [0.70, 0.83] <0.0001
Commence broad-spectrum
antibiotics
All 15,022
0.78 <0.0001
0.86 [0.79, 0.93] <0.0001
Achieve tight glucose control All 15,022
0.65 <0.0001
0.67 [0.62, 0.71] <0.0001
Administer drotrecogin alfa Multi-organ failure 8,733
0.90 0.26
0.84 [0.69, 1.02] 0.07
Administer drotrecogin alfa Shock despite fluids 7,854
0.91 0.30
0.81 [0.68, 0.96] 0.02
Administer low-dose steroids Shock despite fluids 7,854
1.06 0.18
1.06 [0.96, 1.17] 0.24
Demonstrate CVP ≥ 8 mm Hg Shock despite fluids 7,854
1.08 0.10
1.00 [0.89, 1.12] 0.98
Demonstrate ScvO2 ≥ 70% Shock despite fluids 7,854
0.94 0.24
0.98 [0.86, 1.10] 0.69
Achieve low plateau pressure control Mechanical ventilation 7,860
0.67 <0.0001
0.70 [0.62, 0.78] <0.0001

58. - Kaukonen et al JAMA 2014
Survival in Sepsis is Improving

59. Conclusions
• The SSC has raised awareness regarding
sepsis management and defined
optimal approaches to care
• This has been associated with improved
survival
• But the elements responsible for that
improvement need further study

60. Thank You!!

61. QUESTIONS?
RAISE YOUR HAND / LEVEZ LA MAIN
OR/OU
CHAT TO “ALL PARTICIPANTS”

62. 62
a Canadian Critical Care
Knowledge Translation Network
“aC3KTion Net”

63. 63
aC3KTion Net
• Network of ICUs (Networks) from across
Canada
• Academic
• Community
• Primary activity will be Knowledge Translation
and development of Critical Care Knowledge
Synthesis products
• Not KT Research
• Measurement of uptake/outcomes

64. 64
Network Activities
• Measurement of current practice
• Knowledge Synthesis: Development of clinical practice guidelines,
evidence syntheses and scoping reviews.
• Testing of Knowledge Products: Reviewed and tested before
implementation, to ensure acceptability, ability to achieve intended
purpose and ascertain possible barriers
• Knowledge Implementation: Local teams will use strategies/tools
tailored to knowledge product.
– Education, protocols, checklists, order sets, organizational changes and
reminder systems
– PDSA cycles to track implementation activities

65. 65
 Even when motivated to change our behavior, we
cannot manage what we do not measure.
 Measurement can identify gaps in best practice.
 Measurement can illuminate the results of our
efforts at implementing best practice.
 Measurement can inform future research direction.
Measurement- Why?

66. Model for Participation
• Main benefits of participation
– Access to KT activities/initiatives
– Access to KS products
– Access to educational events/webinars
– Access to a repository of knowledge products, protocols etc.
– Opportunity to participate in incubator units
– Ability to influence network activities
– Benchmarked reports of performance with national peers
– A vehicle to drive critical care quality improvement
• ICUs provide periodic data in return
66

67. Current Status
• Baseline Data Collection
– Started and ongoing. Site recruitment ongoing.
• Development of barriers/enablers
Questionnaires
– Completed
• Repository of KT tools/Products
– Being populated
• KT activities
– Slated for 2014
67

68. 68
Questions/Comments?

69. Canadian ICU Collaborative
Faculty
Paule Bernier, P.Dt., Msc, Présidente, Ordre professionnel des diététistes du Québec; Sir MB David Jewish General Hospital
(McGill University), Montreal
Paul Boiteau MD, Department Head, Critical Care Medicine, Alberta Health Services; Professor of Medicine, University of Calgary
Mike Cass, BSc, RN, MScN, Advanced Practice Nurse, Trillium Health Centre
Leanne Couves, Improvement Advisor, Improvement Associates Ltd.
Maryanne D’Arpino, Patient Safety Improvement Lead, CPSI
Bruce Harries, Collaborative Director, Improvement Associates Ltd.
Denny Laporta MD, Intensivist, Department of Adult Critical Care, Jewish General Hospital; Faculty of Medicine, McGill University
Claudio Martin MD,Intensivist, London Health Sciences Centre, Critical Care Trauma Centre; Professor of Medicine and Physiology,
University of Western Ontario; Chair/Chief of Critical Care Western
Cathy Mawdsley, RN, MScN, CNCC; Clinical Nurse Specialist – Critical Care, London Health Sciences Centre;
John Muscedere MD, Assistant Professor of Medicine, Queens University; Intensivist, Kingston General Hospital
Yoanna Skrobik MD, Intensivist, Hôpital Maisonneuve Rosemont, Montréal; Expert Panel for the new Pain, Sedation and Delirium
Guidelines, Society of Critical Care Medline (SCCM)
6908/05/2014

70. Reminders
Rappels
 Call is recorded
 Slides and links to
recordings will be
available on Safer
Healthcare Now!
Communities of Practice
 Additional resources are
available on the SHN
Website and
Communities of Practice
 L'appel est enregistré
 Les diapositives et liens
vers les enregistrements
seront disponibles sur Des
soins de santé plus
sécuritaires maintenant!
Communautés de pratique
 Des ressources
supplémentaires sont
disponibles sur le site Web
SSPSM et Communautés
de Pratique
7008/05/2014

71. THANK YOU
MERCI

72. This National Call is hosted by:
Supported by:
72
08/05/2014