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Applying the Surviving Sepsis Campaign Guidelines to Clinical Practice

Applying the Surviving Sepsis Campaign Guidelines to Clinical Practice. Ruth M. Kleinpell PhD RN FCCM Rush University Medical Center Chicago, Illinois USA; President, World Federation of Critical Care Nurses. Conflict of Interest.

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Applying the Surviving Sepsis Campaign Guidelines to Clinical Practice

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  1. Applying the Surviving Sepsis Campaign Guidelines to Clinical Practice Ruth M. Kleinpell PhD RN FCCM Rush University Medical Center Chicago, Illinois USA; President, World Federation of Critical Care Nurses

  2. Conflict of Interest • “I believe there is value in the use of clinical practice guidelines, but at the same time acknowledge their limitations”

  3. Clinical Practice Guidelines: Origins Hieroglyphics outlining treatments for more than 700 remedies, circa 1552 BC

  4. Clinical practice guidelines are recommendations for clinicians about the care of patients with specific conditions. They should be based on the best available evidence and practice experience.

  5. Using Guidelines in Clinical Practice • On average, what percent of healthcare clinicians apply guidelines in clinical practice? • 12% • 20% • 50% • 75%

  6. 30 studies, representing 11,611 clinician responses Guidelines were helpful sources of advice (75%) Good educational tools (71%) Intended to improve quality (70%) Too rigid to apply to individual patients (30%) Reduced clinician autonomy (34%) Oversimplified medicine (34%) Medical Journal of Australia; ; 2002;177:;502-506

  7. Fact: The Interpretation of Medical Guidelines is Somewhat Subjective

  8. Fact: Not all Guidelines are Clear In Their Interpretation

  9. 2011

  10. Kung J et al JAMA Internal Medicine 2012;172:1628-1633

  11. Kung J et al JAMA Internal Medicine 2012;172:1628-1633

  12. How Does This Apply to Sepsis?

  13. Critical Care Medicine 2013;41:580-637

  14. Evidence-based recommendations • Outline the management of severe sepsis and septic shock • Identify key recommendations for treatment The GRADE system Grade 1 – Strong Grade 2 – Weak Quality of Evidence: Grade A – High Grade B – Moderate Grade C – Low Grade D – Very Low Grading of Recommendations Assessment, Development and Evaluation Dellinger RP et al. Critical Care Medicine 2013;41:580-637

  15. http://ims.cochrane.org/gradepro

  16. Despite limitations, the guidelines represent an important advance in the management of patients with severe sepsis. Although a number of recommendations were based on low-quality evidence, strong agreement existed among international experts regarding many level 1 recommendations as the best care for patients with sepsis.

  17. Basic care tasks [microbiological sampling and antibiotic delivery within 1 hour, fluid resuscitation, and risk stratification using serum lactate] are likely to benefit patients most, yet are unreliability performed. Barriers include lack of awareness, lack of supporting controlled trials and complex diagnostic criteria leading to recognition delays.

  18. 620 bed University Medical Center, Chicago Illinois 22 bed Surgical ICU 21 bed Medical ICU 25 bed NeuroSurgical ICU 25 bed CCU/CSU Total ICU admissions/year = 8,349

  19. Clinical ExampleRush University Medical Center Sepsis Initiative ■Started as educational initiative to promote awareness of new sepsis protocol. ■ Evolved to QI project to assess the impact of an educational initiative and focused follow up on protocol implementation.

  20. Clinical Example: Sepsis Protocol Implementation • Surveys conducted prior to protocol implementation • N=240 respondents (MDs, RNs, PharmD, Therapists)

  21. New Focus Area • Screening for Sepsis & Performance Improvement • We recommend routine screening of potentially infected seriously ill patients for severe sepsis to increase the early identification of sepsis and allow implementation of early sepsis therapy (grade 1C). • Performance improvement efforts in severe sepsis should be used to improve patient outcomes (UG). Dellinger RP et al. Critical Care Medicine 2013;41:580-637

  22. Using Performance Improvement to Target Sepsis

  23. Strategies for Implementing Sepsis Performance Improvement • Identify gaps in care and specific areas for improvement • Time to blood cultures • Time to antibiotics • Time to lactate levels • Time to fluid bolus goals Targeting Sepsis as a Performance Improvement Metric: AACN Clinical Issues, In Press

  24. Initial Resuscitation • We recommend the protocolized resuscitation of a patient with sepsis-induced shock, defined as tissue hypoperfusion (hypotension persisting after initial fluid challenge or blood lactate concentration 4 mmol/L). During the first 6 hrs of resuscitation, the goals of initial resuscitation of sepsis-induced hypoperfusion should include all of the following as one part of a treatment protocol: • Central venous pressure (CVP): 8–12mm Hg • Mean arterial pressure (MAP) ≥ 65mm Hg • Urine output ≥ 0.5mL.kg–1.hr –1 • Central venous (superior vena cava) or mixed venous oxygen saturation ≥ 70% or ≥ 65%, respectively (Grade 1C) Dellinger RP et al. Critical Care Medicine 2013;41:580-637

  25. Fluid therapy • We recommend crystalloids be used in the initial fluid resuscitation in patients (Grade 1B). • We recommend that initial fluid challenge in patients with sepsis-induced tissue hypoperfusion with suspicion of hypovolemia to achieve a minimum of 30ml/kg. (Grade 1C). Dellinger RP et al. Critical Care Medicine 2013;41:580-637

  26. Strategies for Implementing Sepsis Performance Improvement • Identify gaps in care and specific areas for improvement • Compliance to elements of the 3 hour bundle • Compliance to elements of the 6 hour bundle Targeting Sepsis as a Performance Improvement Metric: AACN Clinical Issues, In Press

  27. Diagnosis • We recommend obtaining appropriate cultures before antimicrobial therapy is initiated if such cultures do not cause significant delay (>45 minutes) in antimicrobial administration. • To optimize identification of causative organisms, we recommend at least two blood cultures be obtained before antimicrobial therapy with at least one drawn percutaneously and one drawn through each vascular access device, unless the device was recently (<48 hr.) inserted (1C) Dellinger RP et al. Critical Care Medicine 2013;41:580-637

  28. Antibiotic therapy • We recommend that intravenous antimicrobial therapy be started as early as possible and within the first hour of recognition of septic shock (1B) and severe sepsis without septic shock (grade1C). • We recommend that initial empiric anti-infective therapy include one or more drugs that have activity against all likely pathogens (bacterial and/or fungal or viral) (grade 1B).

  29. Vasopressors • We recommend that vasopressor therapy initially target a mean arterial pressure (MAP) of 65 mm Hg (grade 1C). • We recommend norepinephrine as the first choice vasopressor (Grade 1 B). Dellinger RP et al. Critical Care Medicine 2013;41:580-637

  30. Strategies for Implementing Sepsis Performance Improvement • Identify gaps in care and specific areas for improvement • Glucose value levels < 180 mg/dL • Sedation targeted to specific endpoints • Nutritional support Targeting Sepsis as a Performance Improvement Metric: AACN Clinical Issues, In Press

  31. 2008Surviving Sepsis Campaign Guidelines • Consideration for limitation of support (1D) • Discuss end-of-life care for critically ill patients • Promote family communication to discuss use of life-sustaining therapies 1D = Very Low Quality of Evidence Dellinger RP et al Crit Care Med 2008; 36:296-437

  32. Consideration for Limitation of Support Setting Goals of Care • Recommendation 1: We recommend that identification of goals of care, prognosis for achieving those goals and the level of certainty for the prognosis be discussed with patients and families. (1B) • Recommendation 2: We recommend that these communications should be incorporated into treatment plans with integration of palliative care principles, and as appropriate, end-of-life care planning. (1B) • Recommendation 3: It is suggested that goals of care be addressed as early as feasible but no later than within 72 hours. (Grade 2C) Dellinger RP et al. Critical Care Medicine 2013;41:580-637

  33. Strategies for Implementing Sepsis Performance Improvement • Identify gaps in care and specific areas for improvement • Patients receiving family care conference to address goals of care within 72 hours of ICU admission Targeting Sepsis as a Performance Improvement Metric: AACN Clinical Issues, In Press

  34. Performance Improvement • The focus on the new Surviving Sepsis Campaign is not only on the early identification and treatment of patients, but on the recognition that nurses are critical to performance improvement and data collection

  35. Available full text open access www.wfccn.org

  36. Reliable timely delivery of more complex life-saving tasks demands greater awareness, faster recognition and initiation of basic care, and more effective collaboration between clinicians and nurses on the front line.

  37. Summary: Optimizing Outcomes in Sepsis • Role of Astute Clinical Assessment • EARLY: • Recognition • Treatment • Judicious application of guideline recommendations

  38. Congratulations!

  39. Dank Je

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